Health Assessment Online for Physical Examination and Health Assessment 7th Edition

numbers and letters, and then ask the patient to repeat them. c. Ask the patient to place his finger in his ear to occlude outside noise. d. Stand approximately 4 feet away to ensure that the patient can really hear at this distance. Answer:[cpmembership level="2,3,4,5"] B With the head 30 to 60 cm (1 to

is appropriate? a. "Head control is usually achieved by 4 months of age." b. "You shouldn"t be trying to pull your baby up like that until she is older." c. "Head control should be achieved by this time." d. "This inability indicates possible nerve damage to the neck muscles." Answer:[cpmembership level="2,3,4,5"] A Head control is achieved by

used to listen for low-pitched sounds. c. Should be lightly held against the person's skin to block out low-pitched sounds. d. Should be lightly held against the person's skin to listen for extra heart sounds and murmurs. Answer:[cpmembership level="2,3,4,5"] A The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath,

to assess in a patient with dementia? Select all that apply. a. Ask the patient, "Do you have pain?" b. Assess the patient's breathing independent of vocalization. c. Note whether the patient is calling out, groaning, or crying. d. Have the patient rate pain on a 1-to-10 scale. e. Observe the patient's body language for

a shower." b. "If you notice an enlarged testicle or a painless lump, call your health care provider." c. "The testicle is egg shaped and movable. It feels firm and has a lumpy consistency." d. "Perform a testicular examination at least once a week to detect the early stages of testicular cancer." Answer:[cpmembership level="2,3,4,5"] B If

twice each day. The nurse should suspect: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches. Answer:[cpmembership level="2,3,4,5"] B Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last

ask a postmenopausal woman if she has ever had vaginal bleeding. b. Once a woman reaches menopause, the nurse does not need to ask any history questions. c. The nurse should screen for monthly breast tenderness. d. Postmenopausal women are not at risk for contracting STIs; therefore, these questions can be omitted. Answer:[cpmembership level="2,3,4,5"] A Postmenopausal

all that apply. a. Collect the patient's data in a direct, face-to-face manner. b. Enter all the data as the patient states them. c. Ask the patient to wait as the nurse enters the data. d. Type the data into the computer after the narrative is fully explored. e. Allow the patient to see the

Arteries can greatly expand to accommodate a large blood volume increase. Answer:[cpmembership level="2,3,4,5"] B The pumping heart makes the arterial system a high-pressure system.[/cpmembership] An older patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical

These lesions are characteristic of: a. Carcinoma. b. Syphilitic chancres. c. Genital herpes. d. Genital warts. Answer:[cpmembership level="2,3,4,5"] D The lesions of genital warts are soft, pointed, moist, fleshy, painless papules that may be single or multiple in a cauliflower-like patch. They occur on the shaft of the penis, behind the corona, or around the anus, where

identify correctly an object placed in the hand (see Chapter 23).[/cpmembership] A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The

foods. d. An imbalance within his or her spiritual nature. Answer:[cpmembership level="2,3,4,5"] B The basic premise of the magicoreligious perspective is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil.

and spirit. c. Maintained by wearing jade amulets. d. Being in harmony with nature. Answer:[cpmembership level="2,3,4,5"] D The belief that health is being in harmony with nature reflects the health beliefs of those of African heritages. The other examples represent Iberian and Central and South American heritages, American-Indian heritages, and Asian heritages (See Table 2-3).[/cpmembership] When

at home. b. It determines how children are meeting developmental milestones. c. The functional assessment can identify any problems with memory the individual may be experiencing. d. It helps determine how a person is managing day-to-day activities. Answer:[cpmembership level="2,3,4,5"] D The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect

of pigmentation that look greasy, dark, and 'stuck on" his skin. Which is the best prediction? a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons, which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous Answer:[cpmembership level="2,3,4,5"] D Seborrheic keratoses appear

for this? a. An aged person has a longer story to tell. b. An aged person is usually lonely and likes to have someone with whom to talk. c. Aged persons lose much of their mental abilities and require longer time to complete an interview. d. As a person ages, he or she is

"Is caused by moisture in the alveoli." b. "Indicates that air is present in the subcutaneous tissues." c. "Is caused by sounds generated from the larynx." d. "Reflects the blood flow through the pulmonary arteries." Answer:[cpmembership level="2,3,4,5"] C Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung

your breasts every month on the same day of the month." c. "Examine your breasts shortly after your menstrual period each month." d. "The best time to examine your breasts is immediately before menstruation." Answer:[cpmembership level="2,3,4,5"] C The best time to conduct a BSE is shortly after the menstrual period when the breasts are the

feedback and reassurance during the examination. c. Do not ask the child to remove his or her clothes because children at this age are usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen. Answer:[cpmembership level="2,3,4,5"] B With preschool children, short, simple explanations should

lesion. Answer:[cpmembership level="2,3,4,5"] B Opisthotonos is a form of spasm in which the head is arched back, and a stiffness of the neck and an extension of the arms and legs are observed. Opisthotonus occurs with meningeal or brainstem irritation (see Chapter 23).[/cpmembership] A patient has a normal pupillary light reflex. The nurse recognizes

determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. a. Intact skin appears red but is not broken. b. Partial thickness skin erosion is observed with a loss of epidermis or dermis. c. Ulcer extends into the subcutaneous

questions. b. Assess for middle ear infection as a possible cause. c. Ask the patient what medications he is currently taking. d. Look for the source of the obstruction in the external ear. Answer:[cpmembership level="2,3,4,5"] C A simple increase in amplitude may not enable the person to understand spoken words. Sensorineural hearing loss may be caused

Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Fever, dry nonproductive cough, and diminished breath sounds Answer:[cpmembership level="2,3,4,5"] A A person with heart failure often exhibits increased respiratory rate, shortness of breath on exertion, orthopnea,

prevent it. The nurse instructs her to: a. Use a cotton-tipped swab to dry the ear canals thoroughly after each swim. b. Use rubbing alcohol or 2% acetic acid eardrops after every swim. c. Irrigate the ears with warm water and a bulb syringe after each swim. d. Rinse the ears with a warmed

Friction rub c. Crackles d. Wheezing Answer:[cpmembership level="2,3,4,5"] B A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made when the pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated

temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain.[/cpmembership] Which of these would be formulated by a nurse using diagnostic reasoning? a. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. Diagnostic assessment Answer:[cpmembership level="2,3,4,5"] C Diagnostic

level="2,3,4,5"] A The incidence of breast cancer varies within different cultural groups. White women have a higher incidence of breast cancer than black women starting at age 45 years; but black women have a higher incidence before age 45 years. Asian, Hispanic, and American Indian women have a lower risk for development

patient about a history of frostbite. b. Suspect that the patient has venous insufficiency. c. Consider this a delayed capillary refill time, and investigate further. d. Consider this a normal capillary refill time that requires no further assessment. Answer:[cpmembership level="2,3,4,5"] C Normal capillary refill time is less than 1 to 2 seconds. The following conditions can

the report? a. "I"m worried that his gastrointestinal bleeding is getting worse." b. "We need an order for oxygen." c. "My name is Ms. Smith, and I"m giving the report on Mrs. X in room 1104." d. "He is 4 days postoperative, and his incision is open to air." Answer:[cpmembership level="2,3,4,5"] D During the Background portion, the

is inevitable with aging. b. Older adults with cognitive impairments feel less pain. c. Alleviating pain should be a priority over other aspects of the assessment. d. The assessment should take priority so that care decisions can be made. Answer:[cpmembership level="2,3,4,5"] C If the older adult is experiencing pain or discomfort, then the depth of knowledge

proportions of the head and trunk of the newborn? a. At birth, the head is one fifth the total length. b. Head circumference should be greater than chest circumference at birth. c. The head size reaches 90% of its final size when the child is 3 years old. d. When the anterior fontanel closes

Side effects of medications. b. Decreased libido with aging. c. Decreased sperm production. d. Decreased pleasure from sexual intercourse. Answer:[cpmembership level="2,3,4,5"] A In the absence of disease, a withdrawal from sexual activity may be attributable to side effects of medications such as antihypertensives, antidepressants, sedatives, psychotropics, antispasmotics, tranquilizers or narcotics, and estrogens. The other options are

be in a monogamous relationship?" c. "Have you carefully thought this choice through?" d. "If you smoke, how many cigarettes do you smoke per day?" Answer:[cpmembership level="2,3,4,5"] D Oral contraceptives, together with cigarette smoking, increase the risk for cardiovascular side effects. If cigarettes are used, then the nurse should assess the patient's smoking history. The

cholesterol, diabetes, and smoking c. Smoking, hypertension, obesity, diabetes, and high cholesterol d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol Answer:[cpmembership level="2,3,4,5"] C To assess for major risk factors of coronary artery disease, the nurse should collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 100 mg/dL or known diabetes