NR 509 Advanced physical assessment Quiz 4 Questions & Answers - €12,20   In winkelwagen

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NR 509 Advanced physical assessment Quiz 4 Questions & Answers

NR 509 Advanced physical assessment Quiz 4 Questions & Answers 1. Question : During an examination, the patient states he is hearing a buzzing sound and says that it is “driving me crazy!” The nurse recognizes that this symptom indicates Student Answer: vertigo. pruritus. tinnitus. cholesteatoma. Instructor Explanation: Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Points Received: 2 of 2 Comments: Question 2. Question : A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to Student Answer: speak loudly so he can hear the questions. assess for middle ear infection as a possible cause. ask the patient what medications he is currently taking. look for the source of the obstruction in the external ear. Instructor Explanation: A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea. Points Received: 2 of 2 Comments: Question 3. Question : The nurse is explaining to a patient that there are “shock absorbers” in his back to cushion the spine and to help it move. The nurse is referring to his Student Answer: vertebral column. nucleus pulposus. vertebral foramen. intervertebral disks. Instructor Explanation: Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine like shock absorbers and help it move. The vertebral column is the spinal column itself. The nucleus pulposus is located in the center of each disk. The vertebral foramen is the channel, or opening, for the spinal cord in the vertebrae. Points Received: 2 of 2 Comments: Question 4. Question : The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is Student Answer: highly vascular. thick and tough. thin and nonstratified. replaced every 4 weeks. Instructor Explanation: The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones. Points Received: 2 of 2 Comments: Question 5. Question : The nurse is examining a 6-month-old infant and places the infant’s feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding? Student Answer: This is a positive Allis sign and suggests hip dislocation. The infant probably has a dislocated patella on the right. This is a normal finding for the Allis test for an infant of this age. The infant should return to the clinic in 2 weeks to see if this has changed. Instructor Explanation: Finding one knee significantly lower than the other is a positive Allis sign and suggests hip dislocation. Normally, the tops of the knees are at the same elevation. The other statements are not correct. Points Received: 2 of 2 Comments: Question 6. Question : A patient drifts off to sleep when she is not being stimulated. The nurse can arouse her easily when calling her name, but she remains drowsy during the conversation. The best description of this patient’s level of consciousness would be Student Answer: lethargic. obtunded. stuporous. semialert. Instructor Explanation: Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she responds appropriately to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses train of thought. Spontaneous movements are decreased. See Table 5-3 for definitions of the other terms. Points Received: 2 of 2 Comments: Question 7. Question : A 65-year-old man is brought to the emergency department after he was found dazed and incoherent, alone in his apartment. He has an enlarged liver and is moderately dehydrated. When evaluating his serum albumin level, the nurse must keep in mind that Student Answer: serum albumin levels will increase as liver function decreases. serum albumin levels are a sensitive measure of early protein malnutrition. low serum albumin levels may be caused by reasons other than protein-calorie malnutrition. the results of the serum albumin measurement along with the patient’s hemoglobin level should be considered. Instructor Explanation: Low serum albumin levels may be caused by reasons other than protein-calorie malnutrition, such as an altered hydration status and decreased liver function. Points Received: 2 of 2 Comments: Question 8. Question : The nurse is checking the range of motion in a patient’s knee and knows that the knee is capable of which movement(s)? Student Answer: Flexion and extension Supination and pronation Circumduction Inversion and eversion Instructor Explanation: The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed. Points Received: 2 of 2 Comments: Question 9. Question : A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, “I don’t know what the matter is. All of a sudden, I can’t hear you out of my left ear!” What should the nurse do next? Student Answer: Make note of this finding for report to the next shift. Prepare to remove cerumen from the patient’s ear. Notify the patient’s healthcare provider. Irrigate the ear with rubbing alcohol. Instructor Explanation: Any sudden loss of hearing in one or both ears that is not associated with an upper respiratory infection needs to be reported at once to the patient’s healthcare provider. Hearing loss associated with trauma is often sudden. It is not appropriate to irrigate the ear or remove cerumen at this time. Points Received: 2 of 2 Comments: Question 10. Question : A 40-year-old man has come into the clinic with complaints of “extreme tenderness in my toes.” The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest Student Answer: osteoporosis. acute gout. ankylosing spondylitis. degenerative joint disease. Instructor Explanation: Acute gout occurs primarily in men over 40 years of age. Clinical findings consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid. See Table 22-1 for descriptions of the other terms. Points Received: 2 of 2 Comments: Question 11. Question : A 19-year-old college student is brought to the emergency department with a severe headache he describes as “like nothing I’ve ever had before.” His temperature is 104° F, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? Student Answer: Head injury Cluster headache Migraine headache Meningeal inflammation Instructor Explanation: Acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck. Points Received: 2 of 2 Comments: Question 12. Question : A mother brings her newborn baby boy in for a checkup; she tells the nurse that he doesn’t seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle and would observe for Student Answer: a negative Allis test. a positive Ortolani’s sign. limited range of motion during the Moro’s reflex. limited range of motion during Lasègue’s test Instructor Explanation: For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro’s reflex. The other tests are not appropriate for this problem. Points Received: 2 of 2 Comments: Question 13. Question : While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate Student Answer: a fungal infection. acute otitis media. perforation of the ear drum. cholesteatoma. Instructor Explanation: Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media. See Table 15-5 for descriptions of the other conditions.

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