Health & Physical Assessment in Nursing, Canadian Edition By Donita T D mico Test Bank

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Health & Physical Assessment in Nursing, Canadian Edition By Donita T D mico Test Bank

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WITH ANSWERS
Health & Physical Assessment in Nursing, Canadian Edition By Donita T DAmico Test Bank

Chapter 15

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

  • A nurse is preforming auscultation on a client who has significant atelectasis in the right lower lung field. What would the nurse anticipate hearing in this area of the lung?
  • Sonorous wheeze
  • Increased whisper pectoriloquy
  • Decreased breath sounds
  • Lack of tactile fremitus

 

  • 3

Explanation:

  1. A sonorous wheeze (rhonchi) would be heard in narrowed or fluid filled airways.
  2. With atelectasis one would expect to have a decrease in the voice sounds such as whisper pectoriloquy.
  3. This is what you would expect to hear in the right lower lobe due to collapsed alveoli.
  4. A lack of tactile fremitus does occur in atelectasis but this is found on palpation and not on auscultation.

Assessment

Application

Objective 10

Page 340 and 349

Difficulty = 3

 

2)   A nurse is performing a respiratory assessment on a pregnant client at term. She finds that her breathing pattern is faster at rest than her normal, non-pregnancy state. The client also states that she has dyspnea. How should the nurse interpret these findings?

1)   Expected for third trimester of pregnancy.

2)   Evidence of chronic pulmonary disease.

3)   Abnormal findings that require reporting.

4)   Abnormal findings, but not significant.

 

2)   1

Explanation:

  1. Shortness of breath, dyspnea, and a respiratory rate increase of approximately two breaths per minute are normal findings of pregnancy, especially in the last trimester as the chest expands to accommodate the growing baby.
  2. Chronic pulmonary disease would not be conclusive with only these findings further testing including pulmonary function tests would be performed before this diagnosis was given.
  3. This is not an abnormal finding in the third trimester of pregnancy.
  4. This is not an abnormal finding in the third trimester.

Assessment

Application

Objective 9

Page 322, 323, and 328

Difficulty = 1

 

3)   A nurse is percussing the anterior chest of an elderly client.  What would the nurse expect to find in this client?

1)   Tympany

2)   Flatness

3)   Dullness

4)   Hyperresonance

 

3)   4

Explanation:

  1. Tympany is heard when percussion is performed over a gastric air bubble.
  2. Flatness is heard over muscle (see chapter 6).
  3. Dullness is heard over bone, organs, consolidated lungs, or over a tumour.
  4. As a client ages, the function of the respiratory system becomes less efficient lungs lose their elasticity, muscles begin to weaken, and bones lose their density. Trapping of air in the alveoli will produce a hyperresonance sound upon percussion of the chest.

Assessment

Application

Objective 9

Page 323 and 344

Difficulty = 2

 

4)   A nurse is assessing an infants respiratory rate and sees that the infant is primarily using abdominal muscles. How should the nurse interpret this finding?

1)   An indicator of respiratory dysfunction.

2)   Accessory muscles are assisting with breathing.

3)   A normal pattern.

4)   A slightly irregular pattern.

 

4)   3

Explanation:

  1. Abdominal breathing is a normal finding in an infant; therefore this is not an indicator of respiratory dysfunction.
  2. The use of accessory muscles (intercostal muscles and sternocleidomastoid) would be a worrisome finding for a client of any age group. Using the abdominal muscles is normal in an infant.
  3. Abdominal breathing is the normal pattern for an infant and continues during childhood until ages five to seven years when the child develops costal breathing patterns.
  4. The use of abdominal muscles is normal and not an irregular pattern for this age group.

Assessment

Application

Objective 9

Page 322

Difficulty = 1

 

 

5) Bob presents to the street nurse, with a persistent cough that is productive for rust coloured mucus. What health issue does Bob likely have based on this finding?

  • Pneumonia
  • Asthma
  • Tuberculosis
  • Pleural effusion

 

5)   3

Explanation:

  1. Typically the mucus produce in a lung infection like pneumonia is greenish yellow in colour.
  2. Asthmatics produce a large amount of yellow mucus that is often accompanied with a wheeze.
  3. Rust coloured mucus is associated with tuberculosis.
  4. Mucus production does not generally occur with a pleural effusion.

Assessment

Application

Objective 10

Page 325

Difficulty = 2

 

6)   A nurse is monitoring a clients respiratory rate. What is the most accurate method for the nurse to use in assessing respiratory rate?

1)   Count only the respirations that are audible.

2)   Ask the client not to talk while you listen to his respirations.

3)   Lay a hand on the clients chest to count.

4)   Count without the client knowing what is happening.

 

6)   4

Explanation:

  1. Not all clients have audible respiratory cycles and this would not be an effective method to ensure accuracy.
  2. If a client knows his/her respirations are being counted, it may alter the normal breathing pattern.
  3. Though laying a hand on the clients chest allows the nurse to feel the rise and fall of the chest, this may be considered an intrusive move and might cause the client anxiety, which would affect the respiratory rate.
  4. Do not tell the client that you are counting respirations as it may alter the normal breathing pattern.

Assessment

Application

Objective 6

Page 333

Difficulty = 2

 

7)   While palpating respiratory expansion the nurse notes unilateral chest movement. What health issue is most likely to cause this alteration?

1)   Acute bronchitis

2)   Pneumothorax

3)   Abdominal pain

4)   Pneumonia

 

7)   2

Explanation:

  1. Acute bronchitis is more likely to cause dyspnea or wheezing than absence of air movement on one side.
  2. A pneumothorax is the result of air moving into the pleural space causing a partial or complete collapse of the lung on the affected side which is evident by unilateral decrease or delay in chest expansion.
  3. Abdominal pain typically results in dyspnea and guarding of the area. Chest expansion should remain equal.
  4. Pneumonia usually causes dyspnea. Decreased chest expansion on the affected side can occur but is not a typical finding.

Assessment

Analysis

Objective 10

Page 334 and 351

Difficulty = 2

 

8)   A nurse auscultates low-pitched, continuous respiratory sounds that have a snoring quality. How should the nurse document this finding?

1)   Rhonchi

2)   Rales

3)   Crackles

4)   Wheezes

 

8)   1

Explanation:

  1. Rhonchi are low pitched and have a snoring quality
  2. Rales are intermittent, non-musical, brief sounds.
  3. Crackles can also be called rales. Course crackles are lower in pitch, moist and are discontinuous
  4. Wheezes are high pitched with a shrill quality and are continuous.

Assessment

Application

Objective 11

Page 340 (Table 15.2)

Difficulty = 2

 

9)   A client is 1 day post-operative for a left lower lobectomy. The nurse is palpating around the chest tube insertion site and notes crepitus. What has caused the crepitus?

  • Mucus plug in the left bronchus.
  • Air leaking into subcutaneous tissue.
  • Increase fremitus from fluid in the lung on the surgical side
  • Consolidation of the alveoli in the affected lung

 

9)   2

Explanation:

  1. A mucus plug would not cause crepitus. A wheeze would be more likely with an obstructed bronchus.
  2. Subcutaneous emphysema (air leaking into the subcutaneous tissue) is a common occurrence with a chest tube. On palpation the area feels crunchy which is called crepitus.
  3. Fremitus is a vibration felt on palpation and occurs when there is fluid in the lungs.
  4. Consolidation is identified through auscultation.

Assessment

Analysis

Objective 10

Page 342 and 333

Difficulty = 2

 

10) A nursing instructor is observing a student during the respiratory assessment of a client. How will the student demonstrate proper technique for auscultating the posterior thorax?

1)   Base to apices of the lungs

2)   Side to side moving toward the bases

3)   First down one side of the thorax, then the other

4)   Midaxillary line to bases then to the apex of the lungs

 

10) 2

Explanation:

  1. Auscultation should move from the apices to the bases of the lungs.
  2. Auscultation should start at the apices of the lung moving from side to side comparing sounds while moving toward the bases and finally laterally to each midaxillary line.
  3. This is incorrect because the nurse cannot accurately compare sounds in the corresponding intercostal spaces.
  4. Wrong order. See number 2 for the correct technique.

Assessment

Application

Objective 2 and 7

Page 338 (Figure 15.16)

Difficulty = 1

 

11) A nurse is percussing the posterior thorax of a client with emphysema. What sound does the nurse anticipate hearing?

  • Resonance
  • Hyperresonance
  • Fremitus
  • Bronchial

 

11) 2

Explanation:

  1. The usual sound in the posterior thorax is resonance but this sound changes in disease states such as emphysema.
  2. Hyperresonance occurs in conditions such as emphysema when there is an over inflation of the lungs.
  3. Fremitus is a palpable vibration on the chest wall when the client speaks.
  4. Bronchial sounds are normal breath sounds heard next to the trachea on auscultation not on percussion.

Assessment

Application

Objective 8

Page 336 and 350

Difficulty = 3

 

12) During auscultation where are vesicular breath sounds heard on the thorax?

  • Over the lung fields
  • Over the trachea
  • Next to the trachea
  • Between the scapula

 

12) 1

Explanation:

  1. This is correct. Vesicular breath sounds are normal sounds heard over the lungs.
  2. Tracheal sounds are over the trachea.
  3. Bronchial sounds are heard next to the trachea.
  4. Bronchovesicular breath sounds are heard between the scapula and next to the sternum.

Assessment

Knowledge

Objective 6

Page 338 (Table 15.1), 339 (Figure 15.17), and 345 (Figure 15.22)

Difficulty = 1

 

13) Jordan, 3 years old, has an obstructed airway. The nurse hears a loud high pitched crowing on inspiration. What is the medical term used to document this finding?

  • Rhonchi
  • Sibilant wheeze
  • Stridor
  • Friction rub

 

13) 3

Explanation:

  1. Rhonchi are sonorous wheezes that occur on both inspiration and expiration. This sound indicates a narrowed or a fluid filled airway.
  2. Sibilant wheeze occurs primarily on expiration and is associated with diminished airflow due to asthma, infection, or a foreign body.
  3. Stridor has a distinctive crowing sound that can be heard without a stethoscope and is indicative of an obstructed airway.
  4. A friction rub sounds like a grating or rubbing sound because of inflammation of the pleura.

Assessment

Analysis

Objective 11

Page 340 (Table 15.2)

Difficulty = 2

 

14) A nurse is assessing a clients respiratory pattern and notes periods of deep breathing alternating with periods of apnea.  What term should be used to document this assessment finding?

1)   Hypoventilation

2)   Cheyne-Stokes

3)   Orthopnea

4)   Eupnea

 

14) 2

Explanation:

  1. Hypoventilation is too shallow or too slow breathing.
  2. The breathing described is a Cheyne-Stokes pattern.
  3. Orthopnea is difficulty breathing when lying down.
  4. Eupnea is normal breathing.

Assessment

Application

Objective 11

Page 329 (Box 15.01)

Difficulty = 1

 

15) A student nurse is asked to describe how to assess for bronchophony. What instructions should the student give the client during the assessment?

  • Say E each time I put the stethoscope on your chest.
  • Whisper 1, 2, 3 when directed to do so.
  • Say ninety-nine when I place the stethoscope on your chest.
  • Take slow deep breathes in and out when directed to do so.

 

15) 3

Explanation:

  1. This statement is appropriate for assessing egophony but not bronchophony.
  2. This statement is appropriate for assessing whisper pectoriloquy.
  3. This is the appropriate instructions for assessing bronchophony.
  4. This is how to assess breath sounds and not voice sounds.

Assessment

Application

Objective 6

Page 341

Difficulty = 2

 

16) Amrita, is 36 week pregnant and reports having shortness of breath.

How should the nurse respond to Amritas concern?

1)   This is due to a decrease in oxygen demand.

2)   You must be having Braxton Hicks contractions.

3)   This is common at this point in the pregnancy.

4)   The enlarged uterus can decrease lung expansion.

 

16) 4

Explanation:

  1. This is incorrect. Maternal and fetal demand for oxygen increases leading to dyspnea.
  2. She may be experiencing Braxton Hicks contractions which are normal in the last trimester but these contractions will not cause shortness of breath.
  3. This is correct but it does not provide the client with a rationale for this physiologic change.
  4. During the third trimester, the enlarging fetus/uterus puts pressure on the diaphragm thus causing decreased lung expansion resulting in shortness of breath.

Assessment

Analysis

Objective 3

Page 322 and 328

Difficulty = 2

 

17) What is the landmark used to locate the angle of Louis?

1)   Manubrium

2)   First rib

3)   Clavicle

4)   Xiphoid process

 

17) 1

Explanation:

  1. The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.
  2. The first rib is obscured by the clavicle consequently it is not used as a landmark.
  3. The clavicle articulates with the sternum but is not used as a landmark for the angle of Louis.
  4. The xiphoid process is a landmark used to identify the level of the diaphragm.

Assessment

Comprehension

Objective 2

Page 341

Difficulty = 1

 

18) During auscultation where are bronchial breath sounds heard on the thorax?

  • Over the lung fields
  • Over the trachea
  • Next to the trachea
  • Between the scapula

 

18) 3

Explanation:

  1. Vesicular breath sounds are heard over the lungs.
  2. Tracheal sounds are over the trachea.
  3. Bronchial sounds are heard next to the trachea.
  4. Bronchovesicular breath sounds are heard between the scapula and next to the sternum.

Assessment

Knowledge

Objective 6

Page 338 (Table 15.1), 339 and 341

Difficulty = 1

 

19) What landmarks are used to auscultate the bronchi?

  • From below the scapula down to the 6th intercostal space (ICS)
  • Above the suprasternal notch on each side
  • At the 2nd and 3rd ICS on either side of the sternal border
  • At the 5th ICS, at the midclavicular line

 

19) 3

Explanation:

  1. This is the position for auscultating the lungs.
  2. This is the position for auscultating the trachea.
  3. This is the correct position for auscultating the bronchi.
  4. This is the position for auscultating or palpating the apex of the heart

Assessment

Knowledge

Objective 2

Page 345

Difficulty = 2

 

20) During a health history interview the nurse wants to know more about a clients health behaviours. What question would elicit information on health behaviours?

  • Do you have a cough?
  • Is there a family history of allergies?
  • Do you get the seasonal flu shot?
  • Are you exposed to respiratory irritants in the workplace?

 

20) 3

Explanation:

  1. This is an example of a question related to common concerns related to illness.
  2. This is an example of a question used to gain information on past or family health history.
  3. This question will provide information on the clients health behaviour/practice.
  4. This is an example of a question that will elicit information on the physical environment.

Assessment

Application

Objective 4

Page 326

Difficulty = 2

 

21) A client, 45 years old, with emphysema is being assessed by the nurse.  What physical finding would the nurse expect to find in this client?

1)   Pectus excavatum

2)   Barrel chest

3)   Scoliosis

4)   Pigeon chest

 

21)      2

Explanation:

  1. Pectus excavatum is also called funnel chest because the chest has a caved-in or sunken appearance.
  2. Clients with chronic obstructive pulmonary disease often have barrel chests due to an increase in the anterioposterior diameter of the chest wall from over inflation of the alveoli.
  3. Scoliosis is a lateral deviation of the spine that causes one scapula to be elevated.
  4. Pigeon chest, or pectus carinatum, is a congenital abnormality characterized by forward displacement of the sternum.

Assessment

Application

Objective 9

Page 330(Box 15.3) and 350

Difficulty = 1

 

22) The nurse is examining a client who is diagnosed with a fracture of a floating rib. Which rib is fractured?

1)   9

2)   5

3)   1

4)   12

 

22) 4

Explanation:

  1. The ninth rib articulates with the cartilage of rib 7.
  2. The first seven ribs articulate with the body of the sternum.
  3. The first seven ribs articulate with the body of the sternum.
  4. The eleventh and twelfth ribs are called floating ribs, because they do not articulate anteriorly.

Assessment

Knowledge

Objective 1

Page 318

Difficulty = 1

 

23) During auscultation where are bronchovesicular breath sounds heard on the posterior thorax?

  • Over the lung fields
  • Over the trachea
  • Next to the trachea
  • Between the scapula

 

23) 4

Explanation:

  1. Vesicular breath sounds are heard over the lungs.
  2. Tracheal sounds are over the trachea.
  3. Bronchial sounds are heard next to the trachea.
  4. Bronchovesicular breath sounds are heard between the scapula and next to the sternum.

Assessment

Knowledge

Objective 6

Page 338 (Table 15.1) and 339 (Figure 15.17)

Difficulty = 1

 

24) A student nurse is practicing auscultation on a classmate and is concerned that the voice sounds were muffled. How should the instructor respond to this concern?

  • This is an expected finding in areas of lung consolidation.
  • This is an anticipated finding in the normal lung.
  • The voice sounds should be loud and clear.
  • The voice sounds should be absent in this situation.

 

24) 2

Explanation:

  1. In consolidated lung tissue voice sounds will be loud and clear.
  2. Voice sounds are heard as muffled sounds in the normal lung. Voices sounds are only assessed when pathology is suspected and is not part of the routine physical examination.
  3. This is true when there is lung consolidation but not in normal lung tissue which is most likely the situation when practicing auscultation on a classmate.
  4. Voice sounds may be absent in situations such as atelectasis, pleural effusion, or a pneumothorax. This is unlikely in this situation when students are practicing auscultation on one another.

Assessment

Application

Objective 8

Page 340 and 341

Difficulty = 1

 

25) A nurse notes a clients respirations are less than 10 breaths per minute. What is the appropriate terminology to use in documenting this finding?

1)   Bradypnea

2)   Tachypnea

3)   Apnea

4)   Atelectasis

 

25) 1

Explanation:

  1. Bradypnea is slow, regular respirations less than 10 per minute.
  2. Tachypnea is rapid, shallow respirations greater than 24 per minute.
  3. Apnea is the cessation of breathing lasting from a few seconds to a few minutes.
  4. The findings do not indicate atelectasis, which is alveolar or lung collapse.

Assessment

Application

Objective 11

Page 329 (Box 15.1)

Difficulty = 1

 

26) A nurse is preparing to percuss a clients chest. How should the nurse position the client for this assessment?

  • Ask the client to lean forward and round the shoulders.
  • Have the client raise his arms over his head and sit up straight.
  • Have the client stand for this portion of the examination.
  • Ask the client to flex the neck and extend arms on a bedside table.

 

26) 1

Explanation:

  1. This is the correct position.
  2. It is unnecessary for the client to raise his arms in the air. This position does not facilitate the assessment and it may be difficult for an older client to hold this position.
  3. This is unnecessary and in fact may make it difficult for the nurse to complete the assessment on a client much taller than the nurse.
  4. This is an over exaggeration of the correct assessment position.

Assessment

Application

Objective 5

Page 336

Difficulty = 2

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

27) A nurse is preparing to interview a client with asthma.  What topics should the nurse include during this interview to determine triggering factors?  (Select all that apply.)

_______ Workplace environment

_______ Presence of pets

_______ Age of onset

_______ Diet preferences

 

27)      ____X___ Workplace environment

____X___ Presence of pets

_________Age of onset

____X___ Diet preferences

 

Explanation:

Factors affecting a clients respiratory status and especially a client with asthma include exposure to chemicals, fumes, and textile fibers that may trigger respiratory compromise. Pet dander and some foods will also contribute to respiratory changes. Age of onset is not vital to identify triggering factors.

Assessment

Application

Objective 4

Page 323 and 348

Difficulty = 1

 

28) Draw an arrow to the area where tracheal breath sounds would be heard:

 

 

 

 

 

 

28)

Explanation:

Tracheal breath sounds are heard over the trachea when the client inhales and exhales.  They are harsh and high pitched.

Assessment

Comprehension

Objective 1

Page 345

Difficulty = 1

 

 

Chapter 27

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse notes edema in bilateral knees in an elderly client.  The client has complaints of joint stiffness and pain upon awakening.  What disorder would the nurse suspect based on this data?

1)   Rheumatoid arthritis

2)   Osteoarthritis

3)   Gouty arthritis

4)   Tendonitis

 

1)   2

Explanation:

  1. Rheumatoid arthritis produces the same symptoms, but is more likely to be seen in younger adults.
  2. Osteoarthritis causes swelling and joint deformity with early morning stiffness and pain.
  3. Heat, redness, swelling, and pain on movement of joints is an indication of gouty arthritis.
  4. These symptoms are not related to tendonitis.

Diagnosis

Analysis

Objective 8

Page 790

Difficulty 2

 

2)   A nurse is assessing deep tendon reflexes in an elderly client and notes that the brachial and patellar reflexes are 2+ bilaterally on the 0 to 4+ scale.  What would the nurse do next?

1)   Document the findings as normal

2)   Perform additional neurological assessments

3)   Inquire about the clients medication regimen

4)   Check past medical history

 

2)   1

Explanation:

  1. Reflexes normally diminish with aging; therefore no additional subjective or objective data is required at this time.
  2. This is not necessary because diminished reflexes are part of the normal aging process.
  3. The diminished reflexes are a normal finding; therefore a review of the medications is not required.
  4. Unnecessary with a normal assessment finding

Assessment

Application

Objective 7

Page 792

Difficulty 1

 

 

3)   A nurse is interviewing an elderly client who is concerned about bumps on my body.  Moist, brownish, wart-like lesions are noted on the clients neck and chest.  What condition would the nurse suspect?

1)   Actinic keratoses

2)   Acrochordons

3)   Seborrheic keratoses

4)   Cherry angiomas

 

3)   3

Explanation:

  1. Actinic keratoses are normal aging growths that are red, yellow, or flesh-colored plaques appearing on exposed areas such as ears, cheeks, lips, nose, upper extremities, or balding scalp.
  2. Acrochordons, also called skin tags, are pedunculated, flesh-colored lesions that occur on the neck, back, axillary area, and eyelids.
  3. Seborrheic keratoses are benign, greasy, wart-like lesions that are yellow-brown in color. They commonly appear of the neck, chest, and back.
  4. Cherry angiomas are vascular lesions that produce tiny, red spots usually on the trunk.

Diagnosis

Analysis

Objective 6

Page 796

Difficulty 2

 

4)   A nurse is examining the oral cavity of an elderly client with concerns of mouth soreness.  Red, cracked skin is noted at each corner of the mouth.  How should the nurse document this finding?

1)   Periodontal disease

2)   Herpes infection

3)   Cheilitis

4)   Dehydration

 

4)   3

Explanation:

  1. Periodontal disease presents with redness, spongy swelling of the gums, and recession of the gums from the teeth.
  2. Herpetic infections cause vesicular lesions.
  3. Cheilitis, also called angular stomatitis, is seen in persons with poorly fitting dentures, or persons who are not swallowing saliva well due to stroke or muscular weakness, and can also be caused by candida infection.
  4. A dry, red tongue with longitudinal furrows indicates dehydration.

Diagnosis

Analysis

Objective 9

Page 796

Difficulty 1

 

 

5)   A nurse is presenting information on the wear -and -tear theory of aging to her colleagues. What statement is consistent with this theory?

  • Longevity and healthy aging is due to the chromosomal differences between people.
  • Strands of DNA that should remain separate are linked together causing cell death.
  • Highly reactive molecules damage cellular components but antioxidants can neutralize these effects.
  • Healthy behaviours have a positive effect by protecting cells and allowing cells to repair themselves.

 

5) 4

Explanation:

  1. This is the genetic theory of aging.
  2. This is the cross-linkage theory.
  3. This describes the free radical theory.
  4. This is the wear-and-tear theory.

Assessment

Knowledge

Objective 1

Page 768

Difficulty 2

 

6)   A nurse is interviewing Mr. Douglas, 78 years old, who reports painful sores that start on the left side of his back and cross over to the left side of his abdomen.  What condition would the nurse suspect?

1)   Ecchymoses

2)   Purpura

3)   Petechiae

4)   Herpes zoster

 

6)   4

Explanation:

  1. Ecchymoses is bruising.
  2. Purpura is latin for purple. Purpura is caused by bleeding underneath the skin resulting in red or purple discolourations on the skin.
  3. Petechiae are small pin point bruises.
  4. Herpes zoster, also commonly called shingles, yields painful, red, vesicular or pustular lesions that may be in a line or in patches on the thorax, front or back.

Diagnosis

Analysis

Objective 6

Page 782

Difficulty 1

 

7)   A nurse is examining the eyes of an elderly client using the ophthalmoscope.  The vessels of the eyes are narrow and straight in appearance.  What would the nurse do next?

1)   Document the findings as normal

2)   Observe the red reflex

3)   Repeat the visual screening test

4)   Obtain an ophthalmology referral

 

7)   1

Explanation:

  1. Age related changes in the eyes include narrower and straighter vessels, which should be documented as normal.
  2. No additional assessments are required because this is a normal finding in the elderly.
  3. The vessels of the eye are normal; therefore, vision screening is unnecessary.
  4. A physician referral is not necessary at this time.

Diagnosis

Application

Objective 7

Page 785

Difficulty 2

 

8)   A nurse is examining the eyes of an elderly client using the ophthalmoscope.  The vessels of the eyes are narrow and tapered in appearance.  What would the nurse do next?

1)   Inquire about a history of diabetes

2)   Document the findings as normal

3)   Check for past history of hypertension

4)   Assess PERRLA

 

8)   3

Explanation:

  1. The vessels in diabetic retinopathy display small, red spots or creamy, round lesions that indicate punctate hemorrhages.
  2. This finding is not a normal finding.
  3. Narrowing and tapering of the arterioles are abnormal findings and are seen in hypertensive disease; thus the nurse must obtain additional information about previous disease and/or compliance with prescribed regimen.
  4. The assessment of PERRLA is used to evaluate changes in intracranial pressure; therefore, this is unnecessary at this time.

Diagnosis

Analysis

Objective 6

Page 785

Difficulty 2

 

9)  The daughter of an elderly client reports that her father has a decrease in hearing ability.  The nurse suspects a conductive hearing loss due to the presence of dried cerumen in the ear canal.  How would the nurse validate this finding?

1)   Examine the external ear

2)   Perform the Weber test

3)   Perform the Rinne test

4)   Complete the whisper test

 

 

9)   2

Explanation:

  1. Cerumen cannot always be visualized by external ear examination.
  2. Excessive cerumen may cause a conductive hearing loss in the elderly due to dryness and inability to remove the cerumen properly. The Weber test can validate this finding by showing sound lateralizing to the good ear or equal in both ears if hearing is diminished bilaterally.
  3. The Rinne test is used to validate sensorineural hearing loss, which normally demonstrates that air conduction is greater than bone conduction.
  4. Performing the whisper test is not a relevant action at this time.

Diagnosis

Analysis

Objective 5

Page 785 and 786

Difficulty 3

 

10) A nurse is interviewing an elderly client who reports mouth dryness and tunnels on the tongue.  What condition would the nurse suspect?

1)   Fungal infection

2)   Vitamin deficiency

3)   Leukoplakia

4)   Dehydration

 

10) 4

Explanation:

  1. A dark red, swollen tongue with white or yellow patches is a sign of a fungal infection, commonly experienced after antibiotic administration in the elderly.
  2. A bright red tongue may be indicative of vitamin B1 or C deficiency.
  3. Leukoplakia, thickened white patches in the mouth, is caused by irritations, such as poor-fitting dentures or tobacco products.
  4. A dry red tongue with longitudinal furrows may indicate dehydration in the elderly.

Diagnosis

Analysis

Objective 6

Page 783

Difficulty 3

 

11) A nurse is interviewing an elderly client and notes several soft, yellow plaques on the eyelids at the inner canthus.  What term would be used to document this finding?

1)   Xanthelasma

2)   Pterygium

3)   Presbyopia

4)   Pingueculae

 

11) 1

Explanation:

  1. Xanthelasma are soft, yellow plaques on the lids at the inner canthus and are a part of normal aging, not related to vision or eye problems.
  2. Pterygium is an opacity of the bulbar conjunctiva that can grow over the cornea and block vision.
  3. Presbyopia is nearsighted vision due to lens changes.
  4. Pingueculae are yellowish nodules that are thickened areas of the bulbar conjunctiva caused by prolonged exposure to sun, wind, and dust.

Diagnosis

Application

Objective 9

Page 770 and 796

Difficulty 2

 

12) A client, 68 years old, tells a nurse that he is experiencing erectile dysfunction since starting on a new medication. The nurse reviews the clients medication profile. What drug classification has the most potential to cause this problem?

1)   Antidepressant

2)   Analgesic

3)   Antiarrhythmic

4)   Anti-inflammatory

 

12) 1

Explanation:

  1. Antidepressants such as serotonin reuptake inhibitors, monoamine oxidase inhibitors, and tricyclic antidepressants all have erectile dysfunction as a side effect.
  2. Analgesics are not known to have this side effect.
  3. A beta blocker, antihypertensive can cause erectile dysfunction but antiarrhythmics do not.
  4. Anti-inflammatory medications do not have this side effect.

Evaluation

Analysis

Objective 8

Page 774

Difficulty 2

 

13) A nurse is assessing the vital signs of an elderly client and obtains a temperature of 36 degrees celsius.  What action would the nurse take?

1)   Provide warm fluids to the client

2)   Ask the client if the room is too cold

3)   Document the finding as normal

4)   Apply warm blankets to the client

 

13) 3

Explanation:

  1. The clients temperature is normal so this is an unnecessary action.
  2. The nurse wants to ensure that the examination room temperature is comfortable but the client body temperature is normal so there is no need to alter the room temperature.
  3. The body temperature in older adults is lower than those of younger clients. The mean temperature is 36.2 degrees celsius. The temperature described is within normal limits for an elderly client and requires no further assessments or interventions by the nurse.
  4. The client does not require blankets because the temperature is normal.

Diagnosis

Application

Objective 3

Page 781

Difficulty 1

 

14) A nurse hears a bruit when auscultating the right carotid artery of an elderly client.  What would the nurse do next?

1)   Obtain a surgical consult

2)   Assess for jugular vein distention

3)   Document the findings as normal

4)   Auscultate the heart for murmurs

 

14) 4

Explanation:

  1. Further assessment is not required and a physician is responsible for making referrals to medical specialists.
  2. Assessment of jugular vein distention is not relevant at this time
  3. A bruit is not a normal finding.
  4. Bruits are abnormal signs of carotid stenosis and may signal an impending stroke. If a bruit is heard, auscultation of the aortic and pulmonic valves of the heart should be done to assess for murmurs that may be radiating into the neck.

Diagnosis

Analysis

Objective 6

Page 784

Difficulty 1

 

15) A nurse is assessing an elderly client who reports a chronic cough.  Upon auscultation, crackles are detected bilaterally in both lower lobes.  These sounds do not clear when asked to cough.  What condition would the nurse suspect?

1)   Pneumonia

2)   Emphysema

3)   Pulmonary fibrosis

4)   Pulmonary edema

 

15) 4

Explanation:

  1. Scattered or discrete rales can be due to alveolar or small airway exudates.
  2. Emphysema produces diminished breath sounds.
  3. Course, loud rales may be signs of pulmonary fibrosis, seen in people with long-standing lung disease.
  4. Crackles that extend upward and do not clear with cough suggest pulmonary edema.

Diagnosis

Analysis

Objective 6

Page 786

Difficulty 2

 

 

16) A nurse is performing an assessment on a 70-year-old client.  The nurse notes that there is cupping of the optic disc and the eyeballs are rock hard. What condition would the nurse suspect?

1)   Cataracts

2)   Glaucoma

3)   Hypertension

4)   Diabetic retinopathy

 

16) 2

Explanation:

  1. Cataracts would present with black spots in the red reflex and cloudiness over the iris and pupil.
  2. Cupping of the disc and rock hard orbits are indicators of glaucoma.
  3. Narrowing and tapering of the arterioles occurs with hypertensive disease.
  4. Small red spots (punctate hemorrhages) or creamy round lesions (exudate) are seen in diabetic retinopathy.

Assessment

Application

Objective 6

Page 785

Difficulty 2

 

17) During a health teaching session with Mrs. Samuelsson, who has no natural teeth, the nurse recommends that the client make an appointment with a dentist for a routine check up.  The client asks the nurse why this is important since she has no teeth.  What statement by the nurse is most appropriate?

1)   It is important to assess you for mouth cancer.

2)   Although you do not have natural teeth, you are still at risk for disorders affecting the gums.

3)   You will need to be evaluated for dentures.

4)   You are probably right, no dental care is needed.

 

17) 2

Explanation:

  1. There are no indications the client is at a heightened risk of oral cancer.
  2. The client without natural teeth is still at risk for gingivitis and periodontal disease. It is important for clients without teeth to have regular dental care.
  3. Although the client may benefit from dentures, it is not the primary reason for recommending dental care.
  4. This is an inappropriate response because the client does need to see a dentist.

Implementation

Analysis

Objective 4

Page 770

Difficulty 1

 

18) During a routine physical examination, a 66-year-old client reports feeling tired.  She asks what is wrong with her.  What is the best initial action by the nurse?

1)   Encourage the client to alter their evening routine to reduce stressors.

2)   Encourage the client to begin to take a short nap each day.

3)   Assess the clients sleep patterns.

4)   Ask the physician to prescribe a sleeping pill.

 

18) 3

Explanation:

  1. Although changes in the evening routine may be helpful, there is inadequate information to make that recommendation.
  2. Not all clients are candidates for napping.
  3. The clients sleep habits will need to be investigated. If they are inadequate, action will be warranted.
  4. It is inappropriate for the nurse to make recommendations to the physician concerning a prescription when the nurse has not completed an assessment of the clients sleep habits..

Assessment

Analysis

Objective 4

Page 773

Difficulty 1

 

20) Mr. Basso who has a lengthy history of arthritis, reports to the physicians office for a routine physical examination.  Mr. Basso reports his skin has become fragile and has experienced skin tears with little trauma inflicted.  Which statement by the nurse is most appropriate?

1)   Tell me what medications you are taking.

2)   There is nothing you can do for this problem.

3)   You may not have been aware of the amount of stress the skin was under when it became injured.

4)   The skin changes you report are a normal part of aging.

 

20) 1

Explanation:

  1. The elderly client who has a history of arthritis may be taking corticosteroids. Long term use of corticosteroids is associated with tearing and bruising of the skin.
  2. It is not appropriate for the nurse to dismiss the clients concerns.
  3. It is not appropriate for the nurse to dismiss the clients concerns.
  4. Although the skin becomes increasingly fragile with aging, the clients complaints must still be evaluated.

Diagnosis

Analysis

Objective 6

Page 782

Difficulty 2

 

21) A 76-year-old client presents to the ambulatory care clinic with concerns consistent with influenza.  During the interaction, the nurse notes the client appears unkempt.  The clients hair is uncombed and the clothing appears too large.  What would the nurse do next?

1)   Document the findings.

2)   Engage the client in a discussion regarding dietary practices.

3)   Contact social services.

4)   Report the findings to the physician.

 

21) 2

Explanation:

  1. The findings must be documented but should be done after the interaction is finished.
  2. The client who appears dishevelled may be experiencing periods of altered cognition. Baggy clothing may be reflective of recent weight loss.  Obtaining information needed to assess for these problems can best be assessed by conversation between the client and nurse.
  3. There is no evidence at this point that social services needs to be involved.
  4. There is no need to consult with the physician at this juncture of the interaction.

Assessment

Analysis

Objective 4

Page 771 and 782

Difficulty 1

 

22) A 76-year-old client, presents with a tremor associated with Parkinsons disease. How would the nurse document this tremor?

1)   Head bobbing consistent with a senile tremor

2)   A resting tremor

3)   Dystonia

4)   A pin-rolling tremor of the hand

 

22) 4

Explanation:

  1. This is not a tremor associated with Parkinsons disease.
  2. A resting tremor diminishes with a willed movement whereas in Parkinsons disease the tremor worsens with purposeful movement.
  3. Dystonia has sustained muscle contractions that cause twisting and repetitive movements or postures.
  4. The classic tremor in Parkinsons is called pin-rolling.

Assessment

Analysis

Objective 9

Page 791

Difficulty 2

 

23) A client reports to the Emergency Room with concerns consistent with a fractured hip.  The client reports sitting down on the toilet seat and feeling the bone snap.  The client asks how this could have happened.  What information can be provided by the nurse?

1)   You should discuss this with your physician.

2)   There is no good explanation for what has happened to you.

3)   Unfortunately, this may signal a serious underlying health problem.

4)   The bodys bones become increasingly brittle and lose density with aging.

 

23) 4

Explanation:

  1. Although the client should be encouraged to speak with the physician, the nurse should attempt to meet the clients needs for immediate education.
  2. This is not a helpful statement and may increase the clients anxiety about what happened.
  3. The clients fracture may simply be a normal adverse effect associated with aging.
  4. The bodys bones have an increasing loss of density with aging. It is related in part to hormone levels.  Fractures can result with little stress.

Implementation

Application

Objective 2

Page 774

Difficulty 1

 

24) A client who is seen in the clinic for a routine blood pressure assessment states they have been experiencing the normal pain associated with aging.  What statement by the nurse is most therapeutic?

1)   Normal aging can be quite painful.

2)   Tell me more about your pain and discomfort.

3)   Do you take medications for the discomfort you are experiencing?

4)   You must have osteoarthritis.

 

24) 2

Explanation:

  1. Normal aging does not have to be filled with pain
  2. Reports of pain should never be dismissed as a normal part of aging. The pain reports made by a client need to be investigated.  The nurse will need to ask an open-ended question to obtain additional assessment data.
  3. Asking about pharmacological therapies being utilized to manage a condition is a part of the assessment; however, it is closed-ended question and will not provide the most information.
  4. It is inappropriate and beyond the scope of practice of the nurse to make a diagnosis.

Assessment

Analysis

Objective 4

Page 775 and 778

Difficulty 1

 

25) A nurse notes a faint murmur while auscultating Mr. Carlsons apical pulse. He is 66 years old and reports no history of heart problems.  Which statement is most correct?

1)   Mr. Carlson is presenting with the normal changes of aging

2)   The client had an underlying heart disorder

3)   The client has clinical manifestations associated with aortic calcifications

4)   The client is demonstrating mitral calcifications

 

25) 1

Explanation:

  1. Faint murmurs are common in older clients. They are related to decreased cardiac muscle tone.
  2. Loud murmurs are associated with underlying cardiac disease.
  3. Clicks and snaps are associated with aortic calcifications.
  4. When a calcified mitral valve opens the nurse will hear a click or snap not a murmur.

Diagnosis

Analysis

Objective 3

Page 787

Difficulty 2

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

26) A nurse is discharging a client with stress incontinence.  The nurse would correctly include which of the following management techniques in the teaching plan?  (Select all that apply.)

1)   Perform pelvic muscle exercises

2)   Limit fluid intake to four glasses a day

3)   Void on a regular schedule

4)   Maintain an ideal body weight

 

5)   1, 3, 4

Explanation:

  1. Loss of muscle tone and stretching of the perineal muscles through childbirth are contributing factors to stress incontinence. Performing pelvic muscle exercises will help to improve muscle tone.
  2. Fluid intake should include eight to ten glasses of non-caffeinated fluid a day, limiting intake only in the evening hours.
  3. Voiding on a regular schedule will help to keep the bladder empty and prevent urine leakage.
  4. Obesity is a contributing factor to stress incontinence.

Implementation

Analysis

Objective 2

Page 773

Difficulty 1

 

27) A nurse is planning an educational program for new nurses regarding health care needs for the elderly.  What should be included in the nurses planning?  (Select all that apply.)

1)   Depression is a common problem for the elderly.

2)   Pneumonia is a significant health issue for older adults.

3)   Falls are the most common type of injuries experienced by older adults.

4)   Influenza vaccines should be given to most elderly clients.

 

27)      1, 2, 3, 4

Explanation:

  1. Depression is often related to the presence of serious health disorders, financial concerns, and isolation. Depression is a major concern with older adults
  2. Pneumonia has a significant impact on morbidity and mortality in the older adult.
  3. Falls are the most common injuries for older adults and represents a significant safety issue
  4. Influenza vaccines are recommended for the majority of older adults.

Planning

Application

Objective 2

Page 778, 774, and 770

Difficulty 1

 

 

 

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