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Jarvis Final Exam Review

Review for Exam

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Health Assessment-Wellness Promotion For The Generic Program (NURS 204)

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York College CUNY

Academic year: 2020/2021

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Technische Universiteit Delft

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Jarvis hesi 125 Final

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Health Assessment (Final Exam Review;

Jarvis 6th Ed.)

1. A 45-year-old mother of two children is seen at the clinic for complaints of

"losing my urine when I sneeze." The nurse documents that she is

experiencing:

A. enuresis. B. stress incontinence. C. urinary frequency. D. urge incontinence.

2. A 70-year-old patient tells the nurse that he has noticed that he is having

trouble hearing, especially in large groups. He says he "can't always tell

where the sound is coming from" and the words often sound "mixed up."

What might the nurse suspect as the cause for this change?

A. Cilia becoming coarse and stiff B. Nerve degeneration in the inner ear C. Scarring of the tympanic membrane D. Atrophy of the apocrine glands

3. A 70-year-old woman tells the nurse that every time she gets up in the

morning or after she's been sitting she gets "really dizzy" and feels like she is

going to fall over. The nurse's best response would be:

A. "I'll refer you for a complete neurologic examination." B. "Have you been extremely tired lately?" C. "You need to get up slowly when you've been lying or sitting." D. "You probably just need to drink more liquids."

4. A nurse notices that a patient has ascites, which indicates the presence of:

A. flatus. B. feces.

C. fibroid tumors. D. fluid.

5. A patient has been admitted to the hospital with vertebral fractures related

to osteoporosis. She is in extreme pain. This type of pain would be classified

as:

A. deep somatic. B. visceral. C. cutaneous. D. referred.

6. A patient has had three pregnancies and two live births. The nurse would

record this information as gravida ___, para _, AB ___.

A. 3; 2; 1

B. 2; 2; 1

C. 3; 2; 0

D. 3; 3; 1

7. A patient is unable to differentiate between sharp and dull stimulation to

both sides of her face. The nurse suspects:

A. scleroderma. B. Bell's palsy. C. damage to the trigeminal nerve. D. frostbite with resultant paresthesia to the cheeks.

8. A patient states that the pain medication is "not working" and rates his

postoperative pain at a 10 on a 1 to 10 scale. Which of these assessment

findings indicates an acute pain response to poorly controlled pain?

A. Increased blood pressure and pulse B. Confusion C. Hyperventilation D. Depression

D. any unusual vaginal discharge or itching?"

13. After completing an assessment of a 60-year-old man with a family history

of colon cancer, the nurse discusses with him early detection measures for

colon cancer. The nurse should mention the need for a(n):

A. annual proctoscopy. B. colonoscopy every 10 years. C. fecal test for blood every 6 months. D. digital rectal examinations every 2 years.

14. An 85-year-old patient comments during his annual physical that he seems

to be getting shorter as he ages. The nurse should explain that decreased

height occurs with aging because:

A. there is a significant loss of subcutaneous fat. B. there is a thickening of the intervertebral disks. C. of the shortening of the vertebral column. D. long bones tend to shorten with age.

15. During a breast health interview, a patient states that she has noticed pain

in her left breast. The nurse's most appropriate response to this would be:

A. "I would like some more information about the pain in your left breast." B. "Don't worry about the pain; breast cancer is not painful." C. "Breast pain is almost always the result of benign breast disease." D. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct."

16. During an examination the nurse observes a female patient's vestibule and

expects to see the:

A. paraurethral (Skene) and vestibular (Bartholin) glands. B. urethral meatus and vaginal orifice. C. vaginal orifice and vestibular (Bartholin) glands. D. urethral meatus and paraurethral (Skene) glands.

17. During ocular examinations, the nurse keeps in mind that movement of

the extraocular muscles is:

A. decreased in the elderly. B. stimulated by cranial nerves I and II. C. stimulated by cranial nerves III, IV, and VI. D. impaired in a patient with cataracts.

18. Fibrous bands running directly from one bone to another that strengthen

the joint and help prevent movement in undesirable directions are called:

A. tendons. B. ligaments. C. bursa. D. cartilage.

19. In assessing the tonsils of a 30-year-old, the nurse notices that they are

involuted, granular in appearance, and appear to have deep crypts. What is

correct response to these findings?

A. Nothing, because this is the appearance of normal tonsils. B. Obtain a throat culture on the patient for possible strep infection. C. Refer the patient to a throat specialist. D. Continue with assessment looking for any other abnormal findings.

20. In performing a breast examination, the nurse knows that it is especially

important to examine the upper outer quadrant of the breast. The reason for

this is that the upper outer quadrant is:

A. the largest quadrant of the breast. B. where most of the suspensory ligaments attach. C. more prone to injury and calcifications than other locations in the breast. D. the location of most breast tumors.

21. In performing an assessment of a woman's axillary lymph system, the

nurse should assess which of these nodes?

A. Lateral, pectoral, axillary, and suprascapular nodes B. Central, lateral, pectoral, and subscapular nodes C. Pectoral, lateral, anterior, and sternal nodes

B. Consider this a delayed capillary refill time and investigate further. C. Consider this a normal capillary refill time that requires no further assessment. D. Ask the patient about a past history of frostbite.

27. The nurse is performing an examination of the anus and rectum. Which of

these statements is correct and important to remember during this

examination?

A. There are no sensory nerves in the anal canal or rectum. B. The rectum is about 8 cm long. C. Above the anal canal, the rectum turns anteriorly. D. The anorectal junction cannot be palpated.

28. The nurse is preparing to assess a patient's abdomen by palpation. How

should the nurse proceed?

A. Quickly palpate a tender area to avoid any discomfort that the patient may experience. B. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. C. Avoid palpation of reported "tender" areas because this may cause the patient pain. D. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths.

29. The nurse is preparing to perform a physical assessment. Which statement

is true about the inspection phase of the physical assessment?

A. Inspection requires a quick glance at the patient's body systems before proceeding on with palpation. B. Inspection takes time and reveals a surprising amount of information. C. Inspection may be somewhat uncomfortable for the expert practitioner. D. Inspection usually yields little information.

30. The nurse is preparing to use an otoscope for an examination. Which

statement is true regarding the otoscope? The otoscope:

A. is often used to direct light onto the sinuses. B. uses a short, broad speculum to help visualize the ear. C. is used to examine the structures of the internal ear.

D. directs light into the ear canal and onto the tympanic membrane.

31. The nurse is reviewing statistics regarding breast cancer. Which woman,

aged 40 years in the United States, has the highest risk for development of

breast cancer?

A. African-American B. Asian C. White D. American Indian

32. The nurse is reviewing the blood supply to the arm. The major artery

supplying the arm is the _____ artery.

A. ulnar B. deep palmar C. brachial D. radial

33. The nurse is reviewing venous blood flow patterns. Which of these

statements best describes the mechanism(s) by which venous blood returns to

the heart?

A. Intraluminal valves ensure unidirectional flow toward the heart. B. The high-pressure system of the heart helps to facilitate venous return. C. Contracting skeletal muscles milk blood distally toward the veins. D. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

34. The nurse is teaching a pregnant woman about breast milk. Which

statement by the nurse is correct?

A. "Your breast milk is present immediately after delivery of the baby." B. "Breast milk is rich in protein and sugars (lactose) but has very little fat." C. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."

D. support systems.

39. The nurse needs to pull the portion of the ear that consists of movable

cartilage and skin down and back when administering eardrops. This portion

of the ear is called the:

A. outer meatus. B. auricle. C. concha. D. mastoid process.

40. The nurse notices that a patient's palpebral fissures are not symmetrical.

On examination, the nurse may find that there has been damage to cranial

nerve:

A. V.

B. VIII.

C. VII.

D. III.

41. The primary purpose of the ciliated mucous membrane in the nose is to:

A. filter coarse particles from inhaled air. B. warm the inhaled air. C. filter out dust and bacteria. D. facilitate movement of air through the nares.

42. When assessing a 75-year-old patient who has asthma, the nurse notes that

he assumes a tripod position, leaning forward with arms braced on the chair.

Based on this observation, the nurse should:

A. recognize that a tripod position is often used when a patient is having respiratory difficulties. B. assume that the patient is eager and interested in participating in the interview. C. assume that the patient is having difficulty breathing and assist him to a supine position. D. evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.

43. When assessing the force, or strength, of a pulse, the nurse recalls that it:

A. demonstrates elasticity of the vessel wall.

B. is usually recorded on a 0- to 2-point scale. C. is a reflection of the heart's stroke volume. D. reflects the blood volume in the arteries during diastole.

44. When assessing the quality of a patient's pain, the nurse should ask which

question?

A. "Is it a sharp pain or dull pain?" B. "When did the pain start?" C. "What does your pain feel like?" D. "Is the pain a stabbing pain?"

45. When beginning to assess a person's spirituality, which question by the

nurse would be most appropriate?

A. "Do you believe in God?" B. "How does your spirituality relate to your health care decisions?" C. "Do you believe in the power of prayer?" D. "What religious faith do you follow?"

46. When examining a patient's eyes, the nurse recalls that stimulation of the

sympathetic branch of the autonomic nervous system:

A. causes contraction of the ciliary body. B. adjusts the eye for near vision. C. elevates the eyelid and dilates the pupil. D. causes pupillary constriction.

47. Which of the following statements is true regarding the internal structures

of the breast? The breast is:

A. composed mostly of milk ducts, known as lactiferous ducts. B. composed of glandular tissue, which supports the breast by attaching to the chest wall. C. mainly muscle, with very little fibrous tissue. D. composed of fibrous, glandular, and adipose tissue.

48. Which of these statements concerning areas of the brain is true?

A. Motor pathways of the spinal cord and brainstem synapse in the thalamus. B. The hypothalamus controls temperature and regulates sleep.

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