Advanced physical assessment quiz 4
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.
Instruct...
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 Tinnitus is a sound that comes from within a person; it can be a ringing,
Explanation: 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 A simple increase in amplitude may not enable the person to understand
Explanation: 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
Instructor Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine
Explanation: 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 The epidermis is thin yet tough, replaced every 4 weeks, avascular, and
Explanation: 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 Finding one knee significantly lower than the other is a positive Allis sign
Explanation: 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 lethargic.
Answer:
obtunded.
stuporous.
semialert.
Instructor Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep
Explanation: 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 Low serum albumin levels may be caused by reasons other than
Explanation: 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 The knee is a hinge joint, permitting flexion and extension of the lower leg
Explanation: 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?
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