1.The nurse is preparing to perform a physical assessment.
Which statement is true about the inspection phase of the
physical assessment?
a.
Inspection usually yields little information.
b.
Inspection takes time and reveals a surprising amount of
information.
c.
Inspection may be somewhat uncomfortable for the expert
practitioner.
d.
Inspection requires a quick glance at the patient's body systems
before proceeding on with palpation. Correct Answer B
A focused inspection takes time and yields a surprising amount
of information. Initially, the examiner may feel uncomfortable
"staring" at the person without also "doing something." A
focused assessment is much more than a "quick glance."
31. A patient with pleuritis has been admitted to the hospital and
complains of pain with breathing. What other key assessment
finding would the nurse expect to find upon auscultation?
a. Stridor
b. Friction rub
,c. Crackles
d. Wheezing Correct Answer B
A patient with pleuritis will exhibit a pleural friction rub upon
auscultation. This is the sound made when 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 with croup, acute
epiglottitis in children, and foreign body inhalation. Crackles are
associated with several diseases, such as pneumonia, heart
failure, chronic bronchitis, and others (see Table 18-6). Wheezes
are associated with diffuse airway obstruction caused by acute
asthma or chronic emphysema.
A 10-year-old is at the clinic for "a sore throat lasting 6 days."
The nurse is aware that which of these findings would be
consistent with an acute infection?
a. Tonsils 1+/1-4+ and pink, same color as oral mucosa
b. Tonsils 2+/1-4+ with small plugs of white debris
c. Tonsils 3+/1-4+ with large white spots
d. Tonsils 3+/1-4+ with pale coloring Correct Answer C
With an acute infection, tonsils are bright red and swollen and
may have exudate or large white spots. Tonsils are enlarged to
2+, 3+, or 4+ with an acute infection.
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?
a. Head injury
b. Cluster headache
,c. Migraine headache
d. Meningeal inflammation Correct Answer D
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.
A 2-week-old infant can fixate on an object but cannot follow a
light or bright toy. The nurse would:
a. consider this a normal finding.
b. assess the pupillary light reflex for possible blindness.
c. continue with the examination and assess visual fields.
d. expect that a 2-week-old infant should be able to fixate and
follow an object. Correct Answer A
By 2 to 4 weeks an infant can fixate on an object. By the age of
1 month, the infant should fix-ate and follow a bright light or
toy.
A 2-year-old child has been brought to the clinic for a well-child
check-up. The best way for the nurse to begin the assessment is
reflected by which statement?
a. Ask the parent to place the child on the examining table.
b. Have the parent remove all of the child's clothing before the
examination.
c. Allow the child to keep a security object such as a toy or
blanket during the examination.
d. Initially focus interactions on the child, essentially "ignoring"
the parent, until the child's trust has been obtained. Correct
Answer C
, The best place to examine the toddler is on the parent's lap.
Toddlers understand symbols, so a security object is helpful.
Initially, focus more on the parent. This allows the child to
gradually adjust and become familiar with you. A 2-year-old
child does not like to take off his or her clothes. Have the parent
undress one body part at a time.
A 25-year-old woman in her fifth month of pregnancy has a
blood pressure of 100/70 mm Hg. In reviewing her previous
exam, the nurse notes that her blood pressure in her second
month was 124/80 mm Hg. In evaluating this change, what does
the nurse know to be true?
a. This is the result of peripheral vasodilatation and is an
expected change.
b. Because of increased cardiac output, the blood pressure
should be higher this time.
c. This is not an expected finding because it would mean a
decreased cardiac output.
d. This would mean a decrease in circulating blood volume,
which is dangerous for the fetus. Correct Answer A
Despite the increased cardiac output, arterial blood pressure
decreases in pregnancy because of peripheral vasodilatation. The
blood pressure drops to its lowest point during the second
trimester and then rises after that.
A 30-year-old woman with a history of mitral valve problems
states that she has been "very tired." She has started waking up
at night and feels like her "heart is pounding." During the
assessment, the nurse palpates a thrill and lift at the fifth left
intercostal space midclavicular line. In the same area the nurse
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