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Health Assessment Quizzes Exam 1

Terms in this set (50)

Which of the following would need to be present, in order to have a complete chain of infection? Select all that apply.

A. Agent
B. Reservoir
C. Portal of Exit
D. Mode of Transmission
E. Susceptible host
All of the above
You are teaching a student nurse how to protect a patient's skin when moving them in bed. You know that teaching has been effective when the student states which one of the following?

A. It is best to have as much surface area of the patient touching the bed as possible when you move them.
B. The patient's arms should not be placed over their chest when you move them in bed.
C. Friction is not harmful, and helps to move the patient into a better position.
D. Friction can be avoided if you place the arms at the side when moving a patient.
E. The more body surface area touching the bed, the more friction when you move the patient.
E
When washing the perineum of a female patient, which one of the following is correct?

A. Wash from front to back.
B. Wash from back to front.
C. It is irrelevant whether you wash from front to back or from back to front.
D. Wash from back to front but dry the skin from front to back.
A
When bathing an older adult patient, which one of the following is true?

A. It is important to use soap during each bath.
B. When giving a bath, do not assess skin; skin assessment is best done later.
C. Nurses should not delegate bathing to a nursing assistant.
D. Sometimes it is best to use water only, and apply lotion after drying the skin.
E. It is not necessary to dry the skin under breasts, as the moisture is good for dry skin.
D
What is the proper order of donning isolation gear?
Gown, mask/fitted respirator, face shield/goggles, gloves
As long as you wear gloves, you do not need to wash your hands after providing care to a patient.

True
False
False
Physician orders for physical restraints need to be renewed every 72 hours for each patient who needs restraints.

True
False
False
Failure to dry the skin well after a bed bath could result in rashes, skin infections, and decubitus ulcers.

True
False
True
What is the correct order of doffing isolation gear?
Gloves, gown, face shield/goggles, mask
Which of the following rules related to sterile technique are true? Select all that apply.

A. Sterile items touching sterile items remain sterile
B. Non-sterile touching sterile, results in a non-sterile field.
C. One inch around the outside of the sterile field is sterile.
D. The field should always be at waist height.
E. If you turn your back from the field, it is no longer considered sterile.
A, B, D, E
If you have a very small patient with thin arms, and you use a large BP cuff, you may find which of the following?

A. An erroneously high blood pressure.
B. An erroneously low blood pressure
C. No blood pressure
D. None of the above.
B
The first sound you hear when you are measuring blood pressure is the diastolic pressure.

True
False
False
Which of the following factors contribute to blood pressure?

A. Cardiac output
B. Volume of Korotkoff sounds
C. Peripheral Vascular resistance
D. Circulating Blood Volume
E. Blood Viscosity
A, C, D, E
The reason for estimating the systolic blood pressure by palpating for the pressure, is so that we don't miss a possible auscultatory gap.

True
False
True
Your patient seems to have an irregular radial pulse. Which of the following actions would be appropriate for you to complete? Select all that apply.

A. Check the radial pulse for 15 seconds and multiply by 4.
B. Check the apical pulse for one minute
C. Check the apical pulse for 30 seconds and multiply by 2.
D. Document that the radial pulse was irregular, and include as much information as you can about the nature of the irregularity.
E. Attempt to check the radial and apical at the same time to see if you can feel each beat peripherally as you lis
B, C, E
Which one of the following is true about the 5th Korotkoff sound?

A. It is the systolic Bp and is a clear, rhythmic sound.
B. It is the diastolic Bp, and is a clear, rhythmic sound.
C. It is a swishing or murmuring sound.
D. It is when the sounds muffle.
E. It is the diastolic Bp and is when the sounds disappear.
E
Which one of the following ranges are considered normal for adult respiratory rates?

A. 12-20
B. 15-30
C. 8-25
D. 30-40
E. 8-16
A
Which of the following temperatures are considered normal? Select all that apply.

A. 38 C
B. 96 F
C. 37C
D. 99 F
E. 35 C
C, D
Your patient has an apical pulse of 143. This condition is known as what?

A. Tachycardia
B. Bradycadia
C. Bradypnea
D. Tachypnea
E. Orthostatic Hypotension
A
Your patient's blood pressure is 146/96. What is her pulse pressure?

A. 146
B. 96
C. 50
D. 1.5
E. 242
B
What are some of the consequences of having pain? Select all that apply.

A. Sleep disturbances
B. Decreased Appetite
C. Impaired ambulation
D. Increased appetite
E. Decreased quality of life
A, B, C, E
In the rare instance where paper/pen charting are still being used, it is acceptable to white out an incorrect entry.

True
False
False
You are testing a patient's skin turgor and find tenting occurs. This means which one of the following?

A. They are likely dehydrated.
B. They are likely well hydrated.
C. They have good capillary refill.
D. They have poor capillary refill.
A
Communication using the SBAR method would include which one of the following?

A. S meaning subjective, or what the patient says
B. B meaning Biographical information, meaning about the patient
C. A meaning Assessment, that is, how they look right now
D. R meaning results of recent findings, vital signs, etc.
E. None of the above
C
Which of the following are physical signs of malnutrition? Select all that apply.

A. Swollen neck glands
B. Wounds or pressure sores
C. Muscle wasting
D. Edema
E. Transverse ridges on fingernail beds
All of the above
Which one of the following scales is best used with pediatric patients?

A. Numeric pain scale
B. Faces pain scale
C. Descriptor pain scales
D. The PAINad scale
B
When a nurse is assessing a patient's pain, and asks them how bad the pain is, Which one of the following are they assessing for?

A. Intensity
B. Quality
C. Onset
D. Duration
A
A small boned, short stature patient used to weigh 100 pounds and she is down to 68 pounds currently. Which one of the following best describes her current weight status?

A. Severely underweight
B. Moderately underweight
C. Mildly obese
D. Moderately obese
E. Normal weight
A
When using the SOAP note, "S" stands for which one of the following?

A. Subjective
B. Standard
C. Stable
D. Situation
A
Which of the following factors can influence food habits? Select all that apply.

A. Ethnicity
B. Culture
C. Increased income
D. Decreased income
E. Preferences, likes, and dislikes
All of the above
If a patient believes that human life is only one aspect of nature and part of the general order of the cosmos, and that forces must be kept in balance for harmony, they believe in what cause of illness?

A. Biomedical
B. Scientific
C. Naturalistic
D. Magico-religious
C
If a patient brings up his religion to the nurse, then it is professionally acceptable for the nurse to give her opinion within this religious discussion.

True
False
False
A patient states, "There is nothing I can do to help myself get better...it is what it is...God decides if we live or die, not me" This is an example of which one of the "Causes of illness" theories?

A. Biomedical
B. Scientific
C. Naturalistic
D. Magico-Religious
D
If a patient believes that supernatural forces dominate, and that one's fate depends of those forces, they believe in which cause of illness?

A. Biomedical
B. Scientific
C. Naturalistic
D. Magico-religious
D
When conducting a cultural assessment, which of the following components should be included in the assessment? Select all that apply.

A. Only the patient's race is needed for the cultural assessment.
B. Cultural beliefs, practices and values
C. Diet, fasting, and medication practices
D. Use of folk healers, folk remedies for medical issues
E. Family roles, religious figures and spiritual symbols
B, C, D, E
Which one of the following are true about the dietary laws that patients follow?

A. Dietary laws do not affect patients.
B. Some dietary laws are applicable at all times
C. Dietary laws are only in place during religious ceremonies.
D. All religious ceremonies include dietary laws.
B
A patient states that due to his culture, he must fast after 3 pm, and as such cannot take his medications. Which one of the following may be the best solution to this situation?

A. The nurse should work with the patient to determine if there is any negotiation around the time of the fast, and then the nurse should contact the physician to attempt to change the time of the medication regimen
B. The nurse should tell the patient that while his religion is important, his medications are more important and he really needs to take them on time.
C. The nurse should bring the patient his medications at the time they are due, and avoid his request to fast.
D. The nurse should document "refused medications:" in the record, and do nothing else until the fast is over.
E. The nurse should try to convince the patient that he should take the medications; if she cannot, then she should document that he refused and do nothing else for the moment.
A
Biomedical causes of illness are based on the assumption that all events in life have a cause/effect; the human body functions mechanically, and reality can be observed and measured.

True
False
True
Regarding spirituality, which of the following are true statements? Select all that apply.

A. Spirituality is solely a result of the person's religious practices.
B. Spirituality may include concern for the meaning of life
C. Spirituality may include a person's values
D. Spirituality may include concerns with one's self
E. Spirituality may includes a relationship with a higher spirit
B, C, D, E
The patient has understood the nursing education about using "My Plate" as a guide, if he repeats which one of the following statements?

A. Proteins should make up 50% of the plate
B. Grains should make up 50% of the plate
C. Fruits should make up 50% of the plate
D. Milk should be low fat
E. Vegetables should be 85% of the plate
D
Which of the following are functions of the skin? Select all that apply.

A. Protection
B. Temperature regulation
C. Wound repair
D. Excretion
E. Production of Vitamin C
A, B, C, D
Your patient has chicken pox, therefore you know that the type of lesions he has are which one of the following?

A. Macules
B. Papules
C. Vesicles
D. Pustules
E. Cysts
C
During a skin assessment, the patient states, "I itch so bad I could scream." This is considered which of the following?

A. Subjective data
B. Objective data
C. Unimportant in relation to the skin assessment
D. Part of the "plan" in your SOAP note
A
A lesion has a scalloped looking rough edge. This would be an abnormality in which of the letters of the ABCDEF rule?

A. A
B. B
C. C
D. D
E. E
B
When the lips or nail beds have a bluish hue, this is called what?

A. Cyanosis
B. Pallor
C. Jaundice
D. Ruddiness
E. Vitiligo
A
Zosteriform lesions are most likely which one of the following?

A. Measles
B. Ruebella
C. Shingles
D. Varicella
E. Purpura
C
A non-palpable lesion that is greater than 1 cm in size is known as which one of the following?

A. Macule
B. Papule
C. Nodule
D. Patch
E. Plaque
D
Upon skin inspection, you note the accumulation of fluid in intercellular spaces. This is known as what?

A. Poor turgor
B. Edema
C. Echymosis
D. Increased vascularity
E. Elevation
B
Which of the following are true regarding petechiae? Select all that apply

A. They are red/purple dots that do not blanch
B. They are spots that blanch when pressed
C. They are considered a rash
D. They are vascular lesions and indicate bleeding
E. They indicate the presence of carcinoma
A, D
Where is it best to assess for pallor of the skin?

Lips, finger nails, mucus membranes
Scalp
Toe nails and feet
Face
Anterior chest wall
A
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