Exam 2
Peripheral arterial disease ___ (more/less) prevalent in African Americans and ___ (greater/lower) in Asian Americans as compared with Whites.
Peripheral arterial disease more prevalent in African Americans and lower in Asian Americans as compared with Whites.
Page 15 of Peripheral Vascular slides
The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what?
A. Ankylosing spondylitis
B. Lordosis
C. Kyphosis
D. Scoliosis
C. Kyphosis
Kyphosis is an exaggerated thoracic curve and is common with aging. Scoliosis is lateral curvature of the thoracic spine with an increase in the convexity on the curved side. An exaggerated lumbar curve is lordosis. Ankylosing spondylitis is associated with a flattening of the lumbar curvature.
T/F Red marrow produces blood cells, platelet and most white blood cells.
True!
Page 5 Musculoskeletal Assessment slides
What type of assessment would a nurse perform on a client being admitted to the hospital?
A. Screening
B. Focused
C. Acute
D. Comprehensive
D. Comprehensive
The nurse in the hospital performs a comprehensive assessment of the client on admission. This assessment is more detailed and complete than screening and focused assessments that evaluate progress toward a goal later in the stay. "Acute" is not a term commonly used to describe a type of assessment.
Joints may be classified as cartilaginous, synovial, or
A. flexible
B. fibrous
C. articulate
D. immobile
B. fibrous
Page 7 Musculoskeletal Assessment slide
T/F Highest rate of venous insufficiency in the United States in White women.
True!
Page 15 of Peripheral Vascular slides
Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis?
A. Calcium
B. Protein
C. Vitamin D
D. Vitamin C
A. Calcium
A calcium deficiency increases the risk osteoporosis. This causes the bones to become softer in nature because the rate at which bone is destroyed is occurring at a faster rate than new bone is made. Protein functions in muscle tone and growth. Vitamin C promotes healing of tissues and bones. Vitamin D deficiency causes osteomalacia, softening of the bones due to defective bone mineralization. Osteomalacia in children is known as rickets.
Prostate enlargement is common in older men. The nurse should be aware of what signs and symptoms when interviewing an older male client? Select all that apply.
A. Sensation of residual urine
B. Straining to urinate
C. Dribbling
D. Increased caliber of urine stream
E. Chronic kidney infection
A.B.C not D or E
The location of the prostate gland can affect urine flow if the prostate becomes enlarged. The following are the signs of partial prostate obstruction: recurrent acute UTIs, the sensation of residual urine, decreased caliber of the urine stream, hesitancy, straining, and terminal dribbling.
A nurse has introduced herself to a new client and asked the client to accompany her to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client’s:
A. Level of consciousness
B. Judgment and Insight
C. Health maintenance
D. Coping skills
A. Level of consciousness
The client’s response to the nurse’s introduction and direction gives useful information about his or her level of consciousness. During this brief interaction, the nurse would be less able to determine the client’s judgment, insight, health maintenance or copings skills, though some elements of these may be evident.
A client visits the health care facility with reports of mild hearing loss. The nurse prepares to perform which test to compare bone and air conduction?
A. Rinnie
B. Audiometry
C. Whisper
D. Weber's
A. Rinnie
The nurse should perform Rinne test to compare between bone and air conduction in the client with mild hearing loss. Weber's test and audiometry are done to determine diminished hearing in one ear. The Whisper test is done to evaluate hearing.
With a client suspected of suffering from presbycusis, the nurse would expect difficulty hearing:
A. Full range of tones
B. High-pitched sounds
C. Low-pitched sounds
D. Medium-frequency sounds
B. High-pitched sounds
Presbycusis is associated with a loss of higher-tone hearing that makes it more difficult for older clients to discern speech.
The nurse should make it a priority to assess which client for papilledema?
A. an 80-year-old diagnosed with chronic open-angle glaucoma
B. a 45-year-old suspected of experiencing a subarachnoid hemorrhage
C. a 12-year-old demonstrating a deviated left eye
D. a 56-year-old reporting double vision
B. a 45-year-old suspected of experiencing a subarachnoid hemorrhage
- Papilledema often signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions.
The nurse is performing an assessment of a client’s nose and sinuses. What should the nurse include in the assessment? Select all that apply.
A. Inspect for symmetry, alignment, and deformity.
B. Palpate the frontal and maxillary sinuses.
C. Have the client identify one familiar scent.
D. Palpate for tenderness and patency.
E. Inspect the mucous membrane, septum, and turbinates.
A. B. C. D. not E. need to identify two different scents with eye closed.
A nurse is discussing breast self-examination (BSE) with a 60-year-old woman. Which of the following should the nurse recommend?
A. Perform BSE monthly, preferably a few days after menstruation.
B. Perform BSE quarterly, on the same day each month.
C. Avoid BSE as it's less effective after menopause.
D. Perform BSE annually during a routine check-up.
E. Perform BSE weekly for optimal detection accuracy.
B. Perform BSE quarterly, on the same day each month.
The nurse is preparing to assess a client’s reflexes. At which point during the assessment should this be completed?
A. after assessing the abdomen
B. after assessing the motor function of the lower extremities
C. after assessing cranial nerve function
D. after assessing the anterior and posterior thorax
B. after assessing the motor function of the lower extremities
Although many parts of the assessment can be completed at any time, assessment of the reflexes usually is completed after assessing the lower extremities and serves as a starting point for assessing neurologic functioning. Assessment of the reflexes would not occur after assessing the abdomen, cranial nerve function, or after assessing the anterior and posterior thorax.
Physiologic murmur is not associated with any physical abnormality: it occurs when the ejection of blood into the aorta is turbulent.
Bonus: What population is this more prevalent in and why?
False!
Turbulent or increased velocity of blood flow through a structure is what creates a murmur.
Page 41 Heart and Neck slides
Physiologic murmurs are more prevalent in younger populations, particularly children and adolescents. This is because their hearts are smaller and have faster blood flow rates, which can create turbulent flow even in the absence of heart disease.
The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents:
A. ptosis
B. ectropion
C. exophthalmos
D. entropion
D. entropion
D. entropion is the inward turning of the lower eyelid, which can cause the eyelashes and skin to rub against the eye surface, leading to irritation, redness, and discomfort. This condition is commonly seen in elderly individuals due to age-related changes in the eyelid structure and muscles.
Ptosis (option A) refers to drooping of the upper eyelid, not inward turning of the lower lid.
Ectropion (option B) is the outward turning of the lower eyelid, which is the opposite of what is described in the scenario.
Exophthalmos (option C) refers to protrusion of the eyeball, typically seen in conditions such as thyroid eye disease, not inward turning of the eyelid.
A nurse performs a focused assessment on a client who is reporting neck pain. The nurse observes the following findings: neck pain that increases with extension, fever, chills, and photophobia. The nurse suspects the client may be experiencing which of the following disorders?
A. bacterial meningitis
B. ankylosing spondylosis
C. acute gout
D. rheumatoid arthritis
A. bacterial meningitis
Choice B is is a flattening of the lumbosacral region of the spine.
Choice C is a condition that affects the small joints of the hands and the feet due to increased uric acid.
Choice D is a systemic disorder that affects bilateral joints.
The results of a client's Rinne test are as follows: bone conduction > air conduction. How should the nurse explain these findings to the client?
A. "You have a conductive hearing loss."
B. "You have loss of high frequency sounds."
C. "You have unilateral hearing loss"
A. "You have a conductive hearing loss."
The Rinne test tests for conductive hearing loss(Weber test measures both unilateral conductive and sensorineural hearing loss.) The client's results indicate that bone conduction is greater than air conduction which indicates conductive hearing loss. Air conduction should be twice as long as bone conduction. The whisper test evaluates loss of high frequency sounds. An audiogram can reveal a nerve related or unilateral hearing loss.
Focal neurological abnormalities are of particular concern in patients with sudden deafness. Loss of facial sensation and weak jaw clench suggest which of the following?
A. Meniere disease
B. A lesion of the 5th cranial nerve
C. Macroglobulinemia
D. A lesion of the 7th cranial nerve
Answer: B: A lesion of the 5th cranial nerve.
A 76-year-old female client's blood pressure is 132/76 in a supine position, 128/71 when dangling at the side of her bed, and 105/58 when she is standing. These assessment findings constitute a risk for which of the following health problems?
A. Stroke
B. Falls
C. Delirium
D. Peripheral vascular disease
B. Falls
Orthostatic hypotension, as demonstrated by the woman's positional changes in blood pressure, constitutes an increased risk of falls. It is not linking as closely with risk of CVA, PVD, or delirium.
A patient who sustained a traumatic brain injury has impaired consciousness, Glasgow Coma Scale score of < 15, focal neurologic findings, and suspected fracture. Which of the following is the most appropriate initial imaging step?
A. CT Scan
B. Magnetic resonance angiography
C. MRI
D. X-ray
Answer: A: CT scan. This imaging study is the best choice for initial evaluation of a patient with a traumatic brain injury because it can detect hematomas, contusions, and fractures.
T/F Tinel's sign is used during physical examination to diagnose carpal tunnel syndrome.
True!
Tinel and Phalen signs are most indicative of carpal tunnel syndrome.
Tinel sign is hitting the median nerve on the palm side and seeing if the hand begins to flex.
Phalen sign is when you place the dorsal palms of your hand against each other.
The presence of a skull fracture confirmed via imaging study is indicative that significant force was involved in the injury. Specific types of skull fractures can result in special risks to the patient. One of these risks includes damage to facial, acoustic, and vestibular nerve function. Fracture of which of the following structures will increase a patient’s risk of this type of damage?
A. Carotid canal
B. Parietal bone
C. Base of the occipital bone
D. Temporal bone
Answer: C: Base of the occipital bone. A basilar skull fracture (base of the occipital bone) may cause impairment of the facial, acoustic, and vestibular nerves.
Any new onset of incontinence in the frail elder should be investigated for:
A. prostatitis.
B. urinary tract infection.
C. fecal impaction.
D. medication side effects.
B. urinary tract infection.
Incontinence and confusion are often signs of infection in the frail older adult.
Choice A can cause urinary symptoms but not first consideration for prostatitis.
Choice C can cause bowel-related symptoms, less likely to be cause of new-onset urinary incontinence.
Choice D can cause urinary incontinence however in context of new onset incontinence UTI takes precedent.