Nursing Health Assessment and Pain Practice Quiz 2

Answer: B – Buccal cyanosis and capillary refill greater than 3 seconds

Explanation: Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased oxygen to the tissues, which requires immediate intervention. Alert and oriented, clear breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte count of 5,300/mm3 are normal data.

Answer: C – Promotive, preventive, and restorative health practices

Explanation: The health-beliefs assessment includes expectations of health care; promotive, preventive, and restorative practices, such as breast self-examination, testicular examination, and seat-belt use; and how the client perceives illness. Use of medications provides information about the client’s personal habits. Educational level, financial status, and family role and relationship patterns represent information associated with role and relationship patterns.

Answer: D – Location of an advance directive

Explanation: Biographic information may include name, address, gender, race, occupation, and location of a living will or a durable power of attorney for health care. The chief complaint, past health status, and history of immunizations are part of assessing the client’s health and illness patterns.

Answer: B – Resonance

Explanation: Normally, when percussing a client’s chest, percussion over the lungs reveals resonance, a hollow or loud, low-pitched sound of long duration. Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation. Hyperresonance would be evidenced by percussion over areas of overinflation such as an emphysematous lungs.

Answer: B – Serum potassium level of 3.1 mEq/L

Explanation: A normal potassium level is 3.5 to 5.5 mEq/L. A normal sodium level is 135 to 145 mEq/L, a normal nonfasting glucose level is 85 to 140 mg/dl, and a normal creatinine level is 0.2 to 0.8 mg/100 ml.

Answer: C – Inserting the otoscope superiorly into the proximal two-thirds of the external canal

Explanation: In the superior position, the speculum of the otoscope is nearest the tympanic membrane, and the most sensitive portion of the external canal is the proximal two-thirds. It is important to avoid these structures during the examination. Tipping the client’s head away from the examiner, pulling the ear up and back, inserting the otoscope inferiorly, and bracing the examiner’s hand against the client’s head are all appropriate techniques used during an otoscopic examination.

Answer: D – Palpating the pedal pulses

Explanation: Palpating the client’s pedal pulses assists in determining if arterial blood supply to the lower extremities is sufficient. Assessing the medial malleoli for pitting edema is appropriate for assessing venous function of the lower extremity. Allen’s test is used to evaluate arterial blood flow before inserting an arterial line in an upper extremity or obtaining arterial blood gases. Homans’ sign is used to evaluate the possibility of deep vein thrombosis.

Answer: D – Oral

Explanation: Gloves should be worn any time there is a risk of exposure to the client’s blood or body fluids. Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. Ophthalmic, breast, or integumentary examinations normally do not involve contact with the client’s body fluids and do not require the nurse to wear gloves for protection. However, if there are areas of skin breakdown or drainage, gloves should be used.

Answer: D – Standing close to provide support

Explanation: During Romberg’s test, the client is asked to stand with feet together and eyes shut and still maintain balance with the minimum of sway. If the client loses his balance, the nurse standing close to provide support, such as having an arm close around his shoulder, can prevent a fall. Allowing the client to keep his eyes open, spread his feet apart, or hang on to a piece of furniture interferes with the proper execution of the test and yields invalid results.

Answer: B – The tail of Spence area must be included in self-examination

Explanation: The tail of Spence, an extension of the upper outer quadrant of breast tissue, can develop breast tumors. This area must also be included in breast self-examination. One half of all women who die of breast cancer are older than age 65. The correct position for breast self-examination is not limited to the supine position; the sitting position with hands at sides, above head, and on the hips is also recommended. A pad is placed under the ipsilateral (e.g., same side) scapula of the breast being palpated.