Exam 2: Health Assessment

EXAM ASSESSMENT Q&A’S 2 HEALTH This exam pulls from information provided in the sources and is based on material found on or around a nursing student's second exam in a nursing program. Topics covered include neuro, HEENT, and the integumentary system. Neuro 1.A nurse is performing a neurological assessment on a patient. What is the correct sequence for the examination? a. b. c. d. Cranial nerves, mental status, motor system, sensory system, reflexes Mental status, cranial nerves, motor system, sensory system, reflexes Motor system, sensory system, cranial nerves, mental status, reflexes Reflexes, sensory system, motor system, cranial nerves, mental status Answer: B - The correct sequence for a complete neurologic examination is mental status, cranial nerves, motor system, sensory system, and reflexes. 2.A patient presents with a complaint of a severe headache that they have never had before. What should the nurse's priority action be? a. b. c. d. Administer an analgesic medication as ordered. Assess the patient’s neurological status. Ask the patient about the characteristics of their headache. Immediately refer the patient to the emergency department. Answer: D - A sudden onset of a severe headache, especially if the patient has never had one before, can be a sign of a serious medical condition such as a stroke or aneurysm. The patient should be referred to the emergency department immediately for further evaluation and treatment. 3.What is the most important factor in a neuro recheck? a. Vital signs b. Pupillary response c. Level of consciousness (LOC) d. Glasgow Coma Scale Answer: C - A change in LOC is the single most important factor in this examination. 4.Which cranial nerve is responsible for smell? a. CN I b. CN II c. CN V d. CN VII Answer: A - Cranial Nerve I, the olfactory nerve, is responsible for the sense of smell. 5.A nurse is testing a patient’s biceps reflex. What is the expected response? a. Extension of the forearm b. Flexion of the forearm c. Dorsiflexion of the foot d. Plantar flexion of the foot Answer: B - Striking the biceps tendon should cause contraction of the biceps muscle and flexion of the forearm. 6.Which of the following is not a component of the mental status examination? a. Appearance Page 1 of 10 EXAM ASSESSMENT Q&A’S 2 HEALTH b. Temperature c. Behavior d. Cognition Answer: B - Temperature is a vital sign and not a component of the mental status exam. The components are health history, appearance, behavior, cognition, and thought process. 7.The nurse is assessing a patient who has experienced a stroke. The patient is unable to speak clearly but seems to understand what the nurse is saying. What type of aphasia is this patient experiencing? a. b. c. d. Global aphasia Receptive aphasia Expressive aphasia Anomic aphasia Answer: C - Expressive aphasia is a neurological condition that affects a person's ability to speak fluently and to find the right words, despite having intact comprehension. This is also known as Broca's Aphasia. 8.A patient who is experiencing a stroke may have difficulty swallowing. What is the medical term for difficulty swallowing? a. b. c. d. Aphasia Dysarthria Dysphagia Aphagia Answer: C - Dysphagia is the medical term for difficulty swallowing. 9.A patient scores a 3 on the Glasgow Coma Scale. How would the nurse interpret this score? a. b. c. d. Mild head injury Moderate head injury Severe head injury Comatose Answer: C - A score of 3-8 on the Glasgow Coma Scale indicates a severe head injury. 10. The Mini-Mental State Exam (MMSE) is used to screen for what condition? a. Depression b. Delirium c. Dementia d. Anxiety Answer: C - The Mini-Mental State Exam (MMSE) is a valid detector of organic disease such as dementia, but lacks sensitivity to detect mild cognitive impairment. It is used to screen for cognitive impairment, most commonly associated with dementia. HEENT 1.Which of the following is a subjective finding related to the head? a. Head injury Page 2 of 10 EXAM ASSESSMENT Q&A’S 2 HEALTH b. Size of the skull c. Symmetry of the face d. Range of motion (ROM) of the neck Answer: A A head injury is a subjective finding because it is something that the patient reports to the nurse. The other options are objective findings that the nurse can observe or measure. 2.A nurse is assessing an older adult’s face. Which of the following findings is expected due to aging? a. b. c. d. Increased subcutaneous fat Increased skin elasticity Mouth appears smaller Facial bones and orbits appear more prominent Answer: D [15] In older adults, the facial bones and orbits appear more prominent, and the facial skin sags as a result of decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin. 3.Otosclerosis is a common cause of conductive hearing loss in which age group? a. b. c. d. Children Adolescents Young adults Older adults Answer: C - Otosclerosis is a cause of conductive hearing loss in young adults between the ages of 20 and 40 years. 4.A patient reports a sudden loss of vision. What should be the nurse’s initial action? a. b. c. d. Assess the patient’s visual acuity. Refer the patient to an ophthalmologist. Ask the patient about their medical history. Immediately refer the patient to the emergency department. Answer: D - Sudden vision loss is a medical emergency. The patient should be referred to the emergency department for immediate evaluation. 5.A nurse is assessing a patient's ears. What is the normal color of the tympanic membrane? a. b. c. d. Red White Yellow Pearly gray Answer: D - The normal tympanic membrane is shiny and translucent, with a pearl-gray color. 6.Which of the following is a risk factor for skin cancer? a. Dark skin pigmentation b. Family history of skin cancer c. Use of sunscreen d. Diet high in fruits and vegetables Answer: B - Risk factors for skin cancer are being male, UV radiation, a family history of skin cancer, atypical or numerous moles, natural blond or red hair, and the tendency to sunburn easily. 7.A patient with dementia may underreport pain because of which of the following reasons? a. They are not experiencing pain. b. They have a higher pain tolerance. Page 3 of 10 EXAM ASSESSMENT Q&A’S 2 HEALTH c. They cannot accurately communicate their pain. d. They do not want to bother the staff. Answer: C - With dementia, adults underreport pain due to ineffective self-reporting. 8.A nurse is performing the Weber test on a patient. What is an abnormal finding? a. Sound lateralizes to the good ear b. Sound is heard in both ears equally c. Sound lateralizes to the impaired ear d. Sound is heard longer in the impaired ear. Answer: C - During a Weber test, if sound lateralizes to the impaired ear, this indicates sensorineural hearing loss in the impaired ear. 9.A red flag for a patient with sinusitis is: a. b. c. d. Clear nasal discharge Pain that resolves on its own. Many sinus infections treated without antibiotics Facial pain that increases with palpation. Answer: C - Many UTIs or sinus infections treated without antibiotics could indicate a more serious problem. 10. Which of the following is an example of a primary skin lesion? a. Scale b. Erosion c. Wheal d. Ulcer Answer: C - A wheal is a primary skin lesion. The others are secondary skin lesions. Integumentary 1.What does clubbing of the nails indicate? a. b. c. d. Iron deficiency anemia b. Chronic hypoxia Fungal infection Psoriasis Answer: B - Clubbing of the nails is a sign of chronic hypoxia. 2.A patient presents with a painful, raised, red lesion that is filled with pus. What type of lesion is this? a. b. c. d. Macule Nodule Vesicle Pustule Answer: D A pustule is an elevated cavity that is circumscribed and elevated and filled with pus. 3.Which of the following are age-related changes of the integumentary system? a. Increased skin elasticity b. Increased subcutaneous fat Page 4 of 10 EXAM ASSESSMENT Q&A’S 2 HEALTH c. Increased sweat and sebaceous gland activity d. Increased risk for skin breakdown Answer: D Changes in the aging adult include skin color and pigmentation changes, decreased elasticity, decreased sweat and sebaceous glands, senile purpura, skin breakdown due to multiple factors, hair changes, hormone changes, and nail changes. 4.Which of the following is a secondary skin lesion? a. b. c. d. Papule Tumor Scar Nodule Answer: C A scar is an example of a secondary skin lesion. 5.What is the medical term for a solid, raised lesion that is less than 1 cm in diameter? a. b. c. d. Macule Papule Plaque Nodule Answer: B - A papule is a solid, raised lesion that is less than 1 cm in diameter. 6.The nurse is assessing a patient’s skin. The nurse notes a large, irregularly shaped, flat, non-palpable lesion that is darker than the surrounding skin. What type of lesion is this? a. Macule b. Patch c. Papule d. Plaque Answer: B - A patch describes macules that are larger than 1 cm. 7.A pressure injury that involves full-thickness skin loss with exposed bone, tendon, or muscle is classified as what stage? a. b. c. d. Stage I Stage II Stage III Stage IV Answer: D - Stage IV pressure injuries involve full-thickness skin and tissue loss. 8.The nurse is assessing a patient's skin and notes a superficial, raised, transient, and erythematous lesion with an irregular shape due to edema. What type of lesion is this? a. b. c. d. Wheal Bulla Nodule Tumor Answer: A - This description is indicative of a wheal. 9.When assessing skin color in a patient with darker pigmentation, where is the best place to look? a. Sclera Page 5 of 10 EXAM ASSESSMENT Q&A’S 2 HEALTH b. Nail beds c. Palms of hands d. All of the above Answer: D - When assessing skin color in a patient with darker pigmentation, the best places to assess for changes in color are less pigmented areas like the sclera, nail beds, and palms of hands. 10. What is the medical term for an encapsulated fluid-filled cavity in the skin? a. b. c. d. Vesicle Bulla Cyst Pustule Answer: C - A cyst is an encapsulated fluid-filled cavity. Substance Abuse 1.Alcohol is a risk factor for the development of: a. b. c. d. Co-morbidities Heart disease Lung cancer All of the above Answer: A - Alcohol is a risk factor for the development of co-morbidities. 2.The CAGE questionnaire is used to screen for: a. b. c. d. Alcohol use Illicit drug use Depression Anxiety Answer: A - The CAGE questionnaire is a screening tool for alcohol use. 3.Which of the following is an objective finding related to substance use? a. Intoxication b. Alcohol use c. Withdrawal d. Tolerance Answer: A - Intoxication and withdrawal are both objective findings of substance use. Tolerance and alcohol use are subjective. 4.Which illicit drug is commonly snorted, inhaled, or injected into the veins? a. Cannabis b. Cocaine c. Inhalants d. Narcotics Answer: B - Cocaine is a strong stimulant that is commonly snorted, inhaled, or injected into the veins. 5.What is the most commonly used and abused psychoactive drug? a. Marijuana b. Cocaine c. Alcohol d. Heroin Page 6 of 10 EXAM ASSESSMENT Q&A’S 2 HEALTH Answer: C - Alcohol is the most used and abused psychoactive drug. 6.Inhalants are most commonly found in which type of product? a. b. c. d. Household cleaners Prescription medications Over-the-counter medications Food products Answer: A - The most common inhalant products are nail polish and gasoline, both of which can be found in household cleaners. Pain 1.Pain is considered the fifth vital sign. a. True b. False Answer: A 2.Which of the following is not a type of pain assessment tool? a. Numeric rating scale b. Verbal descriptor scale c. Visual analog scale d. FACES scale Answer: D - The FACES scale is a pain scale, but it is not included as a type of pain assessment tool in the source material. The other options are all types of pain assessment tools. 3.Chronic pain is pain that lasts for longer than 6 months. a. True b. False Answer: A 4.Which pain scale would be most appropriate to use with a 4-year-old child? a. Numeric rating scale b. Verbal descriptor scale c. Visual analog scale d. FACES scale Answer: D - While not listed as a pain assessment tool, the FACES scale is likely the most appropriate tool to use with a 4-year-old child because it uses pictures to help children rate their pain. 5.The nurse is assessing a patient's pain. The patient reports that the pain is a burning sensation and rates it as a 7 out of 10. Using the PQRST method of pain assessment, what does the "Q" stand for? a. Quantity/Quality b. Region/Radiation c. Severity Scale d. Timing Answer: A - In the PQRST method of pain assessment, the Q stands for quality/quantity. 6.What does FLACC stand for in the FLACC pain scale? a. b. c. d. Face, legs, activity, cry, consolability Facial expression, level of alertness, activity, cry, consolability Face, level of alertness, activity, cry, color Facial expression, legs, activity, cry, color Page 7 of 10 EXAM ASSESSMENT Q&A’S 2 HEALTH Answer: A - The FLACC scale stands for face, legs, activity, cry, consolability. This is used to rate pain in young children or individuals who are unable to communicate their pain level verbally. Miscellaneous 1.A dermatome is: a. A structural unit within the epidermis b. An area of skin supplied by a single spinal nerve c. A type of primary skin lesion. d. A common site for pressure injuries. Answer: B This information is not found in the provided sources, though it may be included in a nursing student's curriculum around this time. A dermatome is an area of skin supplied by a single spinal nerve. 2.The "FAST" acronym is used to teach the public about the warning signs of a stroke. a. True b. False Answer: A 3.Which population has the highest incidence of stroke? a. Caucasian b. African American c. Hispanic d. Asian Answer: B - Though the information is not included in the sources, African Americans are known to have the highest incidence of stroke. 4.The “stroke belt” is a geographic area in the southeastern United States that has a higher incidence of stroke than other areas of the country. a. True b. False Answer: A 5.The mnemonic "Some Say Marry Money But My Brother Says Big Brains Matter More" helps nursing students remember the names of the twelve cranial nerves. a. True b. False Answer: A 6.What is the medical term for the inability to recognize familiar objects? a. Agnosia b. Apraxia c. Aphasia d. Anomia Answer: A This information is not included in the sources. Agnosia is the inability to recognize familiar objects, and may be caused by stroke or other neurological condition. 7.What is the name of the protective reflex tested by gently touching the cornea with a cotton ball? a. Gag reflex b. Corneal reflex Page 8 of 10 EXAM ASSESSMENT Q&A’S 2 HEALTH c. Patellar reflex d. Plantar reflex Answer: B - The corneal reflex is a protective reflex that causes a person to blink when something touches their cornea. 8.Nystagmus is a vision condition in which the eyes make repetitive, uncontrolled movements. a. True b. FalseAnswer: A Page 9 of 10 Maritsa Aguilar EXAM 2 HEALTH ASSESSMENT Q&A’S Page of 10 10