Part 4 Health Assessment

7/27/2019 Part 4 Health Assessment

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1Marks: 1

Complete assessment of the female genitalia includes the palpation of the cervix. When assessingthe cervix, you palpate for the following except:

Choose one answer.

a.Discharge You inspect for cervical color, size, position,appearance of the os, discharge and lesions.When palpating for the cervix, you advancethe fingers until they touch the cervix and yourun your fingers around the circumference.You palpate for contour, mobility, tendernessand consistency. (Weber and Kelley, 2007)

b. Mobility

c. Contour

d.Consistency

Correct

Marks for this submission: 1/1.

Question2Marks: 1

The Glasgow Coma Scale is used to grade or score a patients level of consciousness. A nurseassesses a patient using the three indicators for GCS Eye, Verbal and Motor response. She giveshim a score of E2 V2 M4. What does this score imply?

Choose one answer.

a. Eyes open to speech, incomprehensible

sounds, abnormal extension

b. Eyes open to pain, incomprehensible

sounds, withdraws from pain.

Eye response is graded as follows: 4 -Spontaneous eye opening ,3 - Eyes open tospeech , 2 - Eyes open to pain , 1 - No eyeopening. Verbal response is graded as follows:5 - Alert and Oriented , 4 - Confused, yetcoherent, speech , 3 - Inappropriate words and

jumbled phrases consisting of words , 2 -Incomprehensible sounds , 1 - No sounds.

Motor Response is graded as follows.: 6 -Obeys commands fully , 5 - Localizes tonoxious stimuli , 4 - Withdraws from noxiousstimuli , 3 - Abnormal flexion, i.e. decorticateposturing , 2 - Extensor response, i.e.decerebrate posturing , 1 - No response.

c. Eyes open to pain, inappropriate words and


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phrases, and abnormal flexion

d. Eyes open to speech, Confused coherent

speech and localizes pain

Incorrect


Question3Marks: 1

A nurse is about to perform a digital rectal examination. Which of the following materials is notnecessarily needed?

Choose one answer.

a. Penlight

b. Clean gloves

c. Sterile gloves Digital rectal exam is a clean procedure, not sterileprocedure.Clean gloves would be okay. A penlightis needed to illuminate parts during inspection. Thelubricating jelly is used to minimize discomfort andrisk for tissue trauma. (Jarvis, 1993)

d.Lubricating jelly

Correct


Question4Marks: 1

The nurse is currently inspecting a 26-year-olds penis. Which of the following observations reflectsan abnormal finding?

Choose one answer.

a. Skin of the penis is wrinkled,

hairless and without lesions.

b. Cheesy smegma may collect under

foreskin.

c. At the base of the penis, pubic hairdistribution is consistent with age.

d. Urethral meatus is found on the

dorsal side of the glans.

The skin normally looks wrinkled, hairless andwithout lesions. The dorsal vein may be apparent.The glans looks smooth and without lesions. Askthe uncircumcised male to retract the foreskin, oryou retract it. It should move easily. Some cheesysmegma may have collected under the foreskin.


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After inspection, slide the foreskin back to theoriginal position. The urethral meatus is positionabout centrally. If the urethral meatus is located atthe dorsal location of the meatus, this is abnormaland is called Epispadias. (Jarvis, 1993).

IncorrectMarks for this submission: 0/1.

Question5Marks: 1

You are performing DRE on a 56-year-old male. In the middle of the assessment, he complains ofbeing lightheaded and nauseous. What is the appropriate nursing action?

Choose one answer.

a. Slow down in performing DRE.

b. Ask patient to take deep, slow breaths

and slow down DRE.

c. Stop assessment immediately and

document right away.

d. Stop assessment immediately and

monitor VS.

When a patient complains of being dizzy,lightheaded, nauseous and may even vomit,patient may have been vagally stimulated. Insuch cases, do NOT proceed with the DRE.Instead, stop right away and monitor vitalsigns. Monitor and document accordingly.(Jarvis, 1993).

Incorrect


Question6Marks: 1

There are several ways to test the VIII cranial nerve. Which is NOT one of them?

Choose one answer.

a. Stand about 1 to 2 feetaway (30-60 cm) and softly

whisper a word.

b. Have patient listen to the

ticking of a wrist watch.

c. Have patient stand erectwith his feet close together

and eyes closed.


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d. None of the choices Cranial Nerve VIII is also called the Acoustic orVestibulocochlear nerve. This nerve has one modality;Special Sensory. It has two branches; the Cochlear whichtransmits sound messages to the brain; and Vestibularwhich controls balance or equilibrium. To Test this nervehave the patient occlude one ear with a finger. Stand about

1 to 2 feet away (30-60 cm) and softly whisper a word withtwo distinct syllables such as football, baseball, or doorbell.Make sure the patient can't read your lips. Repeat with theother ear and a different word. Repeat the word slightlylouder if necessary and observe for difficulties distinguishingwords. Equilibrium can be tested using the Romberg test:Have the patient stand erect with his feet close together andhis eyes closed. He might sway slightly, but should not fall.(Stay close to the patient in case he does begin to fall.)(Jarvis, 1993).

Incorrect


Question7Marks: 1

You are ready to assess the anal region of your area. Before you proceed with palpation, you mustkeep in mind the following guidelines except:

Choose one answer.

a. None of the choices.

b. Approach the anus at right angles. Never approach the anus at right

agnles with your index finger extended.Such a jabbing motion does notpromote sphincter relaxation and ispainful. (Jarvis, 1993).

c. Place the pad of your index finger gently

against the anal verge

d. Don clean gloves and lubricate your index

finger.

Incorrect


Question8Marks: 1

Which of the following reflexes is NOT abnormal when found in a 22-year-old male patient?

Choose one answer.

a.Babinski


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b.Abdominal The abdominal reflex is a normal superficialreflex. The abdominal reflex includes contractionof abdominal muscles in the quadrant of theabdomen that is stimulated by scraping the skintangential to or toward the umbilicus. Thiscontraction can often be seen as a brisk motion

of the umbilicus toward the quadrant that isstimulated.The Babinski, Dolls Eyes and GraspReflex are not normal in adult patients. Apresend Babinski reflex may indicate brain orspinal cord damage from many causes. A graspreflex is an involuntary grasp in response tostimulation of palm. This is very much normal ininfants, but abnormal in an adults. Dolls eyes:impairment of eye movement to opposite sidewhen head is turned. This implies damage tobrainstem. (Jarvis, 1993).

c. Dolls eyes

d. Grasp

Incorrect


Question9Marks: 1

A nurse is conducting a physical assessment of a 33 year old male. Upon inspection of his penis,she notes soft, pointed, moist, wartlike papules in his penis. What condition could the patient beexperiencing?

Choose one answer.

a. Priapism

b. Urethritis

c.Condylomata Acuminata Priapism is the prolonged painful erectionof penis without sexual desire. Urethritis isinfection of the urethra and is characterizedby urethral discharge and dysuria.Carcinoma begins as a red, raised growthor as an ulcer with watery discharge. It

grows and may necrose and slough, but isusually painless. Condylomata acuminateis also called as venereal warts. It ischaracterized by soft, pointed, moist,wartlike papules which may be single ormultiple in a cauliflower-like patch. It occurson the shaft of penis or behind corona oraround anus. It is an STD. (Jarvis, 1993).


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d.Carcinoma

Incorrect


Question10Marks: 1

You are going to conduct a physical examination of the genitalia. Which of the following is NOTappropriate?

Choose one answer.

a. Drape the patient and expose only parts to

be visualized when needed

b. Discourage patient to ask questions during

the procedure

Physical examination of the genitalia maycreate client anxiety. Client may beembarrassed about exposing her genitalia

and nervous that an infection or disordermay be discovered. Be sure to explain indetail what you will be doing throughout theexamination and to explain the significanceof each portion of the examination.Encourage the patient to ask questions tohelp educate and alleviate her anxiety.Provide for privacy. (Weber and Kelley,2007)

c. Be sure to explain in detail what you will be

doing throughout the examination

d. Be sure to explain in detail what you will bedoing throughout the examination

Incorrect


Question11Marks: 1

Along with assessing, nurses must also provide health education. The nurse instructs the malepatient (adolescence onwards) how to examine his own testicles every month. Which statement isincorrect?

Choose one answer.

a. Gently feel each testicle using the

palm of your hands.

A good time to examine the testicles is duringshower or bath when the hands and scrotum arewarm. Cold hands stimulate cremasteric reflex,which may retract scrotal contents. The procedureis simple. Tell the patient to hold the scrotum inthe palm of each hand and gently feel eachtesticle using the thumb and first two fingers (not


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using the palm). If it hurts, the patient may beusing too much pressure. The testicle is eggshaped and movable. It feels rubbery with asmooth surface. The epididymis is on top andbehind the testicle, and will feel a bit softer. Ifpatient notices a firm painless lump, hard area or

an overall enlarged testicle, advise him to call hisphysician for further investigation. (Jarvis, 1993).

b. A good time to examine the

testicles is during shower or bath.

c. Cold hands would stimulatemuscle reflex, and may retract scrotal

contents.

d. If you should notice a firm,painless lump, you should notify your

doctor.

Incorrect


Question12Marks: 1

You are inspecting your patients anal region and you observed a longitudinal tear in the superficialmucosa of the anal margin. Patient reports that it is painful as well. You know that this is also calledas:

Choose one answer.

a. Abscess

b. Rectal Polyp

c.Hemorrhoids

d. Fissure Rectal polyp is a protruding growth fromthe rectal mucous membrane that is fairlycommon. An abscess is a localized cavityof pus from infection in a pararectal space.Hemorrhoids are painless flabby papulesdue to varicose vein of the hemorrhoidalplexus.

Incorrect


Question13Marks: 1

Which test is performed to assess for presence of kidney inflammation or other nephritic problems?


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Choose one answer.

a. Shifting Dullness

b. Fluid Wave

c.Obturator Test

d. Indirect fist percussion Fluid Wave and Shifting Dullness are special testsdone to assess or when ascites is suspected. Apositive fluid test occurs with large amounts ofascetic fluid. Shifting dullness is the use of shiftingpositions and the percussion and the soundselicted from it. The obturator test is performedwhen appendicitis is suspected - the right leg islifted and flexed if there is pain, appendicitis ismost probable. Indirect fist percussion at thecostoverterbral angle is also called the Kidney

Punch. To assess the kidney, place one hand overthe 12th rib at the costovertebral angle on theback. Thump that hand with the ulnar edge of theother fist. The person normally feels a thud but nopain. Sharp pain occurs with inflammation of thekidney or paranephric area. (Jarvis, 1993).

Incorrect


Question14Marks: 1

You are preparing a female patient for physical assessment of the genitalia. Which of the followingshould the nurse do?

Choose one answer.

a. Ask patient to assume a dorsal recumbent

position in preparation for examination

b. Ask patient to put her hands over her head to

help relax abdominal muscles.

c. Ask the patient to void and douche herself

prior to examination.

d. Nurse can offer a mirror so the patient can

view the examination.

Physical examination of the genitalia maycreate client anxiety. Client may beembarrassed about exposing her genitaliaand nervous that an infection or disordermay be discovered. Be sure to explain indetail what you will be doing throughoutthe examination and to explain thesignificance of each portion of the


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examination. Encourage the patient to askquestions to help educate and alleviateher anxiety. Provide for privacy. (Weberand Kelley, 2007)

Incorrect


Question15Marks: 1

You are currently performing a digital rectal exam when you patient tells you that he feels pain. Youask him to rate the pain and he gives it a score of 7/10. What is your appropriate nursing action?

Choose one answer.

a. Stop and defer DRE.

b. Stop and use more lubricating jelly and continue

with assessment.

c. Let him rest for a few minutes and continue

assessment

d. Stop DRE and chart findings DRE is not a painful procedure. Youmay tell the patient that the procedureis NOT painful but it may feel likeneeding to move the bowels. Shouldthere be pain, stop the digital rectalexam and note the observation andpatients reports. (Jarvis, 1993).


Question16Marks: 1

You are conducting your initial interview with your client. You asked about her last menstrual period.Which of the following statements warrants further investigation?

Choose one answer.

a. "The length of my menstrual blood

flow is around 3 days.

b. I havent had my period in 3

months.

A normal menstrual cycle usually occursapproximately every 18-45 days. The averagelength of menstrual blood flow is 3 to 7 days.Headache, weight gain, mood swings, abdominalcramping and bloating are common complaintsbefore or during the menstrual period. Theabsence of menstruation excessive bleeding or amarked change in menstrual pattern indicates a


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cannot overcome gravity, and/or moveswith gravity eliminated. 1/5 contractsmuscle to stimulus. 0/5 means there isno observed muscle movement (Jarvis,1993).

b. Strong against resistance

c.Contracts muscle to Stimulus

d. Moves with gravity

Incorrect


Question19Marks: 1

You are conducting a physical assessment of a 14-year-old male when suddenly, in the middle of

assessment, he gets an erection. What is the appropriate nursing action?

Choose one answer.

a. Stop the examination.

b. Stop the examination and leave the

room to give patient privacy.

c. Proceed with the examination

d. Proceed with the examination and

reassure patient that this is a physiologicresponse.

In palpating male genitalia, use a firm deliberate

touch, not a soft stroking one. If an erection doesoccur, do not stop the examination or leave theroom. This only focuses more attention on theerection and increases embarrassment. Reassurethe male that this is only a normal physiologicresponse to touch, just as when the knee jerkswhen tapped with the reflex hammer or when thepupil constricts in response to bright light. Proceedwith the rest of the examination. (Jarvis, 1993).

Incorrect


Question20Marks: 1

A nurse is conducting a full neurological assessment of a 45-year-old patient. She is about to test hisdeep tendon reflexes. Which of the following principles should she keep in mind?

Choose one answer.


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a. Strike the tendon with several brisk strokes. It

should not elicit pain.

The muscle group to be tested must bein a neural position extremity shouldbe positioned such that the tendon canbe easily struck with the reflex hammer.If you are having difficulty locating thetendon, ask the patient to contract the

muscle to which it is attached. When themuscle shortens, you should be able toboth see and feel the cord like tendon,confirming it precise location. You strikethe tendon with a single, brisk stroke. Itshould be done firmly and should notelicit pain. (Jarvis, 1993).

b. If she is having problems locating a tendon,she should ask the patient to relax the muscle

to which it is attached.

c. The muscle group to be tested must be in a

neutral position.

d. All of the Choices

Incorrect


Question21Marks: 1

Complete assessment involves conducting the health interview. You are asking your 33-year-oldpatient about his urinary habits. He says that he drinks about 2 liters of fluids a day, and voids about5-6 times a day. However, he reports that he feels a burning sensation during urination. What is the

term that refers to this condition?

Choose one answer.

a.Dysuria Nocturia is the phenomenon wherein the clienthas to awaken at night due to a need to urinate.Polyuria refers to excessive urination, whereasdysuria refers to diminished quantity (


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Question22Marks: 1

A nurse is assessing a 23-year-old males scrotum. Which of the following statements should thenurse remember during assessment of the scrotum?

Choose one answer.

a. Scrotal size varies with ambient room

temperature.

Asymmetry is normal, the left scrotal halflower than the right. Normally, there areno scrotal lesions except for commonlyfound sebaceous cysts. These areyellowish, 1-cm nodules and are firmnontender and often multiple. Scrotalcontents should slide easily. They areoval, firm and rubbery, smooth andequal bilaterally. They are freelymovable and only slightly tender tomoderate pressure. Each epididymis

normally feels discrete, softer than thetestis, smooth and nontender. Scrotalsize varies with ambient roomtemperature. (Jarvis, 1993)

b. An abnormal finding includes sebaceous cystswhich are small, yellowish nodules chart these

accordingly.

c. Asymmetry is not normal and should be noted.

d. Testes are freely movable and are tender to

moderate pressure.Incorrect


Question23Marks: 1

One of the first things that a nurse assesses in a patient is his level of consciousness (LOC). NurseAmy is assessing a 24-year-old patient brought to the ER. She notices that patient is oriented totime, place, person but has slow sluggish speech and response. Response however is appropriate.What is the proper term to describe the patients LOC?

Choose one answer.

a.Lethargic Confused patients are disoriented to time place andperson and have short attention span, poor memoryand are easily bewildered. Obtunded patients havedecreased LOC and arouses only to stimulation, theyrespond with 1-2 words and follow 1-step commandsto stimulation. Stuporous patients lie quietly withminimal movement and responds only to vigorous andrepeated stimulation. They open their eyes and


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responds to pain appropriately and makesincomprehensible sounds. Lethargic patients areoriented to three spheres, but however had slow,sluggish speech and mental processes. They are ableto respond appropriately (Jarvis, 1993).

b.Stuporous

c.Obtunded

d.Confused

Incorrect


Question24Marks: 1

You are performing examination of the scrotum on a 7-year-old patient. However, upon palpation,

you notice that the testes appears absent. What condition could the patient be currentlyexperiencing?

Choose one answer.

a. Scrotal Edema

b. Scrotal Hernia

c.Cryptorchidism Scrotal edema is manifested by tenderness, anenlarged scrotum with reddening (localirritation) and is taut with pitting. It

accompanies marked edem in the lower half ofthe body due to CHF or other conditions aswell as local inflammation. Scrotal Hernia ismanifested by an enlarged scrotum which doesnot transilluminate. There is a soft mushy massthat palpating fingers cannot get above mass.Mass is distinct from testicle that is normal.Orchitis is an acute or moderate pain ofsudden onset manifested by a swollen testes.Cryptochordism is in which the testes hasnever descended. Incidence at birth is 3-4%,one half of these descend in the first month.Incidence with premature infants is 30%, the

adult 0.7-0.8%. True undescended testes havea histologic change by 6 years, causingdecreased spermatogenesis and infertility. It ismanifested by an empty scrotal half. Atrophicscrotum is on the affected side and no testiscan be palpated. (Jarvis, 1993).

d. Orchitis


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Incorrect


Question25Marks: 1

A nurse is assessing a nulliparous woman. Then nurse visualizes the patients cervix. Which of the

following is not a normal finding?

Choose one answer.

a. Cervical secretions are clear without

unpleasant odor.

b. Cervical os appears slit-like. In a nulliparous woman, the cervical osappears round and is small. It appears slit-like in parous women. (Weber and Kelley,2007)

c. Cervical os appears as a small, roundopening

d. None of the choices

Incorrect


Question26Marks: 1

You are currently inspecting the genitalia of a 6-year-old boy. Upon inspection of the inguinal area,you do not see any bulges but his parents give a positive history of one. Which of the following is notan appropriate nursing action?

Choose one answer.

a. Try to elicit the bulge by increasingintrabdominal pressure by having him blow

up a balloon.

b. Palpate the inguinal area using the little

finger to reach the external inguinal ring

c. Ask the boy to hold his breath and strain

down

d. Note the finding and proceed to assessing

the other aspects of the genitalia.

When the parents give a positive history of abulge or any abnormal finding for that matter,TRY to elicit the said finding. In the case ofsuspected hernia, try to elicit the bulge byincreasing intrabdominal pressure by askingthe boy to hold his breath and strain down orhaving him blow up a balloon. You may alsopalpate the inguinal area using the little


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finger to reach the external inguinal ring. Donot just chart or disregard the findings.(Jarvis, 1993).

Incorrect


Question27Marks: 1

The nurse is inspecting a 65-year-old patients external genitalia. Which of the following findingswarrants further investigation?

Choose one answer.

a.Perineum is smooth.

b. The labia minora is asymmetric. A healed tear or episiotomy scar may bevisible on the perineum if patient has history

of childbirth. The perineum should besmooth. Pubic hair is distributed in aninverted triangular pattern and there are noinfestations. Older clients may have grayand thinning pubic hair. Labia minora shouldappear symmetric, dark pink and moist.

Asymmetric labia may indicate abscess.(Weber and Kelly,2007).

c. Patient has a healed episiotomy scar.

d. There is gray, thinning pubic hair.

Incorrect


Question28Marks: 1

There are several types of reflexes present, some of which include deep tendon reflexes andsuperficial reflexes. Which is NOT a deep tendon reflex?

Choose one answer.

a.Brachioradialis

b. Patellar

c. Biceps

d. Cremasteric Patellar, biceps and brachioradialis are alldeep tendon reflexes which are commonlyelicited by striking with a reflex hammer.The cremasteric reflex is a superficial


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reflex observed in human males. Thisreflex is elicited by lightly stroking thesuperior and medial (inner) part of thethigh.[1] The normal response is acontraction of the cremaster muscle thatpulls up the scrotum and testis on the side

stroked. (Jarvis, 1993).

Incorrect


Question29Marks: 1

The nurse is examining the cranial nerves of a 23 year-old-patient. She asks the patient to smile,then frown and puff her cheeks out. Which cranial nerve is the nurse testing?

Choose one answer.

a.VIII

b.V

c.VI

d.VII Cranial nerve VII is the Facial Nerve. Testingt hemotor function of the nerve incolves noting mobilityand facial symmetry as the person responds torequests such as smile, frown, close eyes lightly, lifteyebrows, show teeth and puff cheeks. (Jarvis, 1993)


Question30Marks: 1

A patient is due for his digital rectal exam. How do you best position your patient for a digital rectalexam?

Choose one answer.

a. Right side lying

b. All of the Choices

c. Prone

d. Left Sims position Left Sims Position allows the examiner tofollow the natural contour of the anatomicstructures. (Jarvis, 1993),

Incorrect


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Question31Marks: 1

A nurse is assessing the deep tendon reflexes of her patient. She is currently testing the AchillesReflex. Which statement is NOT true about this reflex and testing it?

Choose one answer.

a. Patient can be positioned seating (feetdangling over edge of table) or supine

with one leg crossed.

b. The Achilles tendon is a taut, discrete,cord-like structure running from the heel

to the muscles of the calf.

c. The normal response is plantar

extension.

Patient is best positioned in a sitting position with

feet dangling over the edge of the table butpatient can also be positioned supine, so as longas the leg that is to be tested is freely dangling(hence, crossing of legs in a figure 4 or a frog-type position). The Achilles tendon is a taut,discrete, cord-like structure running from the heelto the muscles of the calf. If you are unsure, askthe patient to plantar flex (i.e. step on the gas).You strike the tendon DIRECTLY. The normalresponse is plantar flexion or a contraction of theGastrocnemius. (Jarvis, 1993).

d. You can strike the tendon directly.

Incorrect


Question32Marks: 1

Nurse Joy is currently performing assessment of the cranial nerves on her 26-year-old patient. Whenshe wants to test the 4th cranial nerve, what must she tell the patient to do?

Choose one answer.

a. None of the choices The Fourth cranial nerve is the Trochlear nerve and it

innervates the superior oblique muscle, which depresses,rotates laterally (around the optic axis), and intorts the eyeball.To test this nerve, the nurse asks the patient to "Follow fingerwith eyes without moving head" and tests the 6 cardinal pointsin an H pattern. Eliciting the gag reflex tests the 9th(Glossopharyngeal) and 10th (Vagus) cranial nerve. Whileasking the patient to identify odors is a test for the 1st(Olfactory) cranial nerve. Asking the patient to stick out hertongue is a test for the 12th cranial nerve (Hypoglossal). (Jarvis,


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1993)

b. Elicit Gag Reflex

c. Stick out her tongue

d. Ask patient to identifyspecific odors while eyes

are closed

Incorrect


Question33Marks: 1

You are performing a physical assessment of an adolescent. You note that there are changes in thenormal development of the genitals. Which of the following is NOT a normal change in adolescents?

Choose one answer.

a.Enlargement of testes and scrotum

b.Roughening of scrotal skin

c. Scrotal sac becomes pendulous with less

rugae

Normal changes associated withadolescence include enlargement oftestes and scrotum, pubic hair growth,darkening of scrotal color, roughening ofscrotal skin, increase in penis length andwidth, and axillary hair growth. IN the

older male, there is thinner, graying pubichair and decreased size of the penis. Sizeof testes may be decreased and feel lessfirm. The scrotal sac is pendulous withless rugae. The scrotal skin may becomeexcoriated if the man continually sits on it.(Jarvis, 1993).

d.Darkening of scrotal color

Incorrect


Question34Marks: 1

Which is not a normal finding when assessing the female external genitalia?

Choose one answer.

a.Bartholins glands are soft, nontender with

clear, nonpurulent discharge.

Inguinal lymphnodes should not be enlargedor swollen. Enalrged inguinal nodes may


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indicate a vaginal infection or may be theresult of irritation from shaving pubic hairs.Labia majora are equal in size and free oflesions, swlling and excoriation. Lesionsmay result from infection or disease.Excoriations and swelling may be from

scratching or self-treatment of lesions.Urethral meatus is small and slitlike.Excoriation may result from client scratchingherself. Bartholins glands are usually soft,nontender and drainage free. Swelling, pain,discharge may result from abscess andinfection. If you detect a discharge, obtain aspecimen and sent to lab for culture. (Weberand Kelley, 2007)

b. Inguinal lymph nodes are not enlarged.

c. Labia majora are equal in size.

d. Urethral meatus is small and slitlike.

Incorrect


Question35Marks: 1

Assessment of the Cranial Nerves is an important part of the neurological examination. A nurse askthe patient to turn head against her palm (resistance). Which cranial nerve is being tested?

Choose one answer.

a.Cranial Nerve VIII

b.Cranial Nerve XI Cranial Nerve V is also called the Trigeminal Nerve. It receivessensation from the face and innervates the muscles ofmastication. Cranial Nerve VI is also called the Abducens Nerve

it controls an extraoculomotor muscle, the lateral rectus whichabducts the eye. Cranial Nerve VIII is also called theVestibulocochlear Nerve which is responsible for sensation ofsound, rotation and gravity (balance and movement). CranialNerve XI is also called the Spinal Accessory of the AccessoryNerve. It controls sternocleidomastoid and trapezius muscles. To

test CN XI, you ask the patient to shrug his shoulders (Trapezius)and to turn his head against a resistance (Sternocleidomastoid).(Jarvis, 1993).

c.Cranial Nerve V

d.Cranial Nerve VI

Incorrect


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Question36Marks: 1

A nurse uses the Glasgow Coma Scale to assess the LOC of a patient following acute trauma.Nurse AJ is an ICU nurse, and is currently assessing a 55-year-old stroke patients LOC. Patient

opens eyes to voice, utters inappropriate words/responses and is able to localize painful stimuli.Given the data, what would the patients GCS score be?

Choose one answer.

a.10

b.12

c.9

d.11 When patient is able to open eyes to voice or verbalcommands, this is given a score of 3. Patient uttersinappropriate words or verbal responses is given a score of 3.When patient is able to localize painful stimuli, he is given ascore of 5. 3 + 3 + 5 = 11. (Jarvis, 1993).

Incorrect


Question37Marks: 1

One of the internal structures that must be assessed in the female is the uterus. During palpation ofthe uterus, which of the following reflects an abnormal finding?

Choose one answer.

a. The fundus is round, firm and

smooth.

b. The uterus is fixed. The fundus, is the large end of the uterus, normallyround, firm and smooth. IN most women, it is at thelevel of the pubis; cervix is aimed posteriorly. Anenlarged uterus above the level of the pubis isabnormal, an irregularly shaped uterus suggestsabnormalities such as myomas or endometriosis.

THe normal uterus moves freely and is non tender.A fixed or tender uterus may indicate fibroids,infection, masses. (Weber and Kelley, 2007)

c. The uterus is at the level of the

pubis

d. The uterus is nontender.

Incorrect


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Question38Marks: 1

The Glasgow Coma scale is the most widely used scoring system used in quantifying level ofconsciousness following a traumatic brain injury. Which of the following statements is not true about

the Glasgow Coma Scale (GCS)?

Choose one answer.

a. None of the choices

b. It is not possible to get a score of zero

in the GCS.

c. The GCS measures three responsesnamely: Eye, Verbal and Sensory

Responses.

It is not possible to get a score of ZERO in theGCS. The lowest possible score is 3, indicatingdeep unconsciousness, while the highest score is

15 (fully alert). The three responses being testedand measured are Eye, Verbal and Motorresponses. (Jarvis, 1993).

d. The highest possible score in the GCS

is 15.

Incorrect


Question39Marks: 1

You are conducting an interview with a female patient. Which of the following statements indicates ahigher risk for cervical cancer:i. Patient is a chain smoker for 5 years, smoking about 2 packs a dayii. Patient has been using oral contraceptives for 6 yearsiii. Patient has regular Pap smear testsiv. Patient is married and says she is monogamous

Choose one answer.

a. i only

b. i, ii, iii, iv

c.i,ii Risk factors that increase patients risk for cervical cancerinclude, HPV infection (most important risk factor), females of lateteens to mid thirties, multiple sexual partners, failure to haveregular Pap tests, cigarette smoking, diet low in fruit andvegetables, low socioeconomic status associated with low levelof preventive care, African American or Hispanic heritage,multiple pregnancies, family history, overweight, history ofChlamydia infection, HIV infection, daughter of mother who took


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DES in early pregnancy to prevent miscarriage, possible use ofcontraceptives for 5 or more years. (Weber and Kelley, 2007)

d. i, ii, iii

Incorrect


Question40Marks: 1

The nurse is currently performing assessment of the male genitalia. She notices that the foreskin isadvanced and fixed and that it is impossible to retract over the glans penis. What is this conditioncalled?

Choose one answer.

a. Urethral Stricture

b.Paraphimosis

c.Hypospadias

d. Phimosis Paraphimosis is a condition wherein theforeskin is retracted and fixed. Onceretracted behind the glans, a tight orinflamed foreskin cannot return to theoriginal position. Hypospadias is acondition wherein the meatus opens of theventral side of the glans or at thepenoscrotal junction, it is a congenital

defect. A urethral stricture is a pinpoint,constricted opening at meatus or insidealong the urethra. Phimosis is a conditionwhereun te foreskin is advanced and fixed,so tight it is impossible to retract over theglans. It may be congenital or acquiredfrom adhesions secondary to infection.Poor hygiene leads to retained dirt andsmegma, which increases risk ofinflammation or calculus formation. (Jarvis,1993)

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Part 4 Health Assessment