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Question
The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this?a. The patient has hyperesthesia as a result of the aging process.
b. This response is most likely the result of the summation effect.
c. The nurse was probably not poking hard enough with the pin in the other areas.
d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.
Answer
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Related questions
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The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
a. To measure the rate of lymphatic drainage
b. To evaluate the adequacy of capillary patency before venous blood draws
c. To evaluate the adequacy of collateral circulation before cannulating the radial artery
d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
Q:
When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should:
a. Check for the presence of claudication.
b. Refer the individual for further evaluation.
c. Consider this finding as normal, and proceed with the peripheral vascular evaluation.
d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
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When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next?
a. Document the finding.
b. Auscultate the site for a bruit.
c. Check for calf pain.
d. Check capillary refill in the toes.
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A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
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Which statement is true regarding the arterial system?
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During a cardiovascular assessment, the nurse knows that a thrill is:
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b. Palpated in the right epigastric area.
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In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:
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b. Bell of the stethoscope at the apex with the patient in the left lateral position.
c. Diaphragm of the stethoscope in the aortic area with the patient sitting.
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Q:
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During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:
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When assessing a patient's lungs, the nurse recalls that the left lung:
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b. Is divided by the horizontal fissure.
c. Primarily consists of an upper lobe on the posterior chest.
d. Is shorter than the right lung because of the underlying stomach.
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A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?
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A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?
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Q:
A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:
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Q:
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
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Q:
A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this diagnosis, during assessment the nurse will most likely observe:
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b. Atrophic scrotum and a bilateral absence of the testis.
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Q:
Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man?
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c. "Do you know how to perform a testicular self-examination?"
d. "Has anyone ever touched your genitals when you did not want them to?"
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In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?
a. Hyperreflexia
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d. Atrophy and wasting of the muscles
Q:
A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?
a. Scissors gait
b. Cerebellar ataxia
c. Parkinsonian gait
d. Spastic hemiparesis
Q:
During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response:
a. Indicates a lesion of the cerebral cortex.
b. Indicates a completely nonfunctional brainstem.
c. Is normal and will go away in 24 to 48 hours.
d. Is a very ominous sign and may indicate brainstem injury.
Q:
While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response?
a. This response could indicate brachial nerve palsy.
b. This reaction is an expected startle response at this age.
c. This reflex should have disappeared between 1 and 4 months of age.
d. This response is normal as long as the movements are bilaterally symmetric.