RN Health Assessment (BSN 246/ASN 241)

The correct answer is  moodiness.

During early adolescence (ages 11-14), mood swings and emotional variability are common due to hormonal changes and brain development. Adolescents in this stage may experience rapid shifts in emotions, from happiness to sadness or irritability, without an apparent reason.  This moodiness is a normal part of their psychological and emotional development as they adjust to bodily changes and increasing social pressures.

Why the Other Options Are Incorrect:

Frequent anger – While some irritability can occur, persistent or frequent anger is more characteristic of middle adolescence (15-17 years old), when teens are more focused on asserting independence and may experience frustration with authority figures.

Cooperativeness – Early adolescents are typically more self-focused and less cooperative with adults, especially parents. While they may cooperate in peer settings, they are still navigating identity formation and emotional regulation, making moodiness more likely.

Combativeness – Physical or verbal combativeness is not a typical response in early adolescence. While some teens may be argumentative or test boundaries, aggression is not a defining emotional response for this stage. Persistent combativeness may indicate underlying behavioral or emotional concerns that need further assessment.

Summary:

Moodiness is a normal emotional response in early adolescence due to hormonal fluctuations and psychological changes. While anger, combativeness, or cooperativeness may be observed at times, mood swings are the most typical and expected emotional reaction during this developmental period.

Correct Answer: B. Lung cancer

While breast cancer is the most common cancer among women, lung cancer is the leading cause of cancer-related deaths in women. This is because:

Lung cancer is often diagnosed at a later stage, making treatment less effective.

It has a high metastasis rate, meaning it spreads quickly to other organs.

Smoking, secondhand smoke exposure, and environmental factors contribute significantly to lung cancer cases.

Why the Other Options Are Incorrect:

A. Breast cancer

Breast cancer is the most commonly diagnosed cancer in women, but it is not the leading cause of cancer deaths. Early detection through mammograms and advancements in treatment have significantly improved survival rates.

C. Brain cancer

Brain cancer is not among the leading causes of cancer deaths in women. It is relatively rare compared to lung or breast cancer.

D. Colon and rectal cancer

Colorectal cancer is a major cause of cancer deaths, but lung cancer surpasses it in mortality rates. Screening methods like colonoscopy help with early detection and prevention.

Summary:

Although breast cancer is the most common cancer in women, lung cancer causes the most deaths due to late detection and aggressive progression.

Correct Answer: A) Determine the communication method he prefers.

When communicating with a patient who has a hearing impairment, the most effective approach is to determine the communication method they prefer. This may include asking the patient directly how they prefer to communicate, whether it’s through lip reading, sign language, written notes, or a hearing aid, as each individual’s needs and preferences can differ. This approach ensures that the patient feels respected and understood while allowing for clear communication.

Why the Other Options Are Wrong:

B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading:

 In fact, facial expressions and hand gestures (such as using sign language or non-verbal communication cues) are extremely helpful for people with hearing impairments, especially if they are lip reading or using sign language. Gestures can aid in making communication clearer, not degrading.

C) Request a sign language interpreter before meeting with him to help facilitate the communication:

While a sign language interpreter might be necessary for some patients, it is not always the preferred method for everyone. The best practice is to first determine the patient's preference before arranging for an interpreter, as some people may not use sign language or may prefer other methods of communication (such as lip reading or written communication).

D) Speak loudly and with exaggerated facial movement when talking with him because this helps with lip reading:

Speaking loudly and with exaggerated facial movements can actually hinder communication, as it may distort lip movements and make it harder for the patient to lip-read. It's more effective to speak clearly at a normal volume and ensure you have the patient's attention, rather than using exaggerated movements.

Summary:

The most effective way to communicate with a patient who has a hearing impairment is to determine the patient's preferred communication method, whether that be lip reading, sign language, or another technique. This ensures effective and respectful communication, meeting the individual needs of the patient.

Correct Answer: C) Tinnitus

Tinnitus is the perception of sound (often described as buzzing, ringing, or humming) in the ears when no external sound is present. It is a common symptom, especially in older adults, and can be caused by various factors, including exposure to loud noise, ear infections, earwax buildup, or other ear conditions. The patient's description of hearing a "buzzing sound" that is "driving me crazy" fits the typical experience of tinnitus, which can be bothersome or distressing for those affected.

Why the Other Options Are Wrong:

A) Vertigo:

Vertigo is a sensation of spinning or dizziness, often accompanied by a loss of balance. It is related to issues in the inner ear or brain but does not involve hearing a buzzing sound. The patient’s complaint of a "buzzing sound" is more consistent with tinnitus than with vertigo.

B) Pruritus:

Pruritus refers to itching, usually of the skin, but it can also affect the ears (ear canal itching). It does not describe a buzzing or ringing sensation. Pruritus in the ear is unrelated to the auditory experience of sound like tinnitus.

D) Cholesteatoma:

A cholesteatoma is an abnormal growth of skin in the middle ear behind the eardrum. It can cause hearing loss, ear drainage, and occasionally dizziness, but it does not typically cause the sensation of buzzing. Tinnitus can occur as a result of a cholesteatoma, but the description of the symptom here (buzzing) more directly indicates tinnitus.

Summary:

The patient's report of hearing a buzzing sound is a classic symptom of tinnitus, which is the perception of sound without an external source. It can be distressing and is often related to underlying conditions such as hearing loss, ear infections, or noise exposure. The other options (vertigo, pruritus, and cholesteatoma) are not consistent with the symptoms described.

Correct Answer: A. 140 mg/dL

Explanation of Correct Answer:

According to standard OGTT guidelines, a two-hour postprandial glucose level less than 140 mg/dL is considered normal. Values between 140 and 199 mg/dL indicate impaired glucose tolerance (pre-diabetes). A value of 200 mg/dL or higher suggests diabetes mellitus.

Why the Other Options are Incorrect:

B. 160 mg/dL and C. 180 mg/dL indicate impaired glucose tolerance and are not normal.

D. 200 mg/dL or above meets criteria for diabetes and is abnormal.

Summary:

A two-hour postprandial glucose result of 140 mg/dL or less is considered normal during an OGTT. Therefore, the RN should recognize 140 mg/dL as the normal value among the options.

The correct answer is C. Observe the specific location and appearance of the ulceration.

This statement is correct because the location and appearance of the ulceration are key indicators in differentiating between venous and arterial ulcers. Venous ulcers typically occur on the medial aspect of the lower leg, often near the ankle, and are characterized by irregular, shallow edges with a red or brownish base, often with surrounding edema and skin changes like varicosities. Arterial ulcers, on the other hand, are usually found on the tips of the toes, the heels, or the lateral malleolus, and they tend to have well-defined, round, deep edges with a pale or necrotic base. Observing the ulcer’s specific characteristics can help differentiate the two conditions.

Why the other options are wrong:

Option A: "Measure the degree of joint range of motion in the extremity."

Measuring joint range of motion does not provide useful information to differentiate between venous or arterial insufficiency ulcers. This assessment is more relevant for evaluating musculoskeletal or mobility issues, rather than for understanding the nature of an ulcer.

Option B: "Compare the skin turgor of the client's upper and lower leg."

While skin turgor can provide information about hydration status, it is not a reliable method to differentiate between venous and arterial insufficiency ulcers. The location and appearance of the ulcer are much more indicative of the underlying cause.

Option D: "Note any change in the color of the ulcer when the leg is moved."

While this could be helpful in assessing arterial insufficiency (for example, noting color changes with elevation due to compromised circulation), it is not as directly related to distinguishing between venous and arterial ulcers as the observation of the ulcer's location and appearance.

Summary:

To differentiate between venous and arterial ulcers, Option C, which involves observing the specific location and appearance of the ulceration, is the most effective technique. The characteristics of the ulcer provide important clues to the underlying pathophysiology, helping guide further assessment and treatment.

The correct answer is B) Wash hands before and after every physical patient encounter.

Hand hygiene is one of the most important actions in preventing the spread of infection. Washing hands before and after each patient encounter helps to minimize the transmission of pathogens between patients and healthcare providers. This practice is critical to ensuring both the examiner’s and patient’s safety.

Why the Other Options Are Incorrect:

A) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact:

Even if gloves are intact, they may become contaminated when touching surfaces, the patient’s skin, or body fluids. Hand hygiene is required after removing gloves to ensure that any potential contamination is eliminated.​​​​​​​

C) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another:

While hand hygiene between different body systems could be beneficial, the primary practice should be washing hands before and after patient encounters overall, rather than only between systems. Hand hygiene at the start and end of the exam covers more of the potential for transmission.​​​​​​​

D) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases:

Wearing gloves is not necessary for all aspects of a routine physical examination unless contact with bodily fluids or non-intact skin is expected. Gloves should be worn when appropriate (e.g., when there is a risk of exposure to blood, bodily fluids, or mucous membranes), but wearing gloves throughout an entire examination may not always be needed. The focus should be on proper hand hygiene.

Summary:

To ensure safety and minimize the risk of infection transmission during a physical examination, the nurse should always wash hands before and after each patient encounter. This practice ensures the best protection against the spread of harmful pathogens.​​​​​​​

The correct answer is A) allergies.

The symptoms described, such as chronic watery eyes, sneezing, and clear nasal drainage, are classic signs of allergic rhinitis, which is commonly associated with environmental allergies. The specific findings on physical examination:

Transverse line across the bridge of the nose: This is often referred to as an "allergic salute" and occurs when a child repeatedly rubs their nose upward due to itching caused by allergies.

Dark blue shadows below the eyes: Known as "allergic shiners," these are caused by congestion in the blood vessels under the eyes due to allergic reactions, leading to a darkened appearance.

Double crease on the lower eyelids: This is known as "Dennie-Morgan lines" and is another sign commonly seen in individuals with allergies.

Other conditions:

Sinus infection (B) usually involves symptoms like facial pain, pressure, and purulent nasal discharge, which were not described here.

Nasal congestion (C) is common in various conditions, but without the associated allergic symptoms like sneezing and watery eyes, it is not the best match.

Upper respiratory infection (D) would generally present with more severe symptoms like fever, sore throat, and thick nasal discharge, which are not present in this case.

In summary:

The child's presentation with chronic watery eyes, sneezing, clear nasal drainage, and characteristic signs such as the transverse nasal line, dark blue shadows, and double eyelid creases is most consistent with allergies.

The correct answer is C. Ask the client to describe the episodes of dyspnea in more detail.

Option C is correct because it is important to gather more detailed information about the episodes of shortness of breath (dyspnea) to understand their context, frequency, triggers, severity, and duration. This information is essential for determining the underlying cause of the symptoms, whether they are related to physical activity, a medical condition, or anxiety. A thorough history will help the nurse and healthcare provider decide on further assessments and interventions.

Why the other options are wrong:

Option A: "Ask the client to perform light exercise and observe the respiratory effect."

This could be helpful in a situation where the nurse suspects exercise-induced dyspnea, but it is not the first action to take. The client already reports experiencing shortness of breath at times, and the nurse should first obtain more detailed information before attempting any interventions or exercises. Directing the client to exercise could be risky without a better understanding of the potential cause.

Option B: "Document 'dyspnea on exertion' in the client's medical record."

While documenting is important, the nurse should first gather more details about the client's symptoms before labeling the condition. The client may experience shortness of breath at rest, with no exertion involved, or the shortness of breath might be triggered by other factors that need to be identified. A more comprehensive assessment is necessary before assigning a specific diagnosis.

Option D: "Explain to the client the possible causes of dyspnea or 'shortness of breath.'"

It is important to explain potential causes of symptoms, but it is premature to provide such an explanation without first gathering detailed information about the client's experience. Providing information without understanding the underlying cause could lead to confusion or anxiety for the client.

Summary:

The best nursing action is to ask the client to describe the episodes of shortness of breath in more detail (Option C). This allows the nurse to better understand the context of the symptom and guide appropriate next steps, whether further assessment, referral, or intervention is needed.