Fundamentals of Nursing Practice Test Part 2

Bowel sounds are generally described as normal, audible, absent, hyperactive, or hypoactive. The nurse must listen for 3-5 minutes before deciding that bowel sounds are absent in any one quadrant. Absent sounds may indicate cessation of GI motility that may result from late stage bowel obstruction, paralytic ileus, or peritonitis. (Potter and Perry, Fundamentals of Nursing)

A Hering Breuer Reflex prevents the lungs from over expanding.

A score of three denotes a motor function where active movement against gravity is noted. No muscular contraction detected has a score of zero. Active movement of the body with gravity eliminated has a score of two. Active movement against gravity and some resistance is for motor function with a score of 4.

A patient is said to be in stupor if the condition of deep sleep or unresponsiveness is noted and is only aroused by pain stimulation.

The hypothalamus is responsible for regulating body heat. Wernicke’s area is involved in the understanding of written and spoken language. Broca’s area is responsible for speech production. Choroid plexus is the one that forms the CSF.

Tactile fremitus is a vibration felt on the patient’s chest or back during low frequency vocalization. Commonly, the patient is asked to repeat a phrase while the examiner feels for vibrations by placing a hand over the patient's chest or back. Phrases commonly used include 'ninety-nine' and 'boy oh boy'. A- Tactile fremitus is the vibration felt by the patient on humming with the mouth closed. – subjective fremitus B- Tactile femitus is the vibration felt by a male patient feels in the testicles when coughing. – tussive fremitus C- Tactile fremitus is the palpable vibration produced during breathing caused by partial airway obstruction. – rhonchial fremitus

In children the pinna is pulled down and backwards and positioned at the affected ear area when administering otic medications. In adults, it is pulled up and backwards.

Rinne Test is used to assess conductive hearing loss by comparing the air conduction with bone conduction. Weber test is a lateralization test that compares the right and left ear function. An Ishihara’s plate is a visual test that detects color blindness. Schwabach test is used to assess the auditory function of a patient by comparing the client’s hearing with that of the examiner.

A barrel chest is characterized by a wider AP diameter than transverse diameter. A pigeon chest is a permanent deformity where a narrow transverse diameter, increased AP diameter and a protruding sternum is noted. A funnel chest is characterized by a depressed sternum, narrowed AP diameter and an abnormal pressure is exerted on the heart.

Korotkoff’s sound is the sound heard when taking BP.

A pustule is an elevated skin layer containing pus such as in acne or impetigo. Vesicles contain a serous fluid, while bulla has the same properties of vesicles but is just larger.

Bruits are soft rushing sound on an enlarged thyroid. An ecchymosis is a hematoma or a bruise. A friction rub is an adventitious breath sound that is caused by the superficial grating sound due to rubbing of inflamed pleural spaces. Korotkoff sounds are the sounds heard during BP taking.

When palms are facing upward a supination is noted, and its opposite is pronation. When a bone moves away from the midline abduction is performed, while moving it towards the midline is adduction.

Spontaneous lack of movement and speech but is easily aroused by environmental stimulation is said to be a manifestation of a lethargic person.

When the climate is hot or the person has a fever the blood becomes warmer. The warmer than normal blood activates the hypothalamus to loss heat by dilating the skin blood vessels, thus, B is wrong because it is not the skin blood vessels but the warm blood that activates the hypothalamus.

If the denominator is greater than the numerator myopia or nearsightedness would be the diagnosis. 20/200 vision is the legal definition of blindness. Farsightedness or hyperopia is positive when the Snellen’s chart test result shows that the denominator is lesser than the numerator.

Internal respiration or perfusion is the process of exchanging gases between the cells and the blood. Ventilation or otherwise known as the external respiration is the process of exchanging gases in the lungs.

A- Warmth – calor B- Redness – rubor C- Pain – dolor D- Swelling – tumor

If light is present the normal pupillary reaction is constriction. Pupils should be equal and there should be a consensual response (bilateral), meaning to say even if the other eye is not stimulated with light it still constricts.

Because of the word “least likely” Letter B is the answer. Lithotomy position is used for vaginal examination. A supine position is used in abdominal assessments.

A- Warmth – calor B- Redness – rubor C- Pain – dolor D- Swelling – tumor

Schwabach test is used to assess the auditory function of a patient by comparing the client’s hearing with that of the examiner. Perimetry tests the client for loss of peripheral vision. Gonioscopy is used to measure the angle to differentiate the close and open angle glaucoma. Tonometry measures the intraocular pressure.

Palpation is the last technique to perform in doing an abdominal assessment.

A funnel chest is characterized by a depressed sternum, narrowed AP diameter and an abnormal pressure is exerted on the heart. A barrel chest is characterized by a wider AP diameter than transverse diameter. A pigeon chest is a permanent deformity where a narrow transverse diameter, increased AP diameter and a protruding sternum is noted. There is no such thing as a scoliotic chest.

Farsightedness or hyperopia is positive when the Snellen’s chart test result shows that the denominator is lesser than the numerator. If the denominator is greater than the numerator myopia or nearsightedness would be the diagnosis. 20/200 vision is the legal definition of blindness.