Health Assessment and Promotion In-Class Quizzes

GI/GU Which patient statement alerts the nurse to perform a thorough GI history and focused assessment? A) "I take ibuprofen three times daily for arthritis." B) "I don't like the taste of spicy foods." C) "I experience occasional constipation." D) "I got dentures four years ago."

A ("I take ibuprofen three times daily for arthritis.")

Peripheral Vascular and Lower Lymphatics A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A) Assess the apical pulse for a full minute. B) Assess the pedal pulses for a full minute. C) Assess the pedal pulses with a Doppler device. D) Assess the apical pulse with a Doppler device.

A (Assess the apical pulse for a full minute.)

Neuro When assessing a patient's deep tendon reflexes, the nurse does not get a strong response with their patellar reflex. What is the most appropriate action? A) Document as a diminished response/1. B) Notify the physician of the unexpected finding. C) Have the patient tighten their quadriceps to aid in a response. D) Try again and have the patient use a distraction technique

A (Document as a diminished response/1.)

Health Assessment Basics A patient comes to the emergency room with a suspected fracture of their lower leg. Which of the following assessments would the nurse complete? A) Focused B) Comprehensive C) Basic

A (Focused)

Musculoskeletal When assessing your patient you notice their knee joint is red, swollen and warm to the touch. Which of the following would best describe your findings? A) Inflammation B) Effusion C) Crepitus D) Atrophy

A (Inflammation)

What is the abbreviation for the right eye when documenting its score on the Snellen chart? A) OD B) OS C) OU

A (OD)

Neuro The nurse is caring for an older adult who is usually alert and oriented. When the patient exhibits a change in mental status, which cause does the nurse assess for first? A) Oxygen insufficiency B) Electrolyte imbalance C) Use of sedatives D) Infection

A (Oxygen insufficiency)

When the nurse performs the corneal light reflex, the light reflects on different parts of each eye and not directly in the center of each pupil. This finding is documented as: A) ocular misalignment B) ocular deviation C) hyperopia D) anisocoria

A (ocular misalignment)

GI/GU When obtaining a health history from a 22-year-old female client who has new-onset urinary incontinence, which finding or factors does the nurse consider significant? Select all that apply. A) A burning sensation occurring on urination B) Urinating 10 times daily although fluid intake remains unchanged C) A foul odor from the urine D) A new inability to hold urine E) A recent change in the client's oral contraceptive prescription F) Chemical exposure in the workplace

A, B, C, D (A burning sensation occurring on urination, Urinating 10 times daily although fluid intake remains unchanged, A foul odor from the urine, A new inability to hold urine)

Neuro The nurse is caring for a patient with an acoustic neuroma. When preparing to assess the patient further which of the following tests should the nurse anticipate doing? Select all that apply. A) Weber test B) Whisper test C) Romberg test D) Rinne test E) Snellen test

A, B, D (Weber test, Whisper test, Rinne test)

Neuro When assessing a patient, the nurse notes that they cannot identify the scent as coffee. How should the nurse document this? A) Ptosis of nares bilaterally. B) Anosmia present bilaterally. C) Olfactory nerve is intact. D) Cranial nerve III is not intact.

B (Anosmia present bilaterally.)

Health Assessment Basics You are caring for a newly admitted patient with congestive heart failure. Which of the following assessments would you complete? A) Basic B) Comprehensive C) Focused

B (Comprehensive)

Health Assessment Basics A 35-year old female patient is scheduling a Pap smear. She has never had an abnormal result. What is the recommended timeline for this type of screening? A) Every year B) Every 5 years C) Every 2 years D) Every 3 years

B (Every 5 years)

GI/GU A patient with a history of kidney disease is admitted with acute shoulder pain. Which order should the nurse question? A) Pan cultures for a temperature >38.5º C B) Ibuprofen 800 mg by mouth every 4 hours as needed for pain C) Digoxin 0.125 mg by mouth daily D) Metoprolol 50 mg by mouth twice daily

B (Ibuprofen 800 mg by mouth every 4 hours as needed for pain)

Peripheral Vascular and Lower Lymphatics Which of the following patients would you prioritize first? A) Patient with a pedal pulse of +1 bilaterally B) Patient with +2 on the right, 0 on the left C) Patient with SBP of 130 D) Patient with bilaterally cool feet

B (Patient with +2 on the right, 0 on the left)

Musculoskeletal Knowing the intended range of motion for joints, which of the following would the nurse anticipate the patient being able to perform using their elbow? Select all that apply. A) Abduction B) Extension C) Circumduction D) Supination E) Flexion

B, E (Extension, Flexion)

Neuro A patient with cerebral edema after a motor vehicle accident opens their eyes to noise, grunts when the nurse asks questions and withdraws from painful stimuli. When documenting these findings, what is the associated Glascow Coma Scale score? A) 13 B) 11 C) 9 D) 5

C (9)

Neuro A nurse comes into a patient's room to perform an assessment and administer medication. When asked if they would like to take their medication with water or juice, the patient starts yelling at the nurse and tells her to get out of the room. How should the nurse document this patient's response? A) Flat affect B) Impulsive C) Aggressive D) Confused

C (Aggressive)

Peripheral Vascular and Lower Lymphatics When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following? A) Thrombus formation in the vein B) Within the expected range C) Arterial insufficiency D) Venous insufficiency

C (Arterial insufficiency)

Health Assessment Basics You are starting your shift and begin to see your patients. One of which has been on the unit for two days with Covid. Which of the following assessments would be most appropriate? A) Comprehensive B) Focused C) Basic

C (Basic)

GI/GU When administering a new GI medication to an older patient, the nurse anticipates what? A) Nausea and vomiting may develop rapidly and are common side effects in older adults. B) Older adults always require a lower-than-normal dose than younger patients. C) Close monitoring is needed because toxic levels may develop. D) A higher-than-normal dose may be needed.

C (Close monitoring is needed because toxic levels may develop.)

GI/GU The nurse is assessing a patient's AV fistula and notes there is not a thrill present. What is the priority action? A) Reschedule dialysis for tomorrow. B) Reassess in 1 hour. C) Notify the physician. D) Administer dialysis via the AV fistula.

C (Notify the physician.)

Musculoskeletal Falls can lead to complications including fractures and soft tissue injury. Which of the following patient populations are most at risk for these types of complications? A) Middle-aged adults B) Toddlers C) Older adults D) Adolescents

C (Older adults)

Health Assessment Basics A patient has made an appointment for a physical exam. This is an example of which of the following types of disease prevention? A) Primary B) Tertiary C) Secondary

C (Secondary)

GI/GU When assessing a patient with an indwelling catheter the nurse notes the color as brown. Which of the following is most likely the cause of this finding? A) Congestive heart failure B) Old urinary tract bleed C) Severe dehydration D) 10-year history of diabetes mellitus

C (Severe dehydration)

Health Assessment Basics A patient with diabetes is administering insulin as directed by their physician. This is an example of what type of disease prevention? A) Secondary B) Primary C) Tertiary

C (Tertiary)

Musculoskeletal You are educating a patient with osteoporosis. They are interested in learning more about weight-bearing activities. Which of the following would you suggest? A) Biking B) Swimming C) Walking D) Using resistance bands while seated

C (Walking)

When assessing the pediatric patient's ears with an otoscope the nurse notes an excess of wax. Another way to document is excess__________. A) drainage B) furuncle C) cerumen D) tinnitus

C (cerumen)

When assessing a patient's tonsils, the nurse notes many red spots. The cause of this is most likely ________. A) tonsillitis B) post nasal drip C) strep throat D) fungal infection

C (strep throat)

Peripheral Vascular and Lower Lymphatics A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A) Increased hematocrit B) Increased temperature C) Increased blood pressure D) Increased respiratory rate E) Increased heart rate

C, D, E (Increased blood pressure, Increased respiratory rate, Increased heart rate)

Neuro The emergency department nurse is caring for a 78-year old patient whose daughter reports a decrease in cognition. Which nursing statement directed to the patient helps the nurse to assess cognition? A) "Tell me how you were transported to the hospital today." B) "Please count backward from 100 by 7s." C) "I will write a word on this paper, and you copy it." D) "Tell me what this fable means to you."

D ("Tell me what this fable means to you.")

Musculoskeletal The nurse is caring for four female patients. Which patient is identified as being at greatest risk for low bone density? A) 50 year old African American B) 44 year old Native American C) 22 year old Asian American D) 39 year old Caucasian American

D (39 year old Caucasian American)

GI/GU A patient with kidney failure reports dyspnea. The patient's pulse oximeter reading is 95% on room air, but is visibly distressed with a respiratory rate of 32 breaths/min. What is the priority intervention? A) Administer a respiratory nebulizing treatment. B) Administer lorazepam as the patient's tachypnea is related to anxiety. C) Notify the respiratory therapist. D) Administer oxygen by nasal cannula.

D (Administer oxygen by nasal cannula.)

Peripheral Vascular and Lower Lymphatics A student nurse is documenting their lymphatic assessment of a patient admitted for fever of unknown origin. Which of the following actions by the student nurse would cause the instructor to intervene? A) Documenting lymph nodes as enlarged and fixed. B) Palpating the epitrochlear lymph nodes on the medial side by the bend of the arm. C) Using the pads of their fingers in a circular motion to assess the lower lymph nodes. D) Assessing the inguinal lymph nodes first, then moving to the upper lymphatics (pre-auricular, post-auricular, etc.).

D (Assessing the inguinal lymph nodes first, then moving to the upper lymphatics (pre-auricular, post-auricular, etc.).

Neuro A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: A) Bell's palsy B) Frostbite with paresthesia to the cheeks C) Scleroderma D) Damage to the trigeminal nerve

D (Damage to the trigeminal nerve)

Neuro The nurse is caring for a 30-year-old patient who experienced a frontal lobe infarction after a motorcycle accident. What is the appropriate nursing intervention? A) Instruct the patient to use a call light prior to getting out of bed. B) Use a picture board to assist with communication. C) Place all items directly in front of the patient. D) Enable the bed alarm safety system.

D (Enable the bed alarm safety system.)

The nurse asks the patient to close their eyes tightly. By doing so, the patient is demonstrating that which of their cranial nerves is intact? A) III B) IV C) VI D) VII

D (VII)