Health Assessment Quizzes

What is the desirable body weight (DBW) for a male is 5'10 tall and weighs 150lb? 168 lbs, 93.6% 166 lbs, 95% 168 lbs, 92.4% 166 lbs, 90.4%

166 lbs, 90.4%

An RN is assessing a client's tonsils who complain of throat pain. She noticed that the tonsils are halfway between the pillars and uvula with white patches on them. Which grading should this nurse document this enlargement of tonsils? 1+ 2+ 3+ 4+

2+

The nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next? 5th left intercostal space midclavicular line 2nd intercostal space left sternal border 3rd intercostal space left sternal border 4th left intercostal space

2nd intercostal space left sternal border

A nurse is calculating the body mass index (BMI) of a 35-year-old male patient. The patient's height is 5'6" and his current weight is 325lb. What would the nurse document as his BMI? 50.5 52.6 55.2 54.5

52.6

The FACES pain scale is best used with the following (Select All That Apply): 98-year old female with acute delirium Children younger than 7-years-old 89-year-old male with dementia 34-year-old male who primarily speaks Spanish 78-year-old male with chest pain 18-year-old with abdominal pain

98-year old female with acute delirium Children younger than 7-years-old 89-year-old male with dementia 34-year-old male who primarily speaks Spanish

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use FIRST in order to assess the client's pain level? Pulse and blood pressure findings Scheduled treatment and client illness A self-report pain rating scale Behavioral indicators and affect

A self-report pain report rating scale

Glasgow coma scale

A tool to assess mental status

In which patient would a pulsation within the epigastric area be considered a normal finding during inspection? A very thin client An elderly client An obese client A client with ascites

A very thin client

Which of the following will take over if the SA node failed to fire an effective electrical signal in the heart? Purkinje fibers AV node Right Bundle of HIs Left Bundle of His

AV node

A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status? Ability to purchase food Nutritional value of food Taste of the food Dentures fitting properly

Ability to purchase food

Acute pain can be differentiated from chronic pain because Acute pain always scores more on the visual analog scale than chronic pain Acute pain occurs only in persons aged less than 45 years, whereas chronic pain occurs in persons aged 46 or above Acute pain is not treated and left to subside on its own, whereas chronic pain is referred for treatment Acute pain is associated with a recent onset of illness or injury with a duration of less than 6 months, whereas chronic pain persists longer than 6 months

Acute pain is associated with a recent onset of illness or injury with a duration of less than 6 months, whereas chronic pain persists longer than 6 months

The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which members would benefit from receiving this vaccination? (Select all that apply). Adult patient caring for children under age 5 A young adult patient who lives alone Adult patients with COPD Older adults attending adult daycare Adolescent patient being homeschooled

Adult patient caring for children under age 5 Adult patients with COPD Older adults attending adult daycare

Which conduction would a registered nurse expect to last longer when assessing hearing with a tuning fork? Bone conduction Air conduction Cartilage conduction Pinna conduction

Air conduction

Which transmission-based precaution requires a nurse to wear an N-95 mask while delivering care? Droplet Contact Standard Airborne

Airborne

Which of the following is or are risk factors for osteoporosis? Select All That Apply. Alcohol use Low calcium Low estrogen Corticosteroid use Smoking

Alcohol use Low calcium Low estrogen Corticosteroid use Smoking

Where is the maximum impact of the heart located? Pulmonic valve Apical pulse Erb's point Aortic valve

Apical pulse

The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should: Ask the client to hold his breath for a few seconds. Ask the client to empty his bladder. Tell the client to raise his arms above his head. Place the client in a side-lying position.

Ask the client to empty his bladder.

Focused Assessment

Assess symptoms restricted to a specific body system

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? The client can read the 20/50 line correctly and two other letters on the line above The client did not wear his glasses for the test and therefore it is not accurate At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet At 50 feet from the chart, the client can see better than a person standing at 20 feet

At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet

Which of the following is or are risk factors for stroke? Select all that apply. Atrial fibrillation Coronary artery disease Hypertension Cystic fibrosis Sickle cell disease Hyperlipidemia Obesity

Atrial fibrillation Coronary artery disease Hypertension Sickle cell disease Hyperlipidemia Obesity

All of the following are fat-soluble vitamins EXCEPT K B A E

B

A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse? Tachycardia Sinus rhythm Bradycardia Arrhythmia

Bradycardia

A registered nurse is assessing a client for a possible eating disorder. She noticed that the client has poor oral hygiene with multiple teeth decay and staining, an acidic-smelling breath, & appears very thin. The client described himself as a perfectionist. Which of the following eating disorder best fit the nurse's assessment? Binge-eating disorder Bulimia nervosa Anorexia nervosa Depression

Bulimia nervosa

Which vessel is the nurse assessing if the major artery of the neck is being examined? Temporal Jugular Radial Carotid

Carotid

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III? Check the pupillary response to light Eliciting the gag reflex Observing for facial symmetry Testing visual acuity

Check the pupillary response to light

Which one of the following is considered subjective data in health assessment? Heart sounds no murmurs and no gallops Blood pressure 142/88 mmHg Chest pain level 2/10 Peripheral radial pulse 64 bpm

Chest pain level 2/10

When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following? Concave Protuberant Flat Rounded

Concave

Central Nervous System

Consisting of brain and spine

A student nurse is educating a client to practice the ABCDE method for assessing a mole on his right chest. What does D stand for? Dissemination Dilation Decent Diameter

Diameter

The nurse is interviewing a client regarding urinary health. Which questions would the nurse include during the collection of subjective data? (Select all that apply.) Do you have to hurry to the bathroom when you have to urinate? After you urinate, does your bladder feel full or empty? Do you ever have an accident or wet yourself when you sneeze? Do you know the results of your recent urine analysis tests? Do you have difficulty starting your stream of urine? How is your bowels moving?

Do you have to hurry to the bathroom when you have to urinate? After you urinate, does your bladder feel full or empty? Do you ever have an accident or wet yourself when you sneeze? Do you know the results of your recent urine analysis tests? Do you have difficulty starting your stream of urine? How is your bowels moving?

During the assessment of a client's urinary system, the nurse learns that the client has painful urination. The nurse would document this finding as: Polyuria Hematuria Dysuria Oliguria

Dysuria

A female client exhibits a purplish bruise on the skin after a fall. The nurse would document this finding most accurately using which of the following terms? Purpura Petechiae Ecchymosis Erythema

Ecchymosis

Lordosis

Exaggerated curvature lumbar spine, normal in toddlers and pregnancy

The nurse is assessing the client's cardiovascular system. Which techniques are appropriate for the nurse to use during this assessment? Select all that apply. Examining the client's legs and noting that the client's hair is evenly distributed Continuing the exam when the client complains of discomfort when lying flat Auscultating the apical impulse at the fifth intercostal space on the left side of the chest at the midclavicular line Examining the client's hands and fingers and noting the presence of clubbing Palpating the client's carotid arteries simultaneously to determine pulse strength, rhythm, and rate

Examining the client's legs and noting that the client's hair is evenly distributed Auscultating the apical impulse at the fifth intercostal space on the left side of the chest at the midclavicular line Examining the client's hands and fingers and noting the presence of clubbing

A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve? Optic Facial Olfactory Vagus

Facial

Skin turgor measurement is always reliable for an older adult client who might exhibit decreased skin turgor as part of age-related changes. True False

False

What are signs and symptoms of left side heart failure? Select All that Apply. Fatigue Orthopnea Pink frothy sputum Jugular vein distention Lung sounds - crackles

Fatigue Orthopnea Pink frothy sputum Lung sounds - crackles

During a focused assessment, the female client reports breast tenderness, swelling, and lymph node enlargement around the time of her period. Which response by the nurse is the most appropriate? This sounds like a condition known as nodularity. It is a benign disorder so you will need to monitor your breasts monthly. Fluctuating hormone levels around the time of your period frequently cause these symptoms. I will note this in your chart and notify your PCP. Do you have a history of fibrocystic disease? These symptoms are usually seen with this disease. As long as have you not detected any lumps, you have nothing to worry about.

Fluctuating hormone levels around the time of your period frequently cause these symptoms. I will note this in your chart and notify your PCP.

The nurse is assessing a 72-year-old patient in the clinic. Which statement made by a 72-year-old client describes a normal process of aging? My tongue feels swollen. I have a black spot on my gums. My tonsils are large and sore. Food doesn't taste the same as it used to.

Food doesn't taste the same as it used to.

Follow-Up History

For evaluation

The nursing instructor is observing a student nurse assess the client's respiratory system. Which technique demonstrated by the student is the most appropriate? From side to side From base to the apex of lungs First down one side of the thorax, then down the other First up one side of the thorax, then up the other

From side to side

Which of the following best describes normal healthy lymph nodes? General hard to touch with heat It is normal for patient to report tenderness while palpating lymph nodes Generally impalpable; if palpable, lymph nodes should be soft and mobile Lymph nodes should always be visible

Generally impalpable; if palpable, lymph nodes should be soft and mobile

The nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. The nurse should instruct the client to reduce her risk factors by Getting regular exercise Drinking large quantities of milk Resting frequently Eating a high-protein diet

Getting regular exercise

Protrusion of the eyeball (exophthalmos) with a glaring appearance is usually associated with which illness? Diabetes Graves' disease Cancer of the pancreas Chronic renal failure

Graves' disease

Which one of the following is NOT a part of the skin health history assessment? Rash Hair distribution pattern on legs Lesion Pruritus

Hair distribution pattern on legs

When obtaining a cardiovascular health history on a patient the nurse should ask the patient which questions? Select all that apply. Have you been treated for any CV disease? Have you had any weight changes? Are you able to perform your ADLs? Do you have any body aches? Do you know your cholesterol and triglyceride levels?

Have you been treated for any CV disease? Have you had any weight changes? Are you able to perform your ADLs? Do you know your cholesterol and triglyceride levels?

What is the foundation of nursing practice? Outcome identification Planning Health assessment Diagnosing

Health assessment

When percussing a client's lung area the nurse notes a resonance. What does the tone indicate? Healthy lungs The nurse is percussing over a rib Solidified lungs Air trapped in the lungs

Healthy lungs

Which of the following is NOT a part of the skin lesion assessment? Heat Shape Edge Location

Heat

A client presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The patient describes these as painful. The nurse suspects what condition? Syphilis Actinic cheilitis Angioedema Herpes simplex

Herpes simplex

Which of the following is NOT a prostate cancer risk factor? African-American race History of congestive heart failure Age older than 65 High dairy and calcium intake

History of congestive heart failure

A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform? Extend the right arm upward Hold the right arm straight Flex the right arm at the elbow Hold the wrist at a 90-degree angle

Hold the wrist at a 90-degree angle

All of the following are open-ended questions EXCEPT Describe yourself. How many days have you been running a fever? What bring you in to the clinic today? How have you been feeling?

How many days have you been running a fever?

Which one of the following disorders will NOT present any symptoms until a significant cardiovascular event occur? Bulimia nervosa Hyperlipidemia Kidney failure Obesity

Hyperlipidemia

Which of the following statement made by the nursing student about Jugular Vein Distention indicates further education? I expect to see JVD on a client with left-side heart failure. I expect to see JVD on a client with right-side heart failure. JVD is a sign of increased central venous pressure. JVD should be best assessed from the right internal jugular vein.

I expect to see JVD on a client with left-side heart failure.

Which of the following is not a component of health history? My first day of last menstrual cycle was around 1/1/2022 I feel sad because of my mother's death My dad takes medicine for his blood pressure I have a fever for about 6 days

I feel sad because of my mother's death

A female client asks the nurse when the best time is to perform a self-breast examination (SBE). Which response by the nurse is the most appropriate? If you are still menstruating, the best time is about 5 days after your period begins each month. Your primary care provider can tell you when the best time is for you. If you are postmenopausal, the best time is at the beginning of each month. It doesn't really matter as long as you keep a record of when you perform the exam.

If you are still menstruating, the best time is about 5 days after your period begins each month.

Which of the following would the nurse suspect when a client with a cardiac condition complains of not sleeping well and having to get up frequently at night to urinate? This indicates the heart is working efficiently The client most likely sleeps without a pillow at night The client has decreased performance levels of ADLs Increased urination at rest may indicate heart failure

Increased urination at rest may indicate heart failure

The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first: Percuss for tympany Palpate the incision site Inspect the abdominal area Auscultate for bowel sounds

Inspect the abdominal area

The nurse is preparing to assess the client's skin, hair, and nails. Which technique will the nurse use initially during the assessment? Ausultation Percussion Palpation Inspection

Inspection

The nurse is preparing to perform a cardiac assessment on a client. Rank the assessment steps in the order in which they will occur. Percussion of client's chest Palpation of the precordium and pulses Inspection of the client's head and neck, chest, abdomen, and extremities Auscultation of the client's heart, apical pulse, and carotid arteries

Inspection Palpation Percussion Auscultation

Which sequence of assessment techniques is used for an abdominal assessment? Auscultation, percussion, palpation, inspection Palpation, inspection, auscultation, percussion Inspection, auscultation, percussion, palpation Inspection, percussion, palpation, auscultation

Inspection, auscultation, percussion, palpation

The popliteal artery can be palpated at the Knee Groin Foot Ankle

Knee

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client? Kyphosis Lordosis Scoliosis Ankylosis

Kyphosis

A registered nurse is assessing a 72-year-old client who was diagnosed with osteoporosis at age 65. The nurse detects the client has kyphosis on exam. The nurse suspects that: Kyphosis is not normal and must be evaluated further Kyphosis is related to previous injury and should be monitored Kyphosis is a normal finding for this age group because of osteoporosis Kyphosis will require the client to be in a wheelchair

Kyphosis is a normal finding for this age group because of osteoporosis

Which one of the following foods is NOT considered a high-biologic value protein? Legumes Fish Poultry Eggs

Legumes

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for Bruits over the radial artery Poor peripheral pulses Raynaud disease Lymphedema

Lymphedema

A patient asks what can be done to reduce the risk of developing breast cancer. What should the nurse instruct this patient? (Select all that apply). Maintain a normal body weight Wear a support bra at all times Avoid breast-feeding Limit exercise Limit alcohol use

Maintain a normal body weight Limit alcohol use

Abduction

Movement of a body part away from the midline of the body

Adduction

Movement of a body part toward the midline of the body

A nurse is reviewing risk factors for respiratory infection with an older adult patient. Which physiologic change that occurs with aging predisposes the older adult to respiratory infections? There is a reduction of interalveolar folds. Calcification occurs at the rib articulation points. The alveoli become less elastic and more fibrous. Mucous membranes become drier and more difficult to clear.

Mucous membranes become drier and more difficult to clear.

The nurse wants to assess the apex of a client's right lung. Which locations should the nurse place the stethoscope to assess this area on the client? Near the right clavicle Below the scapula Near the left clavicle Intercostal space fourth rib near the axillary line

Near the right clavicle

The nurse is caring for a client with a wound. Which assessment finding would the nurse report to the physician immediately? Scant serosanguinous drainage Client report of itching at the wound edges Pink wound bed Necrotic tissue covering 25% of the wound

Necrotic tissue covering 25% of the wound

During the assessment of a client's renal system, the nurse is unable to palpate the kidneys. This nurse would consider this finding as: Normal A sign of polycystic kidney disease An indication of an inflammatory condition of the kidneys A sign of acute or chronic renal disease

Normal

Which one of the following is NOT associated with black tarry stool? Excessive iron Obstructive jaundice Bismuth ingestion Upper GI bleeding

Obstructive jaundice

How can a nurse best assess a client's dietary habits? Calculate a body mass index Ask about how much food is eaten at a average meal Assess for the presence of any chronic diseases processes Obtain a 24-hour dietary recall of all foods and fluids consumed

Obtain a 24-hour dietary recall of all foods and fluids consumed

Where is the costovertebral angle (CVA) located? On the back at the middle of ribcage at the 10th rib On the left side of the back between the 12th rib and the vertebral column On the bilateral flank side On either side of the back between the 12th rib and vertebral column

On either side of the back between the 12th rib and vertebral column

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what? Tachypnea Pneumonia Sleep apnea Orthopnea

Orthopnea

The nurse is preparing to examine a client's internal ear. Which equipment would be necessary? Measuring tape Otoscope Tuning fork Watch with a second-hand

Otoscope

When examining and documenting findings associated with the eyes, nurses typically follow the assessment model noted below. HEENT PERRLA PEARL AACN

PERRLA

A nurse is unable to palpate a client's radial and ulnar pulses. Which of the following would the nurse do next? Auscultate the apical pulse Refer the client for medical follow-up Palpate the brachial pulse Document the finding

Palpate the brachial pulse

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for? Obstruction in the femoral artery Diabetes mellitus Peripheral arterial problems Calcium deficiency

Peripheral arterial problems

Which one of the following orientations is last to be lost? Person Location Time Situation

Person

A nurse should include the following items when forming general inspection (Select All That Apply) Present medical complaint Physical appearance Position and posture Emotional status Past medical history Body structure Mood and affect Past surgical history

Physical appearance Position and posture Emotional status Body structure Mood and affect

Comprehensive Health History

Provides fundamental and personalized knowledge

Drooping of one or both eyelids is called: Accomodation Entropian Ptosis Ectropian

Ptosis

What is the most important lifestyle changes a client can make to improve cardiovascular health? Living a more sedentary lifestyle Getting less exercise and more rest Quitting smoking Eating a diet high in fat

Quitting smoking

A student nurse is performing symptom analysis with the OLD CARTS format. The client's responded, "I have not had a bowel movement ever since my abdominal pain started". The client's statement indicates Related symptoms Onset Characteristics Severity

Related symptoms

Autonomic nervous system

Responsible for involuntary control of the body and to regulate internal environment

When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant? RIght kidney, transverse colon, and inguinal ligament Right ovary, pancreas, and sigmoid colon Right ovary, descending colon, and spleen Right kidney, ascending colon, and liver

Right kidney, ascending colon, and liver

A registered nurse uses Braden scale to assess: Risk for developing petechiae Risk for developing wheals Risk for developing melanoma Risk for developing pressure ulcers

Risk for developing pressure ulcers

The priority nursing diagnosis for a client with pruritus who constantly scratches affected areas and appears agitated about the itching sensation would be: Risk for infection related to pruritus Impaired skin integrity related to dehydration from treatment medications Risk for social isolation related to poor self-image Ineffective health maintenance related to lack of knowledge about disease process

Risk for infection related to pruritus

A client scored 5 points on the Glasgow Coma Scale, the nurse knows this indicates Severe brain injury Minor brain injury No brain injury Moderate brain injury

Severe brain injury

During the inspection of a 5-year-old girl's reproductive system, the nurse identified small lacerations and bruises on the labia majora and minora. What does this finding suggest to nurses? Pediculosis pubis Masculinization Sexual abuse Sexually transmitted infection

Sexual abuse

Which of the following pain characteristics is associated with A-delta fibers? Sharp Dull Aching Throbbing

Sharp

Shift Assessment

Short examination focused on disease detection

Which of the following tests should be performed to assess extraocular movements (EOM)? PERRLA Cover-uncover eye test Red reflex Six cardinal fields of gaze

Six cardinal fields of gaze

A student in the vascular surgery clinic is asked to perform a physical examination on a client with known peripheral vascular disease in the legs. Which of the following aspects are most important to note? Nodules in joints Lower extremity strength Muscle bulk and tone Size, symmetry, and skin color

Size, symmetry, and skin color

The student nurse explained to a client the reason why he/she would pinch the skin over the clavicles slightly is to assess: Skin texture Skin thickness Skin elasticity and turgor Skin color

Skin elasticity and turgor

Which of the following is NOT a sign of distress? Slumped posture Tripod position Fetal position Clutching the chest

Slumped posture

During the health history of the urinary system, a patient tells the nurse about "leaking" urine when coughing or laughing. The nurse should focus additional questions to address which health problem? Obstructive incontinence Stress incontinence Urge incontinence Overflow incontinence

Stress incontinence

Which position should be client be placed for abdominal assessment? Left lateral position Sitting upright on the examination table Supine High Fowler's position

Supine

The nurse positions her hands for a thyroid examination with a posterior approach. Once she has identified landmarks and her hands are in place, she advises the patient to ____________. Cough Say "ah" Swallow Turn her head from side to side

Swallow

While assessing the patient's skin, the nurse observes a similar pattern of small, raised lesions on the left and right upper back areas. Which term should the nurse use to document these lesions? Confluent Generalized Zosteriform Symmetric

Symmetric

Active listening skills include all of the following EXCEPT Taking detailed notes Ask open-ended questions to explore the client's perspective Watching for clues in body language Repeating statements back to the client to ensure understanding

Taking detailed notes

Strain

Tearing of a tendon

Sprain

Tearing of ligaments

Which level of health promotion and prevention focuses on minimizing the severity and disability of the disease? Secondary Primary Tertiary Primordial

Tertiary

A patient was brought to the emergency department and complained of chest pain. This patient experience a head-on collision. The patient was a restrained driver. Airbags deployed. Upon arrival, the nurse noticed that patient is having paradoxical breathing. His respiration rate is 28 breaths/minute. SaO2 is 99% on 2L oxygen through a nasal cannula. Which of the following are the most appropriate assessment interpretation and nursing actions? The assessment suggests a flail chest. The emergency provider should be notified immediately. The assessment suggests diabetic ketoacidosis. The emergency provider should be notified immediately. The assessment suggests pneumothorax. The emergency provider should be notified immediately. The assessment suggests a funnel chest. No further intervention is needed.

The assessment suggests a flail chest. The emergency provider should be notified immediately.

A client reports severe pain in the left lower quadrant of three (3) days duration. How should the nurse conduct palpation of the abdomen due to this history? The left lower quadrant is palpated last. Encourage the client to relax to minimize pain. This area should be avoided completely Medicate for pain before beginning the assessment

The left lower quadrant is palpated last.

The nurse auscultates the abdomen to gain information regarding: The peristaltic activity of the intestinal tract The metabolic activity of the liver The perfusion of mesentery The production of erythrocytes by the spleen

The peristaltic activity of the intestinal tract

If the clinician documents that the tonsils are graded as 3+ in size, it means: The tonsils are visible The tonsils are nearly touching the uvula The tonsils are halfway between tonsillar pillars and uvula The tonsils are touching one another

The tonsils are nearly touching the uvula

Acoustic/Vestibulocochlear

This nerve can be tested by Romberg's test and finger to nose test

Trigeminal Nerve

This nerve can be tested by asking patient to clench teeth while palpating temporal muscle

Spinal Accessory

This nerve can be tested by asking patient to raise and lower shoulders and to turn head

Hypoglossal

This nerve can be tested by asking patient to stick tongue out and to move in several directions

Olfactory

This nerve can be tested by having the patient smell a known substance

Facial Nerve

This nerve can be tested by inspecting the face at rest and during conversation, noting symmetry, tics, or abnormal movements

Romberg Test

To assess balance

Which of the following is NOT a purpose of deep palpation? To assess palpations To determine organ size To determine organ contour To determine organ shape

To assess palpations

The nurse is asking the client about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason? To establish rapport with the patient To assess the patient's quality of life To get to know the patient better To identify diseases for which the patient might be at risk

To identify diseases for which the patient might be at risk

The apical rate may be faster than the radial rate when the client has atrial fibrillation. True False

True

A registered nurse is listening to a client's heart sound. She hears a murmur and she knows the mechanism of murmur is Pericarditis Emphysema Turbulent blood flow Cardiac tamponade

Turbulent blood flow

Eversion

Turning of a body part away from the midline

To assess vibration during a physical assessment, the nurse would use which part of the hand? Palm Dorsum Pointer finger Ulnar aspect

Ulnar aspect

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible: Intra-abdominal bleeding Pancreatitis Ascites Umbilical hernia

Umbilical hernia

A client with chronic bronchitis is admitted to the hospital. The nurse inspects the client while assessing the client's respiratory system. Which assessment finding is expected? Dry cough Decreased respiratory rate Fever Use of accessory muscles

Use of accessory muscles

Which of the following is or are sensory discrimination tests? Select All That Apply. Vibration Position Light touch Graphesthesia Stereognosis

Vibration Position Light touch Graphesthesia Stereognosis

A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing? Wearing ear guards whenever inside the plant Minimizing the amount of noise exposure to 3 hours a day Taking a 10-minute break every 2 hours Cleaning ears regularly to prevent ear infections

Wearing ear guards whenever inside the plant

The nurse auscultates the client's lungs and prepares to document the assessment. Which breath sounds are considered abnormal and may require further intervention? (Select all that apply. Wheezes Crackles Bronchial Vesicular Bronchovesicular

Wheezes Crackles

The student nurse is studying the difference between middle-age adults and older adults. The student nurse should be aware that the neurologic responses of older adults: should be the same as those of younger adults are enhanced as a result of irritability are present but difficult to evaluate may be slower than those of young adults

may be slower than those of young adults