Exam 1 (Assessments)

Which patient's description of pain is consistent with injury to a bone? 1. "Deep, dull, and boring" 2. "Cramping even when not moving" 3. "Intermittent, sharp, and radiating" 4. "Tingling with pins and needles sensation with movement"

1. "Deep, dull, and boring"

Which question gives the nurse additional information about a patient's report of his hands shaking for the last 2 months? 1. "Does the shaking occur when your hands are at rest or when you are picking up an item?" 2. "Do you experience any abnormal sensations, such as tingling or coldness, at the same time?" 3. "What actions do you take to relieve the shaking when it occurs?" 4. "Have you ever experienced this shaking before?"

1. "Does the shaking occur when your hands are at rest or when you are picking up an item?"

A patient has multiple solid, red, raised lesions on her legs and groin that she describes as "itchy insect bites." How does the nurse document these lesions? 1. Wheals 2. Bulla 3. Tumors 4. Plaques

1. Wheals

Narrowing of the bronchi creates which adventitious sound? 1. Wheeze 2. Crackles 3. Rhonchi 4. Pleural friction rub

1. Wheeze

When a patient complains of chest pain, which question is pertinent to ask to gain additional data? 1. "What were you doing when the pain first occurred?" 2. "What does the pain feel like?" 3. "Do you have shortness of breath?" 4. "Has anyone in your family ever had a similar pain?"

2. "What does the pain feel like?"

The nurse examines a patient's auditory canal and tympanic membrane with an otoscope. Which finding is considered abnormal? 1. Presence of cerumen 2. Yellow color to the tympanic membrane 3. Presence of a cone of light 4. Shiny, translucent tympanic membrane

2. Yellow color to the tympanic membrane

Which finding does the nurse expect during auscultation of the heart? 1. A low-pitched blowing sound is heard over the apex of the heart. 2. A high-pitched vibration is heard over the base of the heart. 3. The S1 heart sound is louder at the apex of the heart. 4. The S3 heart sound sounds like "Ken-tuck-y."

3. The S1 heart sound is louder at the apex of the heart.

The nurse assessing the patient's muscle strength finds that the patient has full resistance to opposition. Using the table, how would this finding be documented? 1. Poor or 2/5 2. Fair or 3/5 3. Good or 4/5 4. Normal or 5/5

4. Normal or 5/5

During inspection of the respiratory system the nurse documents which finding as abnormal? 1. Skin color consistent with patient's race 2. 1:2 ratio of anteroposterior to lateral diameter 3. Respiratory rate of 20 breaths per minute 4. Patient leaning forward with arms braced on the knees

4. Patient leaning forward with arms braced on the knees

Which disorder is an example of a vascular lesion? 1. Dermatofibroma 2. Vitiligo 3. Sebaceous cyst 4. Port wine stain

4. Port wine stain

The nurse is listening to the patient's heart at the 2nd LSB. Which area is being auscultated? 1. Erb's point 2. Mitral area 3. Aortic area 4. Pulmonic area

4. Pulmonic area

A nurse is obtaining a health history from a 52-year-old male patient with a red lesion at the base of the tongue. What additional data does the nurse specifically collect about this patient? 1. Alcohol and tobacco use 2. Date of his last dental examination 3. Use of dentures 4. A history of pyorrhea

1. Alcohol and tobacco use

The nurse asks a patient to stand with her feet together, her arms placed at her sides, and her eyes closed. The nurse then observes the patient moving her foot to maintain balance and opening her eyes. Based on this finding, which additional assessment does the nurse perform to confirm an abnormality with balance? 1. Ask the patient to walk in tandem, putting the heel of one foot directly against the toes of the other foot. 2. Ask the patient to sit down and alternatively tap the thighs with your hands using rapid supination and pronation movements. 3. Place a vibrating tuning fork in the patient's ankle and ask when she no longer detects the vibration. 4. With the patient in a seated position, support one lower leg while sharply dorsiflexing the foot and maintain it in flexion.

1. Ask the patient to walk in tandem, putting the heel of one foot directly against the toes of the other foot.

A patient describes a recent onset of frequent and severe unilateral headaches that last about 1 hour. Based on these symptoms, the nurse suspects which type of headache? 1. Cluster headache 2. Migraine headache 3. Tension headache 4. Sinus headache

1. Cluster headache

While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to perform which movements? 1. Flexion, extension, and hyperextension 2. Circumduction, internal rotation, and external rotation 3. Adduction, abduction, and rotation 4. Flexion, pronation, and supination

1. Flexion, extension, and hyperextension

A patient reports joint pain interfering with sleep and morning joint stiffness for the first hour after getting out of bed. Considering this report, what abnormal findings does the nurse anticipate during the examination? 1. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally 2. Decreased range of motion of one hip and knee, with pain on flexion and crepitus during movement of these joints 3. Erythema in one great toe, ankle, and lower leg that is painful to the touch 4. Abrupt onset of local tenderness, edema, and decreased range of motion of the shoulder and hip bilaterally

1. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally

A patient with darkly pigmented skin has been admitted to the hospital with hepatitis. How does the nurse assess for jaundice in this patient? 1. Inspect the color of the sclera. 2. Inspect genitalia for color. 3. Blanch the fingernails. 4. Jaundice cannot be assessed in patients with darkly pigmented skin.

1. Inspect the color of the sclera.

Which organs is the nurse assessing during palpation of the right upper quadrant of the abdomen? 1. Liver and gallbladder 2. Stomach and spleen 3. Uterus, if enlarged, and right ovary 4. Right ureter and ascending colon

1. Liver and gallbladder

What is the most accurate technique for detecting a venous thrombosis at the bedside? 1. Measure the thigh circumference to detect an increase from the baseline. 2. Dorsiflex the calf and notice if the patient complains of pain. 3. Elevate one leg above the level of the heart to determine if the veins empty. 4. Palpate the pulses distal to the areas of the suspected thrombosis.

1. Measure the thigh circumference to detect an increase from the baseline.

The nurse is interviewing a patient with a history of flank pain, fever, and chills. Which examination technique is most appropriate for this patient? 1. Percussion of the costovertebral angle 2. Deep palpation of the lower abdomen 3. Palpation of the kidney for contour 4. Auscultation of the lower quadrants of the abdomen

1. Percussion of the costovertebral angle

During a physical examination, the nurse is unable to feel the patient's thyroid gland with palpation from an anterior approach. What is the appropriate action of the nurse at this time? 1. Recognize that this is an expected finding. 2. Auscultate the thyroid area. 3. Palpate the thyroid using a posterior approach. 4. Refer the patient for follow-up with an endocrinologist.

1. Recognize that this is an expected finding.

On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding? 1. Rhonchi 2. Wheeze 3. Crackles 4. Pleural friction rub

1. Rhonchi

What are the characteristics of lymph nodes in patients who have an acute infection? 1. They are enlarged and tender. 2. They are round, rubbery, and mobile. 3. They are hard, fixed, and painless. 4. They are soft, mobile, and painless.

1. They are enlarged and tender.

Which breath sounds are expected over the posterior chest of an adult? 1. Vesicular 2. Bronchovesicular 3. Bronchial 4. Bronchoalveolar

1. Vesicular

A patient complains of pain in the calf when walking. Which question should the nurse ask for further data? 1. "Does your calf also swell when this pain occurs?" 2. "Does the pain go away when you stop walking?" 3. "Do you become short of breath when you're walking?" 4. "Do you feel dizzy when the pain occurs?"

2. "Does the pain go away when you stop walking?"

A 32-year-old woman has a 4-day history of sore throat and difficulty swallowing. The nurse observes tonsils covered with yellow patches. The tonsils are so large that they fill the entire oropharynx and appear to be touching. How does the nurse document these findings? 1. "Tonsils yellow and edematous." 2. "Enlarged tonsils 4+ with yellow exudate." 3. "Strep infection to tonsils with 3+ swelling." 4. "1+ edema of tonsils with pus."

2. "Enlarged tonsils 4+ with yellow exudate."

You had to yell his name to get him to open his eyes; he could not tell you his name or location, and he could raise his hands when asked. Using the Glasgow Coma Scale (see Figure), what score would you give to this patient? 1. 12 2. 13 3. 14 4. 15

2. 13

The nurse observes multiple red circular lesions with central clearing that are scattered all over the abdomen and thorax. How does the nurse document the shape and pattern of these lesions? 1. Gyrate and linear 2. Annular and generalized 3. Iris and discrete 4. Oval and clustered

2. Annular and generalized

A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? 1. Make sure the bell of the stethoscope is used rather than the diaphragm. 2. Ask the patient to cough then repeat the auscultation. 3. Ask the patient not to talk while the nurse is listening to the lungs. 4. Change the patient's position.

2. Ask the patient to cough then repeat the auscultation.

A nurse inspects the abdomen for skin color, surface characteristics, and surface movement. What part of the abdominal assessment does the nurse perform next? 1. Palpate lightly for tenderness and muscle tone 2. Auscultate for bowel sounds 3. Palpate deeply for masses or aortic pulsation 4. Percuss for tones

2. Auscultate for bowel sounds

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? 1. Green 2. Clear 3. Yellow 4. Pink tinged

2. Clear

While assessing a patient's bicep muscle strength, the nurse applies resistance and asks the patient to perform which motion? 1. Extension of the arm 2. Flexion of the arm 3. Adduction of the arm 4. Abduction of the arm

2. Flexion of the arm

What is the expected patient response when assessing the function of CN XI (spinal accessory)? 1. Demonstrates full, active range of motion of the neck 2. Moves shoulders against resistance equally 3. Follows an object with eyes without nystagmus 4. Sticks out tongue without tremor or deviation

2. Moves shoulders against resistance equally

During a health history, a patient reports having difficulty swallowing. Based on this report, which assessment technique does the nurse use to collect more data about the patient's ability to swallow? 1. Ask the patient to puff out her cheeks, purse her lips, and blow out. 2. Observe the soft palate when the patient says "ahh." 3. Observe the patient while she swallows water from a paper cup. 4. Wearing gloves, grasp the patient's tongue and palpate all sides.

2. Observe the soft palate when the patient says "ahh."

A patient complains of her jaw popping when chewing. Which examination techniques are appropriate for the nurse to use with this patient? 1. Inspecting the musculature of the face and neck for symmetry 2. Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain 3. Asking the patient to move her chin to her chest, hyperextend her head, and move her head from the right side to the left side 4. Asking the patient to open her mouth as widely as possible and inspecting the lower jaw for redness, edema, or broken teeth

2. Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain

When assessing an adult's liver, the nurse percusses the lower border and finds it to be 5 cm below the costal margin. What is the nurse's appropriate action at this time? 1. Document this as an expected finding for this adult 2. Palpate the upper liver border on deep inspiration 3. Palpate the gallbladder for tenderness 4. Use the hooking technique to palpate the lower border of the liver

2. Palpate the upper liver border on deep inspiration

Where does a nurse palpate the posterior tibial pulse? 1. Behind the knee in the popliteal fossa 2. The inner aspect of the ankle below and slightly behind the medial malleolus 3. Over the dorsum of the foot between the tendons of the first and second toes 4. The outer side of the ankle below and slightly behind the lateral malleolus

2. The inner aspect of the ankle below and slightly behind the medial malleolus

A 48-year-old woman asks the nurse how to best protect herself from excessive sun exposure while at the beach. Which response would be most appropriate? 1. "Limit your time in the sun to 5 minutes every hour." 2. "Wear a wet suit that covers your arms and legs." 3. "Apply a waterproof sunscreen (SPF 15 or higher) to exposed skin surfaces; reapply at least every 2 hours." 4. "Apply sunscreen with a minimum SPF 50 to all skin surfaces before leaving for the beach; this will provide all-day coverage."

3. "Apply a waterproof sunscreen (SPF 15 or higher) to exposed skin surfaces; reapply at least every 2 hours."

A patient reports a gnawing, burning pain in the midepigastric area that is aggravated by bending over or lying down. Which additional question does the nurse ask as part of a symptom analysis? 1. "Do you have a family history of this type of pain?" 2. "How long ago did you eat?" 3. "Is the pain worse after eating or when your stomach is empty?" 4. "Have you noticed any yellow coloring in your eyes or on your skin?"

3. "Is the pain worse after eating or when your stomach is empty?"

Which data from the health history of a 42-year-old man should be evaluated further as a possible risk for hearing loss? 1. "I watch TV in the evenings with my wife and children." 2. "When I was younger, I wore an earring." 3. "My primary hobby is carpentry work." 4. "I have been an accountant for 16 years for an insurance agency."

3. "My primary hobby is carpentry work."

A patient reports having abdominal fullness and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? 1. "Has there been a change in the amount of the distention?" 2. "Did you have heartburn before the vomiting?" 3. "What did the vomitus look like?" 4. "Have you noticed a change in the color of your urine or stools?"

3. "What did the vomitus look like?"

A nurse who is auscultating a patient's heart hears a harsh sound, a raspy machine-like blowing sound, after S1 and before S2. How does this nurse document this finding? 1. An opening snap 2. A diastolic murmur 3. A systolic murmur 4. A pericardial friction rub

3. A systolic murmur

With the patient in a supine position, how does a nurse assess the external rotation of the patient's right hip? 1. Asking the patient to move the right leg laterally with the right knee straight 2. Asking the patient to flex the right knee and turn medially toward the left side (inward) 3. Asking the patient to place the right heel on the left patella 4. Asking the patient to raise the right leg straight up and perpendicular to the body

3. Asking the patient to place the right heel on the left patella

How does the nurse assess a patient's consensual reaction? 1. By touching the cornea with a small piece of sterile cotton and observing the change in the pupil size 2. By observing the patient's pupil size when the patient looks at an object 2 to 3 feet away and then looks at an object 6 to 8 inches away 3. By shining a light into the patient's right eye and observing the pupillary reaction of the left eye 4. By covering one eye with a card and observing the pupillary reaction when the card is removed

3. By shining a light into the patient's right eye and observing the pupillary reaction of the left eye

A nurse finds the patient's AP diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate? 1. Bronchial breath sounds in the posterior thorax 2. Decrease in respiratory rate 3. Decreased breath sounds on auscultation 4. Complaint of sharp chest pain on inspiration

3. Decreased breath sounds on auscultation

Using deep palpation of a patient's epigastrium, a nurse feels a rhythmic pulsation of the aorta. Based on this finding, what is the nurse's most appropriate response? 1. Auscultate this area using the bell of the stethoscope. 2. Percuss the area for tones. 3. Document this as an expected finding. 4. Ask the patient if there is pain in this area.

3. Document this as an expected finding.

How does a nurse determine jugular vein pulsations? 1. Raises the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the bed is slowly lowered 2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle 4. Positions the patient supine and asks him or her to cough; inspects for jugular vein pulsations during the cough

3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle

A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? 1. Dyspnea with diminished breath sounds bilaterally 2. Asymmetric chest expansion and rhonchi on the right side 3. Fever and tachypnea with crackles over the right lower lobe 4. Prolonged expiration with an occasional wheeze in the right lower lobe

3. Fever and tachypnea with crackles over the right lower lobe

During a symptom analysis, the patient reports a pain that radiates from the right lateral thigh, over the knee, and around to the right medial ankle. The nurse refers to the dermatome map (see Fig. 15.8) to determine that the patient's description of pain is consistent with dysfunction of which spinal nerve? 1. Second lumbar (L2) 2. Third lumbar (L3) 3. Fourth lumbar (L4) 4. Fifth lumbar (L5)

3. Fourth lumbar (L4)

A patient has edema and redness of the skin surrounding the nail on his right index finger. Which data elicited from his history best explains this condition? 1. He has a family history of fungal infections of the nails. 2. There has been a scabies outbreak among his family members. 3. He has a new full-time job as a dishwasher at a restaurant. 4. He recently had several warts removed from each of his hands.

3. He has a new full-time job as a dishwasher at a restaurant.

The nurse is comparing the right and left legs of a patient and notices that they are asymmetric. Which additional data does the nurse collect at this time? 1. Passively moves each leg through range of motion and compares the findings 2. Observes the patient's gait and legs as he or she walks across the room 3. Measures the length of each leg and compares the findings 4. Palpates the joints and muscles of each leg and compares the findings

3. Measures the length of each leg and compares the findings

While inspecting the legs of a male patient, the nurse notices that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease? 1. Pitting edema of one or both feet or legs 2. Increased circumference in the thighs bilaterally 3. Pale, cool legs with diminished-to-absent dorsalis pedis pulses 4. Pain when legs are dependent that is relieved when legs are elevated

3. Pale, cool legs with diminished-to-absent dorsalis pedis pulses

Which patient behavior indicates to the nurse that the patient's facial cranial nerve (CN VII) is intact? 1. The patient's eyes move to the left, right, up, down, and obliquely. 2. The patient moistens the lips with the tongue. 3. The sides of the mouth are symmetric when the patient smiles. 4. The patient's eyelids blink periodically.

3. The sides of the mouth are symmetric when the patient smiles.

A 24-year-old female patient has a 2-day history of clear nasal drainage. Based on these data, which question is the most logical for the nurse to ask? 1. "Is there a foul odor coming from your nose?" 2. "Have you recently had nosebleeds?" 3. "Do you snore when sleeping?" 4. "Do you have allergies?"

4. "Do you have allergies?"

A patient reports severe abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to gather more data about the possibility of cholelithiasis? 1. "Has your abdomen been distended?" 2. "Have you experienced fever, chills, or sweating?" 3. "Have you vomited up any blood in the last 24 hours?" 4. "Has the color of your urine or stools changed?"

4. "Has the color of your urine or stools changed?"

As a patient is walking into the exam room, the nurse notices his unsteady gait. What findings does the nurse anticipate during the neurologic exam? 1. When the patient stands with his feet together and eyes closed, his upright posture is maintained. 2. The nurse notices no patient response after striking the right patellar tendon with a reflex hammer. 3. The patient is able to move the heel of one foot down the shin of the other leg while lying supine. 4. A tremor is observed in his hands while he touches his finger to his thumb on the same hand.

4. A tremor is observed in his hands while he touches his finger to his thumb on the same hand.

Which is an abnormal sound the nurse would detect when auscultating the abdomen using the bell of the stethoscope? 1. High-pitched gurgles 2. Borborygmi 3. Venous hum 4. Absent bowel sounds

4. Absent bowel sounds

Which technique is used for palpating lymph nodes? 1. Apply firm pressure over the nodes with the pads of the fingers. 2. Apply gentle pressure over the nodes with the tips of the fingers. 3. Apply firm pressure anterior to the nodes with the tips of the fingers. 4. Apply gentle pressure over the nodes with the pads of the fingers.

4. Apply gentle pressure over the nodes with the pads of the fingers.

How does the nurse determine if a patient's musculoskeletal examination is normal? 1. By reading the examination findings documented in the patient's chart 2. By comparing findings from other patients in the same age group 3. By reading descriptions in health assessment books 4. By comparing the patient's left side with the right side

4. By comparing the patient's left side with the right side

What is the earliest and most sensitive indication of altered cerebral function? 1. Memory impairment 2. Loss of deep tendon reflexes 3. Inability to communicate 4. Change in level of consciousness

4. Change in level of consciousness

A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination? 1. Increased fremitus over the left chest 2. Tracheal deviation to the left side 3. Crepitus on the left chest during palpation 4. Distant to absent breath sounds over the left chest

4. Distant to absent breath sounds over the left chest

When a nurse asks a patient to place the right arm behind the head, the nurse is assessing for which range of motion? 1. Flexion of the elbow 2. Hyperextension of the shoulder 3. Internal rotation and adduction of the shoulder 4. External rotation and abduction of the shoulder

4. External rotation and abduction of the shoulder

Which technique does the nurse use to assess the triceps reflex? 1. Holds the patient's relaxed arm with the elbow extended while striking the appropriate tendon with a reflex hammer 2. Holds the patient's relaxed forearm with the hand slightly pronated while striking the appropriate tendon with a reflex hammer 3. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon, and strikes the thumb with the reflex hammer 4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes the appropriate tendon just above the elbow with a reflex hammer

4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes the appropriate tendon just above the elbow with a reflex hammer

Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient has a blood pressure consistent with expected findings? 1. Ms. J, whose blood pressure has been 140/90 2. Mr. Q, whose blood pressure has been 130/76 3. Ms. Y, whose blood pressure has been 120/80 4. Mr. P, whose blood pressure has been 110/78

4. Mr. P, whose blood pressure has been 110/78

When examining a 16-year-old male patient, the nurse notes multiple pustules and comedones on the face. The nurse recognizes that increased activity of which cells or glands produce these manifestations? 1. Epidermal cells 2. Eccrine glands 3. Apocrine glands 4. Sebaceous glands

4. Sebaceous glands

A 60-year-old male patient states that he has a sore above his lip that has not healed and is getting bigger. The nurse observes a red scaly patch with an ulcerated center and sharp margins. These findings are commonly associated with which malignancy? 1. Kaposi's sarcoma 2. Malignant melanoma 3. Basal cell carcinoma 4. Squamous cell carcinoma

4. Squamous cell carcinoma

While talking with a patient, the nurse suspects that he has hearing loss. Which examination technique is most accurate for assessing hearing loss? 1. Whispered voice test 2. Rinne test 3. Weber test 4. Test using audioscope

4. Test using audioscope

During an eye examination, how does a nurse recognize normal accommodation? 1. The patient has peripheral vision of 90 degrees left and right. 2. The patient's eyes move up and down, side to side, and obliquely. 3. The right pupil constricts when a light is shown in the left pupil. 4. The patient's pupils dilate when looking toward a distant object.

4. The patient's pupils dilate when looking toward a distant object.

Which technique does the nurse use to palpate a patient's abdomen? 1. Asks the patient to breath slowly though the mouth 2. Uses the heel of the hand to perform deep palpation 3. Uses the left hand to lift the rib cage away from the abdominal organs 4. Uses the pads of the fingertips to depress the abdomen.

4. Uses the pads of the fingertips to depress the abdomen.

How does the nurse palpate the chest for tenderness, bulges, and symmetry? 1. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another 2. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another 3. Uses the tips of the fingers to palpate the skin over the chest and the alignment of vertebrae 4. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae

4. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae