Health Assessment Exam #4 Practice Questions

Where do you observe retractions while breathing on infants? a. upper chest b. side of ribcage c. intercostal spaces d. fontanels

c. intercostal spaces

A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid, next time, he will kill me." Which is the appropriate nursing response? 1. Leopards don't change their spots, and neither will he. 2. There are things you can do to prevent him from losing control. 3. Lets talk about your options so that you don't have to go home. 4. Why don't we call the police so that they can confront your husband with his behavior?

3.

When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. Hes being so gentle now and even brought me flowers. Hes going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering? 1. Phase I: The tension-building phase 2. Phase II: The acute battering incident phase 3. Phase III: The honeymoon phase 4. Phase IV: The resolution and reorganization phase

3.

Do you have to report abuse in the state of Florida if the victim is over 18? (yes or no)

no - right to privacy

What should you perform upon entry to the room? a. WIPES b. PERRLA c. Saftey d. sign in

a. WIPES

Your patient can walk however it is not steady and they need the use of a walker, what is this an example of? a. ability b. status c. function d. capability

a. ability

Who is most likely to develop kidney disease? a. African American b. Caucasian c. Hispanic d. equal risk factor

a. African American

You are assessing a client who is wearing a winter coat in summer this is an abnormal? a. appearance b. behavior c. cognition d. thought process

a. apperance

Which of the following would you suggest for a patient with an upper large intestine blockage? a. colonoscopy b. sigmoidoscopy c. anusocscopy d. endoscopy

a. colonoscopy

A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing: a. Dysuria. b. Nocturia. c. Polyuria. d. Hematuria.

a. dysuria

You are testing a patient for potential Alzheimer's which of the following cognition test should you use? a. Mini mental status b. Denver-II c. GAD-7 d. AMT

a. mini mental status

What is palpable through the rectal wall? a. prostate b. bulbourethral gland c. external sphincter d. vans deferens

a. prostate

Nurse Isabelle enters the room of a client with a cognitive impairment disorder and asks what day of the week it is; what the date, month, and year are; and where the client is. The nurse is attempting to assess: A. Confabulation. B. Delirium. C. Orientation D. Perseveration.

c. orientation

Which of the following is only possible in an uncircumcised male? a. warts b. testicular torsion c. phimosis d. glans secretion

c. phimosis

Pressure on which area puts someone at greatest risk for skin breakdown? a. anus b. perianal area c. sacrococcygeal area d. superscalar region

c. sacrococcygeal area

The mental status exam includes( select all that apply) a. appearance b. behavior c. cognition d. distress e. thought process

a,b,c,e

Sequencing of infants should be based on ? (select all that apply) a. sleep and wakefulness state b. temperature c. physical condition d. mothers prefrence e. parent holding child f. weight

a,c,e

Your caring for n 88 year old who can live alone and has had both hips and knees replace you observe her almost trip, you identify that she is? a. functionally able to walk b. not functionally able to walk c. functional status indicates she walks well

a.

If you lack which of the following do you most likely need to be placed in an assisted care facility? a. ADLs b. IADLs c. IDLs d. DLs

a. ADLs

What is the purpose of testing CVA tenderness? a. to ensure kidney function b. to test liver function c. to test abdomen tenderness d. to ensure tactile fremitus

a. to ensure kidney function

Which part of subjective data should you ask about first for male urogenital? a. urinary patterns b. genitalia pain c. sexual activity d. STI contact

a. urinary patterns

Where should a male perform a monthly self exam? a. warm environment b. cool environment c. anywhere d. during sex

a. warm enviroment

What is a better way to perform a functional assessment? a. watching the patient perform b. asking the patient how well they perform c. asking the caregiver how well they perform d. assuming they can perform

a. watching the patient perfrom

What is a follow up contact to asking about if your patient uses contraceptives? a. What kind of protection do you use? b. So you have unprotected sex? c. Why do you only rely on your partner? d. Do you have genital warts?

a. what kind of protection do you use?

Your patient just developed a UTI and has suddenly become confused and irritated this is an example of? a. dementia b. delirium c. depression d. decision fatigue

b delirium

Which lab value indicates a UTI?(select all that apply) a. potassium b. bacteria c. glucose d. platelet e. nitrates f. specific gravity

b,e,f

82-year-old Mr. Robeson together with his daughter arrived at the medical-surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis? A. "Maybe it's just caused by aging. This usually happens by age 82." B. "The changes in his behavior came on so quickly! I wasn't sure what was happening." C. "Dad just didn't seem to know what he was doing. He would forget what he had for breakfast." D. "Dad has always been so independent. He's lived alone for years since mom died."

b.

How many DTR do you typically test during an assessment? a. 0 b. 1 c. 2 d. all

b. 1

A baby is beginning to smile and turn their head toward sounds you predict they are how old? a. 1 month b. 2 months c. 6 months d. 8 months

b. 2 months

When testing JVD what position should you place the patient in? a. supine b. 30-45 degrees c. high fowlers d. 20-35 degrees

b. 30-45 degrees

When performing a genital examination on a 25-year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information, the nurse would: a. Squeeze the glans to check for the presence of discharge. b. Consider this finding as normal, and proceed with the examination. c. Assess the testicles for the presence of masses or painless lumps. d. Obtain a more detailed history, focusing on any scrotal abnormalities the patient has noticed.

b. Consider this finding as normal, and proceed with the examination.

Which of the following assessments is used for anxiety? a. PHQ-9 b. Hamilton c. AMT d. MoCa

b. Hamilton

The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate? a. A good time to examine your testicles is just before you take a shower. b. If you notice an enlarged testicle or a painless lump, call your health care provider. c. The testicle is egg-shaped and movable. It feels firm and has a lumpy consistency. d. Perform a testicular examination at least once a week to detect the early stages of testicular cancer.

b. If you notice an enlarged testicle or a painless lump, call your health care provider.

Which of the following is an example of recent memory? a. Repeat these words b. What did you eat for dinner last night? c. Where did you grow up? d. What does apply mean?

b. What did you eat for dinner last night?

Where does collecting subjective data begin? a. when you first talk to the patient b. in the lobby c. half way through the assessment d. when the client walks in the room

b. in the lobby

Why is detailed documentation for abuse extremely important? a. so you are not called the abuser b. it can be used in court c. so the provider can call the FDA d. health services require it

b. it can be used in court

You are auscultating breath sounds of a toddler and they seem scared of the stethoscope what should you do? a. come back later b. let them play with equipment c. let the parent listen d. distract them

b. let them play with equipment

Which of the following is an example of an ADL? a. washing laundry b. propelling a wheelchair c. driving a car d. taking medications

b. propelling a wheel chair

Which screening is done around age 40-45? a. self testicle exam b. prostate specific antigen c. digital rectal exam d. prostate xray

b. prostate specific exam

What is a benefit of circumcision? a. decreased pain b. reduces STI transmission c. prevent kidney diseases d. religious practice

b. reduces STI transmission

A two year old child should be able too? a. show affection b. show defiant behavior c. wide range of emotions d. hold simple conversations

b. show defiant behavior

Which of the following conditions is emergent? a. warts b. testicular torsion c. phimosis d. glans secretion

b. testicular torsion

Your have decided to perform a fecal occult blood test on your patient why would you choose to perform this? a. suspected hemmroids b. to determine if there is blood in feces c. to ensure a UTI is not present d. to test for the presence of foreign bodies in the feces

b. to determine if there is blood in the feces

A parent calls you 2 days after a child's birth and states they are having black thick stools what should you tell the parent? a. this is a normal finding do to the child abdominal organs not fully functioning yet b. this is an abnormal finding and should be reported to provider for medication c. this is a normal finding of amnionic fluid in the feces d. this is abnormal and the baby needs to come to the ER

c.

A patient has a functional status of performing laundry what does this mean? a. they can perform but it requires help b. it can be performed independently but they are a fall risk c. the patient can perform well independently d. the patient has a diability

c.

The nurse is evaluating a new graduate's ability to perform a rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location ? A) Right upper quadrant B) Left upper quadrant C) Right lower quadrant D) Left lower quadrant

c.

Which part of the assessment might you ask the parent to leave for an adolescent? a. the entire exam b. during the neurological assessment c. when asking questions on alcohol and sexual health d. when asking about past medical history

c.

You are assessing a school aged child who should you ask the questions too? a. the child b. the parent c. the child unless he asks the parent d. the parent unless the child tries to talk

c.

You are performing an APGAR score to a baby to ensure ? a. they are alive b. how well they are going to grow c. their adaptation to the environment after birth d. how well the child can sleep through the night

c.

A child is beginning to understand what stranger danger is how old do you predict they are> a. 3 months b. 6 months c. 1 year d. 2 years

c. 1 year

Your are assesing a client using the mini mental status exam below what number is considered abnormal? a. 20 b. 22 c. 24 d. 28

c. 24

At what age should you let a child answer questions? a. 5 b. 6 c. 7 d. 8

c. 7

Which of the following should you use to test cerebellar function? a. ROM b. Blomberg's sign c. Romberg's test d. Trendelenburg position

c. Romberg's test

When do you screen for IPV? a. once a year b. during initial admittance c. at every health care encounter d. during birth

c. at every health care encounter

Once you have pressed on the inguinal canal what should you ask the client to do? a. sneeze b. relax c. cough d. tense

c. cough

When assesing the fontanels of a newborn you find that they are depressed what does this indicate? a. pressure in skull b. pressure on head c. dehydration d. too much moisture

c. dehydration

Wearing winter clothes in the summer is an example of an abnormal finding of? a. posture b. body movement c. dress d. abuse

c. dress

Which of the following phases of abuse is the victim most likely to report? a. honeymoon b. tension c. explosion d. none

c. explosion

What is a common finding for ears and nose of toddlers? a. infections b. clear lobes c. foreign objects d. pain

c. foreign objects

Which of the following might put someone at risk for hemorrhoids? a. chronic diahrrea b. prostate cancer c. giving birth d. rectal prolapse

c. giving birth

What is the most important concept for adolescence? a. autonomy b. doubt c. identity d. reflection

c. identity

A patient takes a few seconds to answer your question what does this mean? a. they are delirious b. they have cognition impairment c. they have a slower response time but no problem b. their brain is degenerating but there is no problem

c. they have a slower response time but no problem

Your patient is 2 years old and has brusies all over there knees what should you do? a. report abuse b. ask the provider for recommendations c. this is a normal finding d. ask the parent to leave the room

c. this is a normal finding

A student nurse was asked which of the following best describes dementia. Which of the following best describes the condition? A. Memory loss occurring as part of the natural consequence of aging. B. Difficulty coping with physical and psychological change. C. severe cognitive impairment that occurs rapidly. D. Loss of cognitive abilities, impairing ability to perform activities of daily living

d.

What is one way to keep the dignity and identity of an adolescent client intact? a. ask the parent the questions b. kick out the parent always c. ask about their relationship status d. allow them to keep their street clothes on

d.

A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks the nurse to explain what a hernia is. The nurse should: a. Tell him not to worry and that most men his age develop hernias. b. Explain that a hernia is often the result of prenatal growth abnormalities. c. Refer him to his physician for additional consultation because the physician made the initial diagnosis. d. Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

d. Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

Which of the following words should not be used when asking about abuse? a. violence b. injury c. control d. abuse

d. abuse

When performing a genital assessment on a middle-aged man, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of: a. Carcinoma. b. Syphilitic chancres. c. Genital herpes. d. Genital warts.

d. genital warts

what is the #1 sign of abuse? a. not showing up to appointments b. depression c. alcohol abuse d. injuries at different phases

d. injuries at different phases

Tea colored urine indicates? a. blood in urine b. normal color c. meds to treat UTI d. liver conditions

d. liver conditions

When do you perform percussion on an infants? a. first b. last c. second d. never

d. never

What is something you should maximize at end of life care? a. pain b. distractions c. moving d. pain meds

d. pain meds

Which of the following requires palpation? a. esophagus b. lymph nodes c. pyloric sphincter d. trachea

d. trachea

Is it okay to change the order of an assessment for an infant? (yes or no)

yes

Should you assess the caregiver during your patients assessment? (yes or no)

yes