Health Assessment Final Exam Practice

A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?

"I'm sorry, but assessment is ongoing and continous"

he nurse examines a client who complains of a sore throat and finds that the tonsils are enlarged and seen midway between tonsillar pillars and the uvula. The nurse should appropriately document this as

2+

Mr. Franklin is speaking with you, the healthcare provider, about his respiratory problem. Mr. Franklin says, "I've had this cough for 3 days, and it's getting worse." You reply, "Tell me more about your cough." Mr. Franklin states, "I wish I could tell you more. That's why I'm here. You tell me what's wrong!" Which caregiver response would be most appropriate for enhancing communication? a. "After 3 days, you're tired of coughing. Have you had a fever?" b. "I'd like to hear more about your experiences. Where were you born?" c. "I don't know what's wrong. You could have almost any disease." d. "I'll examine you and figure out later what the problem is."

ANS: A "After 3 days, you're tired of coughing. Have you had a fever?" is the only response aimed at focusing on the chief compliant to gather more data and does not digress from the issue

A 36-year-old woman complains that she has had crushing chest pain for the past 2 days. She seems nervous as she speaks to you. An appropriate response is to: a. continue to collect information regarding the chief complaint in an unhurried manner. b. finish the interview as rapidly as possible. c. ask the patient to take a deep breath and calm down. d. ask the patient if she wants to wait until another day to talk to you.

ANS: A With an anxious, vulnerable patient, it is best to not hurry; a calm demeanor will communicate caring to the patient. If you as a healthcare provider are hurried, the patient will be more anxious. The best way to assist an anxious patient is to not hurry and remain calm, because this will communicate caring to the patient. Asking the patient if she wants to wait until another day to talk to you delays the needed health care

A tool used to screen adolescents for alcoholism is the: a. CAGE. b. CRAFFT. c. PACES. d. HITS.

ANS: B The CRAFFT tool is used to screen for alcoholism in adolescents. The CAGE test is used to screen for alcoholism in adults. PACES is used to screen adolescents for important issues in their life. HITS is the screen for domestic violence

Before assessing vital signs, the nurse knows that it is important to assess what?

Any medications the client is currently taking

Midline

Aorta Bladder Uterus

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are:

Aortic and pulmonic

phalens test

Ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. (produces numbness and burning in a person with carpal tunnel).

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:

Auricle

When using otoscope to assess the nasal cavity, what does the nurse need to do?

Avoid touching the nasal septum w/ the speculum

Constitutional symptoms in the ROS refer to: a. height, weight, and body mass index. b. fever, chills, fatigue, and malaise. c. hearing loss, tinnitus, and diplopia. d. rashes, skin turgor, and temperature

B

temporary paralysis of the seventh cranial nerve that causes drooping only on the affected side of the face

Bell's palsy

A patient has an open draining wound located on the underside of the chin. Which lymph nodes should the nurse assess in this patient? a. tonsillar b. superficial cervical c. submental d. preauricular

C. submental

Which of the following would be most appropriate for the nurse to do to determine stroke volume?

Calculate the difference between the diastolic and systolic pressures.

Right Lower Quadrant

CecumAppendix Right ovary and tubeRight ureterRight spermatic cord

In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes?

Central, lateral, pectoral, and subscapular nodes

A client states that the reason he has come into the clinic is for a routine annual physical. In what section of the health history would you document this information?

Cheif Complain

After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n):

Colonoscopy every 10 years

A nurse, conducting a functional assessment on an adult client, assesses overall psychosocial well-being by assessing what?

Coping/stress tolerance

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects:

Damage to the trigeminal nerve

What does an otoscope do?

Directs light into the ear canal & onto the tympanic membrane

The nurse is checking ROM in pts knee & knows the knee is capable of what movements?

Flexion and extension

A pt's annual physical exam reveals lateral curvature of thoracic & lumbar segments of spine. Dissapears when forward bending. This is called:

Functional Scoliosis

Four areas of the body where lymph nodes are accessible:

Head & neck, arms, inguinal area, axillae

A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1 to 10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain?

Increased BP and pulse

Tennis Elbow

Inflammation of the common tendon of origin for all posterior forearm muscles. Patient has pain around lateral epicondyle with radiation down lateral forearm. AKA: lateral epicondylitis

When assessing the force, or strength, of a pulse, the nurse recalls that it:

Is a reflection of the heart's stroke volume

Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in

Kyphosis

Right Upper Quadrant

LiverGallbladderDuodenumHead of pancreasRight kidneyHepatic flexure of colonTop of ascending and part of transverse colon

Example of holistic data collection by a nurse:

Measuring BP, inquiring about client's nutritional intake,assessing for depression, and asking the client how his condition affects family gatherings

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change?

Nerve degeneration in the inner ear

In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings?

Nothing, because this is the appearance of normal tonsils

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

Ongoing or partial

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

Assessment of the pulse amplitude is accomplished by which of the following?

Palpating the flowof blood through an artery

A stiff, shuffling, rigid gait is seen in persons with _____________ disease due to the destruction of dopamine receptors in the brain that maintain balance between contraction and relaxation of the muscles

Parkinson's

When examining the face, what 2 pairs of salivary glands are accessible to exam?

Parotid and Submandibular

Left Lower Quadrant

Part of descending colonSigmoid colonLeft ovary and tubeLeft ureterLeft spermatic cord

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

Primary prevention

What is a bruit?

Soft, whooshing, pulsatile sound best heard w/ bell of stethoscope

Left Upper Quadrant

StomachSpleen Left lobe of liver Body of pancreas Splenic flexure of colon Transverse and top of descending colon

During an assessment, the nurse asks a patient with low back pain what has been used to try and alleviate the pain. The nurse is asking questions to determine which category of the mnemonic OLD CART

T: treatment

The ulnar edge of the hand is highly receptive to which of the following sensations?

Temperature and vibrations. The dorsum and ulnar edge of the hands are both highly receptive to temperature variations as a result of their minimally keratinized skin surfaces. The ulnar edge also has the sensitivity to detect vibrations. It is less sensitive to moisture, vibrations, and contour.

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?

To determine any changes from baseline data

When assessing the quality of a patient's pain, the nurse should ask which question?

What does the pain feel like?

The nurse is searching for continuing education programs to develop cultural humility. What characteristics should these educational programs have to meet the nurse's goal? (Select all that apply a. instructs on the practice of respectful communication b. provides ways to develop collaborative partners with patients c. describes characteristics of specific cultural groups d. focuses on self-awareness e. explains how some cultural groups ...illnesse

a, b, d

After a patient describes abdominal pain to the nurse, which questions can the nurse ask to provide more information about the pain? Select all that apply a. Where does the pain travel b. What other symptoms do you have with the pain? c. Do you have blood in your stool? d. what makes the pain less or worse? e. Where do you feel the pain?

a, b, d, e

A nursing student is preparing to demonstrate how to test the range of motion of the elbow. Which of the following would the student include? Select all that apply. a. extension b. flexion c. abduction d. rotation e. supination f. circumduction

a, b, e

The nurse is assessing a patient's neurologic status within the comprehensive health history. What will the nurse include in this assessment? (Select all that apply a. headache b. dizziness c. head injury d. lighheadedness e. weakness

a, b, e

After completing an integument physical examination, the nurse documents information about the patient's lesions. What will the nurse include in their documentation? Select all that apply a. location and distribution b. condition of surrounding skin c. color d. elevation e. amount of drainage

a, c, d

A male patient tells the nurse about experiencing problems with urination. What should the nurse asses in this patient? (Select all that apply) a. if there is any difficulty starting the urine stream b. if the patient has ever been diagnosed with a sexually transmitted infection c. if there is any pain at the base of the penis d. the number of times the patient voids during the day e. if there is any blood or semen in the urine

a, c, d, e

Which of the following are cues that a person may have dementia? Select all that apply a. disorientation b. finding the right words c. serving as a "good historian" d. looking to a family member to answer questions e. repeatedly failing to follow instructions

a, d, e

The patient has sustained burns over 50% of the body. When planning care for this patient, the nurse will include interventions to address an alteration in the skins barrier function, specifically: (Select all that apply) a. injury caused by mechanical or chemical sources b. penetration by microorganisms c. synthesis of vitamin d d. loss of water and electrolytes e. regulation of body temperature

a,b,d

When are open-ended questions generally most useful? a. During sensitive area part of the interview b. After several closed-ended questions have been asked c. While designing the genogram d. During the review of system

a. During sensitive area part of the interview

A student is performing a physical assessment on a client. While assessing the abdomen, the student percusses for the spleen. What sound would be normal for the student to hear? a. tympany b. hollow sound c. dulless d. friction rub

a. Tympany (because you can't normally find the spleen)

The nurse is preparing to examine a patient's posterior thorax. What should be included in this examination? a. auscultation of lung sounds b. position of trachea c. subclavicular lymph nodes d. sternomastoid muscle strengt

a. auscultation of lung sounds

The nurse percusses the lungs of a patient with pneumonia. What percussion note would the nurse expect to document? a. dullness b. tympany c. hyperresonance d. flatnes

a. dullness

During the physical examination of a patient's eyes, the nurse asks the patient to follow the tracing of a giant H with the eyes. What is the nurse assessing in this patient? a. extraocular movements b. convergence c. corneal light reflex d. pupil reaction to ligh

a. extraocular movements

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would use which measure as prevention of the leading cause. a. fall prevention b. defensive driving c. correct use of firearms d. domestic violence

a. fall prevention

The nurse assesses impaired mobility and incontinence for a patient newly admitted to a long- term care facility. Which musculoskeletal problem will the nurse address when planning care for this patient? a. falls b. neck pain c. low back pain d. osteoporosi

a. falls

During the reproductive system health history, a patient tells the nurse about having excessive menstrual flow. The nurse would document this information as a. menorrhagia b. oligomenorrhea c. metrorrhagia d. polymenorrhea

a. menorrhagia

An avid swimmer presents with ear pain. Her history includes pain and drainage from the left ear. On examination, she has pain when the ear, including the tragus, is manipulated. The canal is narrowed and erythematous with some white debris in the canal. The rest of the examination is normal. What diagnosis would be most appropriate for this client? a. otitis externa b. cholesteatoma c. perforation of the tympanic membrane d. otitis media

a. otitis externa

After completing an assessment, the nurse is generating the patient's problem list. Which problem would have the highest priority? a. shoulder pain b. anxiety about work c. lack of appetite d. insomnia

a. shoulder pain

Which of the following risk factors for osteoporosis is the best predictor of low bone density? a. smoking b. low body weight c. prior vertebral fracture d. estrogen deficiency

a. smoking

An adult visiting the clinic tells the nurse he has chest pain and pain down his left arm. The nurse should refer the client for further evaluation of possible:

angina

The nurse has completed the inspection of a patient's abdomen during the physical examination. Which technique will the nurse use next during this examination?

auscultation

The nurse obtains a client's blood pressure when standing and compares it to the measurement obtained while the client was sitting. The client's blood pressure when sitting was 122/72 mmHg. Which finding would suggest to the nurse that the client is experiencing orthostatic hypotension? a)108/58 mmHg b)98/52 mmHg c)114/68 mmHg d)110/62 mmHg

b) 98/52 mmHg

The nurse wants to include a patient's lifestyle *habits* when conducting the health history of the eye. What will the nurse include in this assessment? (Select all that apply) a. use of corrective eyeglasses/corrective lenses b. use of sunglasses c. current medications that dry the eye d. the use of protective eye e. smoking histor

b, c, d, e

Which of the following are considered genetic red flags which a nurse may identify during a family history assessment? select all that apply a. occurrence in one paired organ e.g. disease in one kidney but not the other b. developmental delays or mental retardation c. single family member affected with a genetic disorder d. single prior miscarriage by mother e. diagnosis of a condition in the less often affected sex f. consanguinity g. one or more major malformations

b, e, f, g

After completing a nutritional history, the nurse determines that a patient is experiencing anorexia nervosa because of which assessment findings (select all that apply) a. preoccupation with eating b. discusses feeling fat in clothes c. body mass index of 16 d. body mass index of 29 e. overeats at least two twice a week

b,c

After assessing a patient's radial pulse, the nurse determines that an apical pulse needs to be assessed. What will the nurse do when assessing the apical rate? a. palpate the radial pulse while assessing the apical pulse b. place the stethoscope at the apex of the heart c. ask the patient to sit quietly for 5 minutes before d. assess the rate for 1 minute e. assess the rate for 30 seconds and multiply by 2

b,d

Which question would be considered a "leading question?" a. "What do you think is causing your headaches?" b. "You don't get headaches often, do you?" c. "On a scale of 1 to 10, how would you rate the severity of your headaches?" d. "At what time of the day are your headaches the most severe?"

b. "You don't get headaches often, do you?"

A patient with a long leg cast is experiencing tight burning pain in the calf muscle. The nurse should implement interventions to address which health problem? a. deep venous thrombosis b. compartment syndrome c. acute lymphangitis d. venous insufficiency

b. compartment syndrome

Mr. Mills is a 55-year-old patient who presents to the office for an initial visit for health promotion. A survey of mobility and activities of daily living (ADL) is part of a(n): a. ethnic assessment. b. functional assessment. c. genetic examination. d. social history

b. functional assessment

The nurse is preparing to conduct a physical exam on an adolescent patient for a school physical. Which exam would be most appropriate? a. grouping body systems together to limit position changes b. head to toe assessment c. major body systems first approach d. examining the right side of the body then the left

b. head to toe assessment

The nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper documentation of this finding by the nurse? a. papule b. macule c. pustule d. vesicle

b. macule

Which of the following tests use a tuning fork in two positions to assess hearing? a. whisper b. rinne c. watch tick d. webers

b. rinne

An older patient with a change in mental status is clenching the jaw closed to avoid taking a prescribed oral medication. The patient is demonstrating the motor function of which cranial nerve? a. vagus b. trigeminal c. facial d. glossopharyngea

b. trigeminal

The nurse is planning to assess for the presence of lower pitch sounds when examining a patients heart. Which item of equipment should the nurse use to make this assessment? a. two test tubes b. tuning fork c. bell of stethoscope d. diaphragm of a stethoscope

c. bell of stethoscope

During a physical examination, the nurse wants to assess a body area for contours and size of organs. The technique that the nurse will use will be: a. asucultation b. inspection c. palpation d. percussion

c. palpation

An older patient asks the nurse what can be done to help with urinary incontinence. What can the nurse respond to this a. limit alcohol intake to 3 drinks per day b. avoid caffeinated beverages c. practice pelvic muscle exercise d. reduce fluids a few hours before bed

c. practice pelvic muscle excercise

Periods of silence during the interview can serve important purposes, such as: a. allowing the clinician to catch up on documentation. b. promoting calm. c. providing time for reflection. d. increasing the length of the visit

c. providing time for reflection.

What area of the heart should be further assessed in a patient with an irregular pulse? a. left ventricle b. right ventricle c. right atrium d. left atrium

c. right atrium

During a physical examination of a female patient's reproductive system, the nurse detects a thick white discharge from the labia. The patient's vulva appears inflamed. How should the nurse document this finding? a. symptoms of primary syphillis b. symptoms of trichomonal vagina c. symptoms of candida vaginitis d. symptoms of bacterial vaginosis

c. symptoms of candida vaginitis

A patients risk for pressure sore development according to the Braden scale is as follows: sensory perception: 4 moisture: 4 activity: 2 mobility: 2 nutrition: 1 friction and shear: 3 From this assessment, the nurse determines that the risk for pressure sore development is: a. no risk b. high risk c. mild risk d. moderate risk

c.mild risk

The nurse is preparing to examine a patient's eyes using an ophthalmoscope. Which technique should the nurse follow when using this equipment? a. the nurse should remove eyeglasses or contacts before using the ophthalmoscope b. the nurse should place the ophthalmoscope in the left hand and look through the right eye. c. The nurse should close the eye.... d. The nurse should place the ophthalmoscope in the right hand and look through the right eye

d. The nurse should place the ophtalmoscope in the right hand and look through the right eye

An older adult client presents with cramping leg pain when walking, which is relieved by rest; cool pale feet; capillary refill in toes of 4 to 6 seconds; negative Humans' sign bilaterally; no edema; and inability to palpate dross pedis and posterior tibial pulses bilaterally. Which of the following would the nurse suspect? a. venous insufficiency b. musculoskeletal weakness c.neurologic impairment d. arterial insufficiency

d. arterial insufficiency

While conducting a comprehensive health history, the nurse asks a patient to describe a typical day's diet. This information is important for the nurse because it assesses the patient's a. general health status b. gastrointestinal status c. throat d. nutritional health pattern

d. nutritional health pattern

A 25 year old male patient is brought to the emergency department by ambulance after being involved in a motor vehicle accident. You find that he has decreased breath sounds over the left lung fields. What might you suspect is the cause? a. muscular weakness b. atelectasis c. asthma d. pneumothorax due to blunt trauma

d. pneumothorax due to blunt trauma

During an assessment, a patient states the importance of spending quality time with family and friends. The nurse would document this information as fulfilling which facet of the patient's health? a. cultural influences b. developmental level c. spiritual influences d. social wellbeing

d. social well being

The nurse determines the heart rate of 100 beats per minute for a 6 year old as being a. evidence of a valve disorder b. supraventricular tachycardia c. sinus bradycardia d. within normal limits

d. within normal limits

When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

elevates the eyelid and dilates the pupil.

nursing student is preparing to demonstrate how to perform ROM of the elbow. what does the student include?

extension, flexion and supination

While the patient says the letter "e" during an assessment, the nurse auscultates the letter "a". What does this finding indicate?

pneumonia

The nurse documents in a patient's medical record. "5-mm oval lesion located on left forearm, color purple with areas of green and yellow." The nurse is describing which type of lesion?

purpuric

when to perform BSE

right after menstral period or the 4th or 7th day of menstral cycle breasts are smallest and least congested

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

stimulated by cranial nerves III, IV, and VI