Chapter 22: Health Assessment Practice Assessment

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which findings require further assessment? Select all that apply. 1. Blood pressure 110/64 mm Hg 2. Pulse rate 118 beats/min 3. Respiratory rate 35 breaths/min 4. Oral temperature 98.6°F (37°C) 5. Blood pressure 118/78 mm Hg

23

The nurse is performing an otoscopic examination on the patient. In assessing the tympanic membrane, the nurse assesses for which normal findings in appearance? Select all that apply. 1. Light red 2. Pearly gray 3. Shiny 4. Translucent 5. Retracted

234

A 48-year-old patient comes to the physician's office complaining of diminished near vision, which the nurse confirms with testing. The nurse should document this finding using which term? 1. Myopia 2. Hyperopia 3. Presbyopia 4. Mydriasis

3

A father brings his 18-month-old child to the pediatric clinic for a well-baby checkup. The father tells the nurse that he is concerned because the child's legs are bowed. Which response by the nurse is appropriate? 1. "Your child will most likely require physical therapy." 2. "You should consider having your child seen by an orthopedic surgeon." 3. "This is a normal finding in children for 1 year after they begin walking." 4. "Your child is walking fine, so you don't need to worry."

3

A female patient has excessive facial hair. The nurse should document this finding using which term? 1. Alopecia 2. Albinism 3. Hirsutism 4. Milia

3

A patient's jugular venous pressure measures 5 cm. What should this finding indicate to the nurse? 1. A normal finding 2. Hypovolemia 3. Heart failure 4. Dehydration

3

An older adult comes to the clinic reporting pain in the left foot. While assessing the client, the nurse notes smooth, shiny skin with no hair on the client's lower legs. Which condition does this finding suggest? 1. Venous insufficiency 2. Hyperthyroidism 3. Arterial insufficiency 4. Dehydration

3

An older adult's fingernails appear concave and spoon shaped. The nurse associates this observation with which condition? 1. A normal finding in older adults 2. Chronic lung disease 3. Iron deficiency 4. Chronic heart disease

3

Bronchovesicular breath sounds are best heard over which area? 1. Midline over the trachea just below the larynx 2. Fifth intercostal space, in the midclavicular line 3. First and second intercostal spaces next to the sternum 4. At the base of the lungs near the diaphragm

3

The 4-year-old child's vision is not 20/20. What does this result indicate? 1. Strabismus 2. Anisocoria 3. Normal finding 4. Presbyopia

3

The nurse finds a small pulsation at the patient's fifth intercostal space midclavicular line. This should be documented as a: 1. Thrill 2. Murmur 3. Normal finding 4. Heave

3

An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response? 1. Apply pressure to the mandible at the jaw. 2. Rub the patient's sternum. 3. Squeeze the trapezius muscle. 4. Gently shake the patient's shoulder.

4

High-pitched breath sounds produced by airway narrowing are known as: 1. Rales 2. Crackles 3. Rhonchi 4. Wheezing

4

Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse. This finding is associated with which condition? 1. Low albumin levels 2. Zinc deficiency 3. Renal disease 4. Bacterial endocarditis

4

The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patient's pulses are: 1. Bounding 2. Normal 3. Full 4. Diminished

4

A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the infant? 1. Have the mother remain outside the room. 2. Ask the mother to remove the infant's clothing and diaper. 3. Weigh the infant with the diaper only. 4. Place the infant supine on the scale with knees extended.

2

Abdominal palpation should be avoided in a child who has which disorder? 1. Appendicitis 2. Wilms' tumor 3. Crohn's disease 4. Small bowel obstruction

2

An 85-year-old patient is brought to the emergency department with lethargy and hypotension. As the nurse assesses the patient's tongue, it appears dry and furry. Which condition would the nurse suspect the patient is experiencing? 1. Fungal infection 2. Dehydration 3. Allergy 4. Iron deficiency

2

Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult? 1. Work rapidly to finish as quickly as possible. 2. Sequence the examination to limit position changes. 3. Demonstrate equipment before using it. 4. Omit portions of the examination that may be tiring.

2

Which situation indicates that the nurse is conducting a focused assessment? 1. The nurse performs a head-to-toe assessment that includes every body system. 2. The nurse performs the Romberg test on a patient who reports problems with balance. 3. The nurse evaluates the patient during every interaction to determine nursing care needs. 4. The nurse evaluates the patient's overall health status.

2

Which test should the patient undergo when the Weber test result is positive? 1. Romberg test 2. Rinne test 3. Snellen test 4. Whisper test

2

Which statement best describes the procedure used to assess capillary refill? 1. Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color. 2. Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction. 3. Tap on the skin with short strokes using middle fingers. 4. Lift a fold of skin, and allow it to return to its normal position.

1

A 6-week-old infant is brought to the pediatrician's office for a well-baby checkup. The nurse notes flattening of the skull. Flattening of the skull in the infant might suggest which finding? 1. Lying in the same position for several hours a day 2. A disorder associated with excessive growth hormone 3. An accumulation of excessive cerebrospinal fluid 4. Temporomandibular joint (TMJ) syndrome

1

The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve (CN)? 1. CN III 2. CN V 3. CN VIII 4. CN X

1

The nurse is bathing a newborn infant in the nursery and notices scaly white patches over the infant's scalp. What is the most appropriate action by the nurse? 1. Wash the scalp, and apply gentle scrubbing. 2. Notify the primary care provider. 3. Obtain a computed tomography (CT) scan of the infant's head. 4. Assess for patches on the infant's lower torso.

1

The nurse is performing an otoscopic examination on an adult patient. The nurse has the patient tilt head to the side not being examined. Which step should the nurse perform next? 1. Straighten the ear canal by pulling the pinna up and back. 2. Insert the speculum into the ear canal slowly. 3. Test the mobility of the tympanic membrane. 4. Gently pull the pinna down and back.

1

The nurse is planning a breast examination class for a group of women at a community health fair. In planning the class, what is most important for the nurse to consider in preparation for the class? 1. Women who perform breast self-examinations should be trained in proper technique to avoid false-negative findings. 2. Breast examinations should be performed yearly for all women over the age of 25 years. 3. Clinical breast exams are recommended for average-risk women at any age. 4. A breast examination that includes assessment of the breast and axillae is indicated only if the woman is at high risk for breast cancer.

1

The nurse is working in an outpatient clinic in the community. Late in the afternoon, three clients come in with suspected pediculosis. Which assessment will the nurse perform? 1. Integumentary assessment for head lice 2. Oral assessment for bad breath and caries 3. Musculoskeletal assessment for spine alignment 4. Lower extremity assessment for athlete's foot

1

The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the physician of the finding, which most likely suggests: 1. Heart failure 2. Coronary artery disease 3. Hypertension 4. Pulmonic stenosis

1

The nurse is performing a vision examination. In assessing for color blindness, the nurse applies which knowledge? Select all that apply. 1. It may be genetically inherited. 2. It is more common in males. 3. It may be the result of macular degeneration. 4. It may be the result of a lens defect of the eye. 5. It can be tested by using the letters on the Snellen chart.

123

The nurse on a medical unit notes fluid accumulation in the feet and ankles of a 75-year-old patient. What are the rationales for the nurse performing a physical examination? Select all that apply. 1. Obtain baseline data. 2. Determine health problems. 3. Address needs of the patient. 4. Receive reimbursement for care. 5. Provide discretion and privacy.

123

Which information describes the nurse's general survey? Select all that apply. 1. Consists of an overall impression of the patient 2. Assists in identifying deviations that need further exploration 3. Includes obtaining a full set of vital signs 4. Includes the comprehensive physical assessment 5. Focuses solely on the physical

123

Which statements regarding common neurological changes in older adults are true? Select all that apply. 1. Older adults have slower reactions and decreased ability for rapid problem solving. 2. With advanced age, the number of functioning neurons decreases. 3. Neurological deficits may be attributed to medications or medication interactions. 4. With normal aging, memory and the ability to discriminate decrease. 5. Intelligence decreases during the normal aging process.

123

The nurse has completed an external genital examination on several female clients in the women's health clinic. Which clients would require an internal genital examination? Select all that apply. 1. A client on hormone therapy 2. A client who has had more than three pregnancies 3. A client with an abnormal finding on the external examination 4. A 15-year-old client who is not sexually active 5. A 32-year-old client with pelvic pain and pressure

1235

Which disorders might limit a patient's visual field? Select all that apply. 1. Poorly controlled diabetes 2. Advanced glaucoma 3. Peripheral vascular disease 4. Cataracts 5. Macular degeneration

1245

Which statements describe the proper technique for auscultating heart sounds? Select all that apply. 1. Auscultate in an orderly fashion, starting at the aortic area and proceeding to pulmonic, tricuspid, and mitral areas. 2. Listen for S1 first in all landmark areas, and then proceed to listening for S2 in all landmark areas. 3. Use the diaphragm of the stethoscope for normal sounds and the bell of the stethoscope to detect any extra sounds. 4. Rotate the starting point of landmarks at each patient assessment to detect any changes. 5. Perform cardiac auscultation from the patient's left side, whenever possible.

13

When performing a skin assessment, the nurse notices a mole on the patient's upper back. Which actions would the nurse take to further investigate the mole? Select all that apply. 1. Ask the patient about any new moles or changes in moles. 2. Do not alarm the patient by asking questions about the mole. 3. Measure the mole's diameter and elevation. 4. Assess for any exudate on or around the mole. 5. Avoid palpating the mole.

134

Which principles apply when performing a focused assessment of the abdomen? Select all that apply. 1. Ask the patient to empty bladder prior to the assessment. 2. Follow the assessment sequence of inspection, palpation, percussion, and auscultation. 3. Position the patient in the supine position, with knees slightly flexed. 4. Begin palpating with light pressure to detect surface characteristics, and move to deep palpation. 5. Examine painful areas first to minimize discomfort.

134

The nurse is performing a comprehensive health assessment on several clients in the community clinic. Which clients are most at risk for developing hemorrhoids? Select all that apply. 1. A client with a history of constipation 2. A client with a history of prostate cancer 3. A woman who has had four children 4. A woman younger than 25 years of age 5. A woman 7 months pregnant

135

The nurse is assessing the level of consciousness of a client who suffered a head injury. The nurse uses the Glasgow Coma Scale and determines that the client's score is 15. Which responses did the nurse assess in this client? Select all that apply. 1. Opens eyes spontaneously 2. Assumes flexor posture 3. Has unequal pupil size 4. Is orientated to person, place, and time 5. Obeys verbal commands for movement

145

A client has noticed a decrease in taste sensation. Which cranial nerve (CN) is most likely involved? 1. CN V and CN VII 2. CN VII and CN IX 3. CN V and CN VIII 4. CN VI and CN X

2

The mother of a 1-month-old infant states to the examining nurse, "There is something wrong with my baby's eyes. She seems to be cross-eyed." What is the most appropriate response by the nurse? 1. "I will need to perform a thorough eye examination." 2. "This is not uncommon in infants in their first 2 months of life." 3. "Please try not to overreact. You are new parents, and there is much for you to learn." 4. "I will report your concerns to the pediatrician."

2

The nurse applies resistance to the top of a male client's foot and asks him to pull his toes toward his knee. The nurse observes active motion against some resistance, but not against full resistance. How should the nurse document this finding? 1. 5: Normal 2. 4: Slight weakness 3. 3: Weakness 4. 2: Poor range of motion (ROM)

2

The nurse asks the patient to spread the fingers and then bring them together again. Which type of movement is the nurse testing when asking the patient to bring the fingers together? 1. Abduction 2. Adduction 3. Flexion 4. Extension

2

The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube for intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient? 1. Avoid palpating the patient's abdomen. 2. Turn off the suction before auscultating bowel sounds. 3. Listen for bowel sounds for 2 minutes in each quadrant. 4. Percuss the abdomen before auscultating bowel sounds.

2

The nurse is concerned that an African American client is experiencing cyanosis. Which sign of cyanosis would the nurse look for in this client? 1. The presence of excessive interstitial fluid, with decreased skin elasticity 2. A bluish tinge in the skin, tongue, and mucous membranes 3. Redness and a variety of rashes over the entire body 4. An absence of underlying red tones in the skin

2

The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triages the patient because the nurse knows that this finding, along with other symptoms, might suggest the patient is experiencing which condition? 1. Hyperthyroidism 2. Stroke 3. Glaucoma 4. Macular degeneration

2

Which abnormal laboratory value is associated with an icteric sclera? 1. Occult blood 2. Bilirubin 3. Hemoglobin 4. Glucose

2

Which assessment question helps assess immediate memory? 1. "How did you get to the hospital today?" 2. "Can you repeat the numbers 2, 7, 9 for me?" 3. "Do you remember the three items I mentioned earlier?" 4. "What is your birth date including the year?"

2

Which assessment should the nurse perform if the patient has a palpable thyroid gland? 1. Illuminate the thyroid gland for the presence of fluid. 2. Auscultate the thyroid gland for bruits. 3. Percuss the thyroid gland for mass size. 4. Measure the thyroid gland to assess change.

2

Which documentation about a patient's level of consciousness is best? 1. Patient is lethargic and slept when undisturbed. 2. Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped. 3. Patient slept throughout the day, missing meals and bath. 4. Patient appears to be tired and slept throughout the day except when bathed.

2

Which length of time accurately describes when the infant's anterior fontanel (soft spot) typically fuses? 1. At about 8 weeks 2. At about 18 months 3. By 6 months of age 4. Before 1 year of age

2

While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborn's back and asks, "What's that? Is something wrong with my baby?" Which response by the nurse is best? 1. "I'll ask the physician to look at the spot." 2. "Those spots are quite common and typically fade with time." 3. "You may want a plastic surgeon to look at that." 4. "That spot is benign so it's nothing you need to worry about."

2

When testing near vision, the nurse should position printed text how many inches away from the patient? 1. 20 (50.8 cm) 2. 18 (45.7 cm) 3. 16 (40.4 cm) 4. 14 (35.5 cm)

4

Which abnormal capillary refill finding would the nurse report? 1. 1 second 2. 2 seconds 3. 3 seconds 4. 4 seconds

4

Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea? 1. Edema 2. Hyperhidrosis 3. Pallor 4. Tenting

4

While palpating the anterior chest, the nurse notes crackling in the skin around the patient's chest tube insertion site. Which term would the nurse use to document this finding? 1. Tactile fremitus 2. Egophony 3. Bronchophony 4. Crepitus

4