Health assessment exam

17. In a client who has anisocoria. The nurse would expect to observe which of the following?

Pupils of unequal size

11. A patient is hospitalized for liver enlargement and tenderness. When performing his admission physical examination you would be especially gentle and careful when palpating his

RUQ

3. When palpating the abdomen of a 20 year old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?

Spleen

.The RN is having difficulty finding bowel sounds on a patient complaining of constipation and abdominal pain. Where is the best place for the RN to listen and for how long does the RN need to listen before "bowel sounds absent" can be documented?

Ans: LLQ, 5 minutes

.A patient presents to the emergency room complaining of right upper quadrant pain along with nausea and vomiting. Which of the following exams would the RN anticipate being positive?

Ans: Murphy's sign

A nurse performs the test pictured below on an adult client. The nurse would expect which of the following findings?

Ans: No Lateralization of vibration

Upon inspection of an adult client's abdomen a nurse notes a 5 cm diameter pulsation in the epigastric region. Given this finding, what sound would you the nurse expect to hear when auscultating the pulsation?

Ans: No sound, as this is an expected finding

30.What is the priority problem for a client who is experiencing a headache

Ans: Pain

.A Client complains of pain in the epigastric region. As a nurse you know this might indicate inflammation to which of the following organs?

Ans: Pancreas

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?

Ans: Passage of flatus/gas, Bowel Sounds

A nurse suspects that a client has a distended bladder. How should the nurse assess for this condition?

Ans: Percuss and palpate midline above the suprapubic bone

The nurse shines a light at the bridge of the client's nose and notices that the light reflects back from the center of the right pupil but medial from the center of the left pupil. The nurse would document these findings?

Ans: Positive Hirschberg's test

When performing a peripheral vascular assessment of the lower extremities, a nurse should place the fingertips just posterior to the medial malleolus in order to assess for which of the following peripheral pulses

Ans: Posterior tibial

What action should the nurse take during an otoscopic examination of an adult patient? Ans: Pull the auricle up and back

Ans: Pull the auricle up and back

Which of the following statement is true regarding PERRLA? Select all that apply

Ans: Pupils dilate when light is directed onto the pupils, Pupils equal, round, react to light, and accommodation

A patient sudden clouding of vision, severe eye pain, and halos around light. What should be the nurse's first intervention?

Ans: Report this to the primary health care provider.

.The nurse gave a client an instruction sheet for a colonoscopy. The client held the instructions approximately 18 inches from their face and read the description of the procedure aloud. The nurse recognizes that the client?

Ans: Requires testing for visual acuity

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further intervention by the nurse?

Ans: Rigid, distended abdomen, Ecchymosis

Which of the following percussion findings would a nurse expect to find in a client with a large amount of ascites?

Ans: Shifting dullness with percussion

21. To assess a client's consensual pupil response the nurse should

Ans: Shine a light into the right eye and assess the left pupillary response, Dim the lights in the examination room

To assess a client's direct pupil response the nurse should

Ans: Shine a light into the right eye and assess the right

33.When testing visual fields, where should the examiner be positioned?

Ans: Sitting directly in front of the patient, facing the patient

5. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis? SELECT ALL THAT APPLY

Ans: Test for Blumberg's sign and Perform the iliopsoas muscle test

A client has a blood pressure of 150/90 in lying position, and 100/60 in a standing position. These assessment findings suggest?

Ans: The change in blood pressure reading is called orthostatic hypotension

The results of the client's vision test (using the Snellen chart) were 20/40 bilaterally, with glasses. Which of the following should the nurse anticipate?

Ans: The client's need to sit closer to the television

The RN is triaging a patient with a complaint of left sided hearing loss with some tinnitus. Which of the following exam findings would support the diagnosis of sensorineural hearing loss?

Ans: Weber test with lateralization to the right ear

35.What is the term used when light is directed into the pupils of the right eye and the left eye constricts?

Ans: consensual

34.The nurse assists a client into the supine position. As the client lifts their right leg from the hip the nurse places his/her hand on the client's thigh just above the knee and pushes down while the client attempts to hold their leg elevated.This test is referred to as the

Ans: iliopsoas sign for appendicitis

4. While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are:

Ans: normal abdominal aortic pulsations

Which of the following findings is revealed by palpation of unaffected maxillary sinuses? A) Tenderness B) Increased nasal discharge C) Photophobia D) Non-tenderness

D) Non-tenderness

19. When performing the corneal light reflex assessment. The nurse notes that the light is reflected at 2 o'clock in each eye. In this situation the nurse should

Ans: Consider this a normal finding

The nurse is assessing a patient who reports having lost the sense of smell. Which cranial nerve may be affected in this picture?

Ans: Cranial Nerve 1

While assessing a newborn, the nurse finds epicanthal folds and large spacing between the eyes. Based on these findings. Which condition is this infant at risk for?

Ans: Down syndrome

While conducting an interview a client reports pain in the right upper abdomen. Given this information the nurse should first Select all that apply.

"When did the pain start?" "What does your pain feel like?", "rate their pain on a scale from 0-10"

During an eye examination, a client tells a nurse that their left eye feels dry and itchy and has noticed a lot of tearing. The nurse notices that the client's left lower eyelid is rolled out with exposure of the palpebral conjunctiva. The nurse would document these findings as?

Ans: Ectropion

A nurse is caring for a client that is hearing impaired. Which of the following actions by the nurse would facilitate communication? Select all that apply?

Ans: Face the client while speaking, Speak in a high tone

23. When assessing a client's oral cavity, the nurse notes that the tonsils fill approximately 45% of the space between the tonsillar pillars. The nurse would record the size of the tonsils as 1+ 2+ 3+ 4+

2+

A noticeable lump or bulge or abdomen that can be pushed back in or disappear when lying down is

Ans: Hernia

22. When assessing the tympanic membrane, where would the nurse expect to visualize the cone of light in the right ear?

Ans: In the 5 o'clock position

9. When assessing a client's oral cavity the nurse notes that the tonsils are enlarged and touching. The nurse would record the size of the tonsils as? 1+ 2+ 3+ 4+

3+

7. While assessing a client's abdomen, which of the following would be considered expected findings?

3cm pulsation in the epigastric region

81.During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding is:

Ans: Is a normal finding and requires no further follow up

A nurse is preparing to perform abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment. 1) Auscultate the abdomen for bowel sounds 2)Inspect the abdomen for skin integrity 3)Ask if the client has abdominal pain 4)Palpate the abdomen lightly for tenderness 5) Percuss the abdomen in each of four quadrant A)3, 2, 1, 5, 4 B)2, 1, 3, 4, 5 C) 3, 1, 2, 5, 4 D)2, 1, 4, 5, 3

A) 3, 2, 1, 5, 4

.Arcus senilis refers to? A) The thin white ring along the margin of the iris seen in older adults B) A drooping of the eyelid over the pupil of the eye seen in older adults C) A disruption in the margin of the eyelid seen in older adults D) Normal pupillary response to accommodation seen in older adults

A) The thin white ring along the margin of the iris seen in older adults

25.When assessing the client's tongue, which of the following should the nurse consider an expected finding? SELECT ALL THAT APPLY A. Curls symmetrically B. Protrudes directly forward C. Has a thick white coating D. Dorsal surface is smooth, moist and shiny E. Is symmetrical with a rough dorsal surface

A. Curls symmetrically B. Protrudes directly forward E. Is symmetrical with a rough dorsal surface

29. The RN is taking vital signs on a patient and records the following BP 110/68, HR 80 R 16, BMI 15.2. What would the RN anticipate on inspection of the abdomen of this patient? A. Flat Abdomen B. Scaphoid Abdomen C. Rounded Abdomen D. Protuberant Abdomen

A. Flat abdomen

26. To palpate the maxillary sinuses the nurse would A. Use thumbs and press above and below the cheekbones B. Use first two fingers on each hand and press over eyebrows C. Have client close eyes and press with index fingers under eyebrows D. Use thumbs and press over the eyeballs

A. Use thumbs and press above and below the cheekbones

When assessing a client's oral cavity, the nurse notes that the tonsils fill approximately 45% of the space between the tonsillar pillars. The nurse would record the size of the tonsils as?

ANS: 2+

A nurse notices a yellow circular area at the convergence of the optical arteries during an exam with an ophthalmoscope and knows this is the? A)Optic disc B)Fovea C)Macula D) Limbus

ANS: A) Optic disc

What is the function of the inner ear?

Ans: It helps to maintain the balance of the body

31.Why is the popliteal pulse frequently more difficult to find than any other pulses?

Ans: It is deeper and more diffuse

A nurse has to test for corneal light reflex, how will the nurse proceed A) You are testing for ocular alignment by reflecting your pen light off the patient's pupils B) Make the lights normal and have patient look at a distant object to dilate pupils, and then have patient stare at pen light and slowly move it closer to the patient's nose C) Do visual field test - a subjective measure of central and peripheral vision, or "side vision," and is used by your doctor to diagnose, determine the severity of, and monitor your glaucoma D) You ask the patient to focus on a target directly in front of you (the nurse's eye, or an upraised finger, for example). With one eye covered, and your focus trained on the target, you'll be asked to describe things you see in the side "side" of your vision

ANS: A) You are testing for ocular alignment by reflecting your pen light off the patient's pupils

During an abdominal assessment, a nurse tests for a fluid wave. The nurse would expect to assess a positive fluid wave test for which of the following conditions?

ANS: Ascites

While assessing a client's abdomen, which of the following would be considered an expected findings? A)Presence of a bruit in the femoral area B) Bowel sounds of one per second over a minute C) Tympany upon percussion in the umbilical region D) Dullness to percussion on inspiration on right anterior axillary line

ANS: B) Bowel sounds of one per second over a minute

A client comes to the clinic complaining of pain in the shoulders and neck. You proceed by asking the client to shrug his shoulders and turn his head against resistance. The cranial tested? A) Hypoglossal nerve B) Spinal accessory nerve C) Facial nerve D) Vagus nerve

ANS: B) Spinal accessory nerve

During an eye assessment, the nurse asks the client to focus on an object that is brought closer to them and notes that there is no convergence of the pupils. The nurse would document this finding as... A)Loss of central vision B) Negative consensual light reflex C) Inability to accommodate D) PERRLA

ANS: C) Inability to accommodate

A client reports weight loss and difficulty swallowing. Which of the following should the nurse document for this client?

ANS: Dysphagia

45.When assessing the abdomen most health care providers divide the abdomen into how many sections?

ANS: Four

A nurse is teaching a class on the pathophysiology of the eyes. Which statement by a student would indicate a need for further teaching?

Ans: "Glaucoma is a common disease in children."

A patient in the hospital experiences epistaxis. What should the nurse instruct the patient to do to stop the bleeding?

Ans: "Sit up with the head tilted forward and pinch the nose"

The RN is percussing along the left midclavicular line to measure the liver. Which of the following measurements would be considered normal?

Ans: 8cm

The nurse conducts a physical assessment with inspection followed by palpation, percussion, and auscultation expect when assessing the?

Ans: Abdomen

36.Tenderness at the anatomical landmark noted below with "X" suggests

Ans: Acute appendicitis

.A client comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that the client may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?

Ans: An enlarged spleen should not be palpated, it can rupture easily

10. When performing a physical assessment of a client's frontal sinuses to determine the presence of an infection the nurse should

Ans: Ask if the client has a history of sinus infections

15 E.K 34-year-old married, White female homemaker brought to the emergency department by police after a reported domestic quarrel States husband struck her about the lace and eyes with his fists about 1 hour PTA . " When he's drunk he goes crazy." Pain in left cheek and both eyes felt immediately and continued . Alarmed at "bright red blood on eyeball bleeding from eye area or cheek Vision intact just after trauma . Now reports difficulty opening lids . What should you do for this patience first?

Ans: Assess the vision and look at the possibility of trauma

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

Ans: Auricle

You are auscultating the abdomen to listen to iliac arteries you would listen

Ans: Bilateral lower quadrants

.A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states when he sticks his tongue out his mouth it curls to the left side. The nurse suspects that he has?

Ans: Cerebrovascular accident (CVA)

13. A visual acuity of 20/30 using the snellen chart means the?

Ans: Client can read at 20 feet what a person with normal vision can read at 30 feet.

37.When assessing a patient's skin, you note his skin of his lower right foot cool to the touch. As a nurse you would?

Ans: Compare right foot to the left foot and document the findings

1. While conducting an interview a client reports acute pain in the left upper quadrant of the abdomen. Given this information the nurse should? A. Perform a complete abdominal assessment beginning with palpation B. Proceed directly to performing auscultation of the abdomen C. Complete the interview to obtain baseline information D. Palpate the left upper quadrant last

D. Palpate the left upper quadrant last

.A doctor asked you to do a near vision test for the patients. Which of this patient qualifies A) A 12 years old boy that is complaining of difficulty seeing the board B) A 16 years old girl that has accommodation at school to seat in the front C) A 42 years old man having difficulty reading D) A 29 years old teacher complaining of difficulty reading

B) A 16 years old girl that has accommodation at school to seat in the front

When auscultating the abdomen for bowel sounds you are most likely to hear them at the: A) RUQ at the ileocecal valve B) RLQ at the ileocecal valve C) LLQ at the ileocecal valve D) LUQ at the ileocecal valve

B) RLQ at the ileocecal valve

28.While asking a client to look straight ahead, a nurse shines a light into the eyes and notes that the light reflects asymmetrically on the corneas. The nurse would document these findings as A. Negative Romberg test B. Normal findings C. Positive Hirschberg test D. Impaired visual acuity

B. Normal findings

20. An Endoscopy unit nurse notices that the client held the pre-procedure instructions approximately 18 inches away from their face and read the information aloud. Based on these findings the nurse would A. Document that the client understood the instructions B. Ask the client if they wear glasses when driving a car C. Discuss with client the need for visual acuity testing at a later date D. Document that the client has a hearing deficit

C. Discuss with client the need for visual acuity testing at a later date

27. The nurse is performing an eye assessment and identifies symmetrical movement with slight oscillation on extreme lateral gaze. The nurse should? A. Notify the provider to findings immediately B. Continue the eye exam and assess for PERRLA C. Document findings as extra-ocular muscle weakness D. Perform an extra-ocular movement eye exam

D. Perform an extra-ocular movement eye exam

32. You had a discussion with your fellow classmates regarding the optic nerve and you explained that A. Cause the transmission of impulse from the lens to the retina B. Transmit the light to the retina C. Adjust the light entering the eye D. Transmits impulse to the brain from retina

D. Transmits impulse to the brain from retina

16. A nurse notices the presence of nystagmus while assessing a client's extraocular movements. Nystagmus typically occurs when the A. Eyelid droops with movement of the eye B. Eyes are in extreme lateral gaze C. Reflection of light is congruent in both eyes D. Upper eyelid overlaps the superior part of the iris

D. Upper eyelid overlaps the superior part of the iris

6. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?

Dullness

2. The nurse knows that during an abdominal assessment, deep palpation is used to determine?

Enlarged organs

38. On auscultation of Mr. Belly's abdomen, you note audible passages of air indicating intestinal motility, this is referred to as?

Peristalsis

8. What is the pupillary response when the patient changes from near vision to far vision?

Pupils constrict

After inspecting the hard palate for color and form, the soft palate is assessed for redness, edema, and which of the following normal findings?

Uvula in the middle position on "Ah"

13. The Optic Nerve mediates which function?

Vision

15. Which of the following is the first important step in helping the patient to relax for the complete abdominal examination? A. Warm the stethoscope before auscultating B. Expose only the abdomen for examination C. Have the patient bend their knees D. Have the patient empty his/her bladder

Warm the stethoscope before auscultating