Chapter 28 The Complete Health Assessment: Adult

The nurse should use which location for eliciting deep tendon reflexes? A) Achilles B) Femoral C) Scapular D) Abdominal

A) Achilles Deep tendon reflexes are elicited in the biceps, triceps, brachioradialis, patella, and Achilles. Pages: 769-770

The examiner is assessing the extraocular muscles. Which of the following tests would be inappropriate? A) Confrontation test B) Corneal light reflex C) Six cardinal positions of gaze D) Cranial nerve III, IV, and VI testing

A) Confrontation test

A female patient tells the nurse that she has four children and has had three pregnancies. How should the nurse document this? A) Gravida 3, para 4 B) Gravida 4, para 3 C) This information cannot be documented using the terms gravida and para. D) "The patient seems to be confused about how many times she has been pregnant."

A) Gravida 3, para 4 Gravida refers to the number of pregnancies, and para refers to the number of children. One pregnancy was with twins. Page: 781

A patient's uvula rises midline when she says "ahh" and she has a positive gag reflex. The nurse has just tested which cranial nerves? A) IX, X B) IX, XII C) X, XII D) XI, XII

A) IX, X Cranial nerves IX and X are being tested by having the patient say "ahh," noting the mobility of the uvula, and when assessing the patient's gag reflex. Page: 766

In which situation should the examiner auscultate for carotid bruits? A) Middle-aged or older patient B) Pregnant patient with gestational diabetes C) Patient that reports abdominal pain D) Patient with enlarged, tender cervical lymph nodes

A) Middle-aged or older patient

When standing with their eyes closed, feet together, and arms at their sides, a patient sways and starts to fall. How should the nurse document this finding? A) Positive Romberg sign B) Positive Babinski sign C) Positive Ortolani sign D) Positive modified Allen test

A) Positive Romberg sign

Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup? A) Testing for Ortolani's sign B) Assessment for stereognosis C) Blood pressure measurement D) Assessment for the presence of the startle reflex

A) Testing for Ortolani's sign Until the age of 12 months, the infant should be assessed for Ortolani's sign. If Ortolani's sign is present, it could indicate the presence of a dislocated hip. The other tests are not appropriate for a 9-month-old child. Pages: 565-620

When gathering information relative to a complete health assessment, the nurse should include which in the decision-making process? (Select all that apply.) A) Treat the health assessment as a legal document. B) Use line drawings to explain and record pertinent findings. C) Do not document findings on the computer while the patient is present. D) Gather needed equipment before the start of the health assessment. E) Write down "word for word" what the patient says as evidence of reliable documentation.

A) Treat the health assessment as a legal document. B) Use line drawings to explain and record pertinent findings. D) Gather needed equipment before the start of the health assessment.

During inspection of a patient's face, the nurse notices that the facial features are symmetric. This finding indicates that which cranial nerve is intact? A) VII B) IX C) XI D) XII

A) VII Cranial nerve VII is responsible for facial symmetry. Page: 766

After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first: A) empty the bladder. B) completely disrobe. C) lie on the examination table. D) walk around the room.

A) empty the bladder Before beginning the examination, the nurse should ask the person to empty the bladder (save the specimen if needed), disrobe except for underpants, put on a gown, and sit with legs dangling off side of the bed or table. Page: 764

The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? A) Snellen B) Shetllen C) Smoollen D) Schwellon

A) snellen The Snellen eye chart is most widely used for vision examinations. The other options are not tests for vision examinations. Page: 764

During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences: A) vertigo. B) tinnitus. C) syncope. D) dizziness.

A) vertigo Vertigo is the sensation of moving around in space (subjective) or of having objects move about the person (objective) and is a result of a disturbance of equilibratory apparatus. See Chapter 23.

For the abdominal assessment, place these assessment techniques in the correct order, with A being performed first and E being performed last. A) Deep palpation, all quadrants B) Light palpation, all quadrants C) Auscultate bowel sounds D) Inspect abdomen for contour, skin characteristics, and pulsations E) Percuss all quadrants

ANS: D, C, E, B, A 1. Inspect abdomen for contour, skin characteristics, and pulsations 2. Auscultate bowel sounds 3. Percuss all quadrants 4. Light palpation, all quadrants 5. Deep palpation, all quadrants After inspection, first perform auscultation of bowel sounds so that the sounds are not altered by percussion and palpation. Follow auscultation by percussion, then light palpation, then deep palpation. See Chapter 21. Pages: 527-564

What should the examiner do during auscultation of breath sounds? A) Listen with the bell of the stethoscope B) Compare sounds on the left and right sides C) Listen only to the posterior chest for adventitious sounds D) Instruct the patient to breathe in and out through the nose

B) Compare sounds on the left and right sides

When auscultating heart sounds, which technique should the nurse use? A) Listen with the bell B) Listen with the diaphragm C) Listen with both the diaphragm and bell working from apex to base in a Z pattern D) Listen with both the bell and diaphragm comparing sides of the heart as progress from apex to base.

B) Listen with the diaphragm

A hospitalized patient does not require a full neurologic examination during every shift assessment. What is a method of assessing the neurologic status of a patient without performing a full neurological examination? A) Palpate the carotid pulse B) Offer the patient a glass of water C) Look at the significant other throughout the examination D) Assign the nursing assistant to ask the patient questions and report the findings

B) Offer the patient a glass of water

Which of these statements is true regarding the recording of data from the history and physical examination? A) Use long, descriptive sentences to document findings. B) Record the data as soon as possible after the interview and physical examination. C) If the information is not documented, then it can be assumed that it was done as a standard of care. D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient.

B) Record the data as soon as possible after the interview and physical examination. The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short clear phrases and should avoid redundant phrases and descriptions. Page: 781

The nurse is preparing to perform an examination of the eyes. Which test will the nurse conduct to assess the patient's vision? A) Weber test B) Snellen test C) Confrontation test D) Corneal light reflex

B) Snellen test

The nurse is assessing the cranial nerves. To assess cranial nerve XII, what should the nurse ask the patient to do? A) Say "ahh" B) Stick out tongue C) Smile and then frown D) Follow the nurses fingers through the six cardinal positions of gaze

B) Stick out tongue

Which of these statements is true regarding the complete physical assessment? A) The male genitalia should be examined in the supine position. B) The patient should be in the sitting position for examination of the head and neck. C) The vital signs, height, and weight should be obtained at the end of the examination. D) To promote consistency between patients, the examiner should not vary the order of the assessment.

B) The patient should be in the sitting position for examination of the head and neck. The head and neck should be examined in the sitting position to best palpate the thyroid and lymph nodes. The male patient should stand during examination of the genitalia. Vital signs are measured early in the assessment. The sequence of the assessment may need to vary according to different patient situations. Page: 764

While conducting a musculoskeletal assessment the nurse stands behind the patient and has the patient bend over and touch his or her toes. What is the nurse assessing? A) Balance B) The spine C) Cervical range of motion D) External rotation of hips

B) The spine

During a complete health assessment, how would the nurse test the patient's hearing? A) By observing how the patient participates in normal conversation B) Using the whispered voice test C) Using the Weber and Rinne tests D) Testing with an audiometer

B) Using the whispered voice test During the complete health assessment, the nurse should test hearing with the whispered voice test. The other options are not correct. Page: 765

During examination, the nurse finds that a patient is unable to distinguish objects placed in his hand. The nurse would document: A) stereognosis. B) astereognosis. C) graphesthesia. D) agraphesthesia.

B) astereognosis. Astereognosis is the inability to identify correctly an object placed in the hand. See Chapter 23. Pages: 621-678

A 5-year old child is in the clinic for a checkup. The nurse would expect him to: A) have to be held on his mother's lap. B) be able to sit on the examination table. C) be able to stand on the floor for the examination. D) be able to remain alone in the examination room

B) be able to sit on the examination table. At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and young children aged 6 months to 2 or 3 years should be positioned in the parent's lap. Pages: 777-778

After the examination of an infant, the nurse documents opisthotonos. The nurse recognizes that this finding often occurs with: A) cerebral palsy. B) meningeal irritation. C) a lower motor neuron lesion. D) a upper motor neuron lesion.

B) meningeal irritation Opisthotonos is a form of spasm in which the head is arched back, and there is stiffness of the neck and extension of the arms and legs. It occurs with meningeal or brainstem irritation. See Chapter 23 Pages: 621-678

An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers: A) posture. B) mobility. C) mood and affect. D) physical deformity.

B) mobility Use of assistive devices would be documented under the mobility section. The other responses are all other categories of the general appearance section of the health history. Page: 764

During inspection of the posterior chest, the nurse should assess for: A) symmetric expansion. B) symmetry of shoulders and muscles. C) tactile fremitus. D) diaphragmatic excursion.

B) symmetry of shoulders and muscles. During inspection of the posterior chest, the nurse should inspect for symmetry of shoulders and muscles, configuration of the thoracic cage, and skin characteristics. Symmetric expansion and tactile fremitus are assessed with palpation; diaphragmatic excursion is assessed with percussion. Page: 766

During an examination, the nurse notices that a patient's legs turn white when they are raised above the patient's head. The nurse should suspect: A) lymphedema. B) Raynaud's disease. C) chronic arterial insufficiency. D) chronic venous insufficiency.

C) chronic arterial insufficiency. Elevational pallor (marked) indicates arterial insufficiency. See Chapter 20. Pages: 499-525

When assessing the neonate, the nurse should test for hip stability with which method? A) Eliciting the Moro reflex B) Performing the Romberg's test C) Checking for the Ortolani's sign D) Assessing the stepping reflex

C) Checking for the Ortolani's sign The nurse should test for hip stability in the neonate by testing for the Ortolani's sign. The other tests are not appropriate for testing hip stability. Pages: 775-776

The nurse will measure a patient's near vision with which tool? A) Snellen eye chart with letters B) Snellen "E" chart C) Jaeger card D) Ophthalmoscope

C) Jaeger card The Jaeger card is used to measure near vision. See Chapter 14. Pages: 279-322

The nurse should wear gloves for which of these examinations? A) Measuring vital signs B) Palpation of the sinuses C) Palpation of the mouth and tongue D) Inspection of the eye with an ophthalmoscope

C) Palpation of the mouth and tongue Gloves should be worn when the examiner is exposed to the patient's body fluids. Page: 766

When performing a health history, the nurse would note immunizations under which category? A) Family history B) Personal history C) Past medical history D) History of present illness

C) Past medical history

The nurse is conducting a hearing screening. Which technique will the nurse use during the whisper test? A) The nurse pulls the pinna up and back B) The nurse covers their lips to obscure them from view C) The nurse asks the patient to repeat 3 letters or numbers D) The nurse stands 4 feet away from the patient and whispers three different words

C) The nurse asks the patient to repeat 3 letters or numbers

A patient is unable to shrug her shoulders against the nurse's resistant hands. What cranial nerve is involved with successful shoulder shrugging? A) VII B) IX C) XI D) XII

C) XI Cranial nerve XI enables the patient to shrug her shoulders against resistance. Page: 766

The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles. This finding indicates: A) lymphedema. B) Raynaud's disease. C) arterial insufficiency. D) venous insufficiency.

C) arterial insufficiency. Ulcerations on the tips of the toes and lateral aspect of the ankles are indicative of arterial insufficiency. See Chapter 20. Pages: 499-525

During the examination of a patient, the nurse notices that the patient has several small, flat macules on the posterior portion of her thorax. These macules are less than 1 cm wide. Another name for these macules is: A) warts. B) bullae. C) freckles. D) papules.

C) freckles A macule is solely a lesion with color change, flat and circumscribed, less than 1 cm. Macules are also known as freckles. See Chapter 12. Pages: 203-250

While recording in a patient's medical record, the nurse notices that a patient's Hematest results are positive. This means that there: A) are crystals in his urine. B) are parasites in his stool. C) is occult blood in his stool. D) are bacteria in his sputum.

C) is occult blood in his stool If a stool is Hematest positive, then it indicates the presence of occult blood. See Chapter 21. Pages: 527-564

A patient tells the nurse that "sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath." When documenting this information, the nurse would note: A) orthopnea. B) acute emphysema. C) paroxysmal nocturnal dyspnea. D) acute shortness of breath episode.

C) paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea occurs when the patient awakens from sleep with shortness of breath and needs to be upright to achieve comfort. See Chapter 18.

The nurse has just recorded a positive obturator test on a patient who has abdominal pain. This test is used to confirm a(n): A) inflamed liver. B) perforated spleen. C) perforated appendix. D) enlarged gallbladder.

C) perforated appendix. A perforated appendix irritates the obturator muscle, producing pain. See Chapter 21. Pages: 527-564

When the nurse flexes the patient's knee and gently compresses the gastrocnemius muscle anteriorly against the tibia, the patient indicates that he is having calf pain. The nurse should document _____ sign. A) positive Allen's B) negative Allen's C) positive Homans' D) negative Homans'

C) positive Homan's Calf pain with these maneuvers is a positive Homans' sign, which occurs in some cases of deep vein thrombosis. See Chapter 20. Pages: 499-525

Which of these is included in assessment of general appearance? A) Height and weight B) Weight and skin color C) Skin color and nutritional status D) Vital signs and body mass index

C) skin color and nutritional status General appearance includes: -Appears stated age -Level of consciousness -Skin color -Nutritional status -Posture/Position -Mobility (gait, joint ROM, involuntary mvmt, ability to rise from seated position) -Facial expression -Mood and affect -Speech (articulation, pattern, content, language) -Hearing -Personal hygiene Height, weight, and VS are measurements.

If the nurse records the results to the Hirschberg test, the nurse has: A) tested the patellar reflex. B) assessed for appendicitis. C) tested the corneal light reflex. D) assessed for thrombophlebitis.

C) tested the corneal light reflex. The Hirschberg test assesses the corneal light reflex. See Chapter 14. Pages: 279-322

While examining a 48-year-old patient's eyes, the nurse notices that he had to move the handheld vision screener farther away from his face. The nurse would suspect: A) myopia. B) omniopia. C) hyperopia. D) presbyopia.

D) presbyopia Presbyopia, the decrease in power of accommodation with aging, is suggested when the handheld vision screener card is moved farther away. See Chapter 14. Pages: 279-322

The nurse has just completed an examination of a patient's extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves? A) II, III, VI B) II, IV, V C) III, IV, V D) III, IV, VI

D) III, IV, VI Extraocular muscles are innervated by cranial nerves III, IV, and VI. Page: 765

During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with successful performance of this action? A) I B) V C) XI D) XII

D) XII Cranial nerve XII enables the person to stick out his or her tongue. Page: 766

During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's ____ function is intact. A) occipital B) cerebral C) temporal D) cerebellar

D) cerebellar The nurse should test cerebellar function of the upper extremities by using the finger-to-nose test or rapid-alternating-movements test. The nurse should test cerebellar function of the lower extremities by asking the person to run each heel down the opposite shin. Pages: 769-770

The nurse documents that a patient has coarse, thickened skin and brown discoloration over the lower legs. Pulses are present. This finding is probably the result of: A) lymphedema. B) Raynaud's disease. C) chronic arterial insufficiency. D) chronic venous insufficiency.

D) chronic venous insufficiency. Chronic venous insufficiency would present as firm brawny edema, coarse thickened skin, normal pulses, and brown discoloration. See Chapter 20. Pages: 499-525

After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist, papules in a cauliflower-like patch around her introitus. This finding is most likely: A) urethral caruncle. B) syphilitic chancre. C) herpes. D) human papillomavirus.

D) human papillomavirus Human papillomavirus appears in a flesh-colored, soft, moist, cauliflower-like patch of papules. See Chapter 26. Pages: 725-762

The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate: A) epigastric hernia. B) pyloric obstruction. C) hypoactive bowel sounds. D) hyperactive bowel sounds.

D) hyperactive bowel sounds. A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach as seen with pyloric obstruction or large hiatus hernia. See Chapter 21. Pages: 527-564

A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would: A) place the stethoscope over the temporomandibular joint and listen for bruits. B) place the hands over his ears and ask him to open his mouth "really wide." C) place one hand on his forehead and the other on his jaw and ask him to try to open his mouth. D) place a finger on his temporomandibular joint and ask him to open and close his mouth.

D) place a finger on his temporomandibular joint and ask him to open and close his mouth. The nurse should palpate the temporomandibular joint by placing your fingers over it as the person opens and closes the mouth. Page: 765

During the examination of a patient's mouth, the nurse observes a nodular bony ridge down the middle of the hard palate. The nurse would chart this finding as: A) cheilosis. B) leukoplakia. C) ankyloglossia. D) torus palatinus.

D) torus palatinus. A normal variation of the hard palate is a nodular bony ridge down the middle of the hard palate, a torus palatinus. See Chapter 16. Pages: 351-382

When the nurse performs the confrontation test, the nurse has assessed: A) extraocular eye muscles (EOMs). B) pupils (PERRLA). C) near vision. D) visual fields.

D) visual fields The confrontation test assesses visual fields. The other options are not tested with the confrontation test. Page: 765