Exam 2 Ch. 31 Physical Assessment Practice Questions

An older-adult patient is being seen for chronic entropion. Which condition will the nurse assess for in this patient?

Infection

The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. Which proper sequence will the nurse follow to perform the initial assessment?

Inspection and light palpation

A patient in the emergency department is reporting left lower abdominal pain. Which proper order will the nurse follow to perform the comprehensive abdominal examination?

Inspection, auscultation, palpation

A nurse is preparing to perform a lung assessment on a patient and discovers through the nursing history the patient smokes. The nurse figures the pack-years for this patient who has smoked two and a half (2 1/2) packs a day for 20 years. Which value will the nurse record in the patient's medical record? Record answer as a whole number. _________ pack-years

50 (Pack-years = Number of years smoking × Number of packs per day: 20 × 2.5 = 50.)

The paramedics transport an adult involved in a motor vehicle accident to the emergency department. On physical examination, the patient's level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli. Which value will the nurse report for the patient's Glasgow Coma Scale score?

9

A nurse is assessing a group of patients. Match the assessment finding the nurse observed to its condition.

1. Koilonychia - Spoon nails 2. Venous problems - Lower extremity swollen and warm with normal pulse 3. Lordosis - Swayback 4. Melena - Black, tarry stools 5. Arterial problems - Lower extremity pale and cool with decreased pulse 6. Jugular vein distention - Neck vein visible when sitting 7. Tinnitus- Ringing in ears

An older-adult patient is taking aminoglycoside for a severe infection. Which assessment is the priority?

Ears

A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which statement made by the new graduate nurse requires the preceptor to intervene?

"Nursing assessment data are used only to provide information about the effectiveness of your medical care.

The nurse is assessing an adult patient's patellar reflex. Which finding will the nurse record as normal?

2+

The nurse considers several new female patients to receive additional teaching on the need for more frequent Pap test and gynecological examinations. Which assessment findings reveal the patient at highest risk for cervical cancer and having the greatest need for patient education?

22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners

A nurse is performing a mental status examination and asks an adult patient what the statement "Don't cry over spilled milk" means. Which area is the nurse assessing?

Abstract thinking

A nurse is caring for a group of patients. Which patient will the nurse see first?

An adult with an S4 heart sound

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which action will the nurse take when performing an abdominal assessment?

Ask the patient about the color of her stools.

An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old American woman of Chinese descent. Which action will the nurse do first?

Assess the patient's feelings about the examination.

During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. Which assessment finding will the nurse report to the health care provider?

Bruit

The nurse completed assessments on several patients. Which assessment finding will the nurse record as normal?

Constricting pupils when directly illuminated

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Which action will the nurse take next?

Contact social services and report suspected abuse.

The patient is a 45-year-old African-American male who has come in for a routine annual physical. Which type of preventive screening does the nurse discuss with the patient?

Digital rectal examination of the prostate

A teen patient is tearful and reports locating lumps in her breasts. Other history obtained is that she is currently menstruating. Physical examination reveals soft and movable cysts in both breasts that are painful to palpation. The nurse also notes that the patient's nipples are erect, but the areola is wrinkled. Which action will the nurse take after talking with the health care provider?

Discuss the possibility of fibrocystic disease as the probable cause.

While assessing the skin of an 82-year-old patient, a nurse discovers nonpainful, ruby red papules on the patient's trunk. What is the nurse's next action?

Document cherry angiomas as a normal older adult skin finding.

The patient has had a stroke that has affected the ability to speak. The patient becomes extremely frustrated when trying to speak. The patient responds correctly to questions and instructions but cannot form words coherently. Which type of aphasia is the patient experiencing?

Expressive

On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. Which condition will the nurse assess for in this patient?

Fluid retention

The nurse is assessing skin turgor. Which technique will the nurse use?

Grasp a fold of skin on the sternal area.

A male student comes to the college health clinic. He hesitantly describes that he found something wrong with his testis when taking a shower. Which assessment finding will alert the nurse to possible testicular cancer?

Hard, pea-sized testicular lump

During a routine pediatric history and physical, the parents report that their child was a very small, premature infant that had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born and developed an infection that required "every antibiotic under the sun" to reach a cure. Which exam is a priority for the nurse to conduct on the child?

Hearing acuity

A nurse is assessing several patients. Which assessment findings will cause the nurse to follow up? (Select all that apply.)

Orthopnea - Pleural friction rub present - Crackles in lower lung lobes

During a school physical examination, the nurse reviews the patient's current medical history. The nurse discovers the patient has allergies. Which assessment finding is consistent with allergies?

Pale nasal mucosa

The patient presents to the clinic with dysuria and hematuria. How does the nurse proceed to assess for kidney inflammation?

Percusses posteriorly the costovertebral angle at the scapular line.

A nurse is conducting Weber's test. Which action will the nurse take?

Place a vibrating tuning fork in the middle of patient's forehead.

During a genitourinary examination of a 30-year-old male patient, the nurse identifies a small amount of a white, thick substance on the patient's uncircumcised glans penis. What is the nurse's next step?

Record this as a normal finding.

The nurse is preparing for a rectal examination of a nonambulatory male patient. In which position will the nurse place the patient?

Sims'

A nurse is preparing to perform a complete physical examination on a weak, older-adult patient with bilateral basilar pneumonia. Which position will the nurse use?

Supine

Upon assessment, the patient is breathing normally and has normal vesicular lung sounds. Which expected inspiratory-to-expiratory breath sounds will the nurse hear?

The inspiratory phase is 3 times longer than the expiratory phase.

A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Which laboratory test will the nurse expect to be ordered, based upon the physical findings?

Thyroid-stimulating hormone test

The nurse is assessing the tympanic membranes of an infant. Which action by the nurse demonstrates proper technique?

Uses an inverted otoscope grip while pulling the auricle downward and back.

A nurse is auscultating different areas on an adult patient. Which technique should the nurse use during an assessment?

Uses the diaphragm to listen for bowel sounds

A febrile preschool-aged child presents to the after-hours clinic. Varicella (chickenpox) is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. Which type of skin lesion will the nurse report?

Vesicles

A nurse is assessing a patient's cranial nerve IX. Which items does the nurse gather before conducting the assessment? (Select all that apply.)

Vial of sugar - Tongue blade - Lemon applicator

A nurse identifies lice during a child's scalp assessment. The nurse teaches the parents about hair care. Which information from the parents indicates the nurse needs to follow up?

We will use lindane-based shampoos.

During a sexually transmitted illness presentation to high-school students, the nurse recommends the human papillomavirus (HPV) vaccine series. Which condition is the nurse trying to prevent?

Cervical cancer

Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse next enters the patient's room and identifies self, washes hands with soap, and states the purpose of the visit. The nurse performs proper identification of the patient before auscultating the patient's lungs. Which critical health assessment step should the nurse have performed?

Cleaning stethoscope with alcohol

The nurse is examining a female with vaginal discharge. Which position will the nurse place the patient for proper examination?

Lithotomy

A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes. Which response by the nurse is the best regarding the eye examination results?

Your child needs to see an ophthalmologist.