Health Assessment Quizzes

The nurse is caring for four female patients. Which patient is identified as being at greatest risk for low bone density? a. 44 year old Native American b. 39 year old Caucasian American c. 50 year old African American d. 22 year old Asian American

39 year old Caucasian American

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? a. Assess the apical pulse for a full minute. b. Assess the pedal pulses with a Doppler device. c. Assess the apical pulse with a Doppler device. d. Assess the pedal pulses for a full minute.

Assess the apical pulse for a full minute.

When assessing the wrist the nurse notes this joint should perform which of the following range of motion? Select all that apply. a. Inversion b. Circumduction c. Adduction d. Hyperextension e. Flexion

a. Inversion b. Circumduction e. Flexion

The nurse is reviewing the risk factors for deep vein thrombosis. Which of the following increases the risk of blood clot formation? Select all that apply. a. Prolonged bed rest b. High sodium diet c. Pregnancy d. Strenuous activity 5 days per week e. Smoking cigarettes f. Taking anticoagulants daily

a. Prolonged bed rest c. Pregnancy e. Smoking cigarettes

When assessing the AV fistula before dialysis, which of the following would lead the nurse to hold dialysis treatment? Select all that apply. a. A positive bruit b. A positive thrill c. A negative bruit d. A negative thrill

c. A negative bruit d. A negative thrill

A patient with cerebral edema after a motor vehicle accident opens their eyes to noise, grunts when the nurse asks questions and withdraws from painful stimuli. When documenting these findings, what is the associated Glascow Coma Scale score? a. 5 b. 11 c. 9 d. 13

9

When palpating and percussing the frontal sinuses, where would the nurse describe its location? a. By the temples b. Above the eyebrows c. On either side of the nose d. On the upper cheeks

Above the eyebrows

Assessing the optic and oculomotor nerves can be done by using PERRLA. The "A" in PERRLA stands for which of the following? a. Anisocoria b. Abduction c. Acuity d. Accommodation

Accommodation

A patient with kidney failure reports dyspnea. The patient's pulse oximeter reading is 95% on room air, but is visibly distressed with a respiratory rate of 32 breaths/min. What is the priority intervention? a. Administer a respiratory nebulizing treatment. b. Notify the respiratory therapist. c. Administer oxygen by nasal cannula. d. Elevate the head of bed to 90 degrees.

Administer oxygen by nasal cannula.

When assessing a patient, the nurse notes that they cannot identify the scent as coffee. How should the nurse document this? a. Ptosis of nares bilaterally. b. Anosmia present bilaterally. c. Cranial nerve III is not intact. d. Olfactory nerve is intact.

Anosmia present bilaterally.

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following? a. Within the expected range b. Thrombus formation in the vein c. Arterial insufficiency d. Venous insufficiency

Arterial insufficiency

A patient comes into the emergency department holding her RLQ and complaining of sharp pain. When assessing the patient, which of the following actions by the student nurse would suggest further education is needed? a. Assessing for rebound tenderness in the RLQ b. Inspecting for any protrusions in all four quadrants c. Auscultating bowel sounds in all four quadrants d. Asking about nausea, vomiting or change in bowel movements

Assessing for rebound tenderness in the RLQ

A student nurse is assessing the peripheral vascular system of a patient. What action by the student would cause the clinical instructor to intervene? a. Classifying capillary refill time of 6 seconds as delayed b. Palpating carotid arteries one at a time c. Assessing the blood pressure in the same arm as an AV fistula d. Occluding the ulnar artery to assess for Allen's sign

Assessing the blood pressure in the same arm as an AV fistula

The student nurse is assessing the nearest pulse point of a patient with recent amputation surgery. Where would they locate the popliteal artery? a. Lateral to the extensor tendon of the great toe b. On the posterior wrist c. In the groove behind the medial malleolus d. Behind the knee

Behind the knee

Knowing the recommendations/timeline for the general population to receive assessments/check ups and labwork. Which of the following exam and timeline is correct? a. Dental exams annually b. Annual Papanicolaou (Pap) test c. Self breast exams bimonthly d. Blood pressure screening every 2 years

Blood pressure screening every 2 years

When administering a new GI medication to an older patient, the nurse anticipates what? a. A higher-than-normal dose may be needed. b. Close monitoring is needed because toxic levels may develop. c. Older adults always require a lower-than-normal dose than younger patients. d. Nausea and vomiting may develop rapidly and are common side effects in older adults.

Close monitoring is needed because toxic levels may develop.

A patient is being admitted to your unit with a new diagnosis of congestive heart failure. What type of assessment is appropriate? a. Basic b. Comprehensive c. Focused d. System-based

Comprehensive

A patient's urine is dark brown in color. Knowing the possible cause of this color, what other findings would the nurse anticipate? a. Straining while urinating b. Decreased urine output c. Foul smelling urine d. Increased urine output

Decreased urine output

When the student nurse is assessing the musculoskeletal system, which of the following would cause the instructor to intervene? a. Applying resistance to the anterior calf to assess strength of the knee. b. Assessing for neck range of motion using elevation and depression. c. Documenting fluid around the knee as genu valgum. d. Documenting red, swollen joints as an unexpected finding.

Documenting fluid around the knee as genu valgum.

The nurse is caring for a 30-year-old patient who experienced a frontal lobe infarction after a motorcycle accident. What is the appropriate nursing intervention? a. Enable the bed alarm safety system. b. Place all items directly in front of the patient. c. Instruct the patient to use a call light prior to getting out of bed. d. Use a picture board to assist with communication.

Enable the bed alarm safety system.

A patient is only responding to sternal rubbing. How would you document this level of consciousness? a. Comatose b. Stupor c. Obtunded d. Lethargic

Stupor

After abdominal surgery, which question should the nurse ask the patient to determine whether peristaltic movement is returning? a. "Is your pain level manageable?" b. "Do you have any nausea?" c. "Have you passed flatus?" d. "Are you hungry?"

"Have you passed flatus?"

After providing education, which patient statement does the nurse identify that best reflects an older patient's understanding of musculoskeletal health interventions? a. "I should ignore my pain and adapt to moving more slowly." b. "I should drink 8 oz of orange juice daily." c. "I should try to exercise at least five times a week." d. "I should use a cane when I walk."

"I should try to exercise at least five times a week."

Which patient statement alerts the nurse to perform a thorough GI history and focused assessment? a. "I got dentures four years ago." You Answered b. "I experience occasional constipation." c. "I take ibuprofen three times daily for arthritis." d. "I don't like the taste of spicy foods."

"I take ibuprofen three times daily for arthritis."

The emergency department nurse is caring for a 78-year old patient whose daughter reports a decrease in cognition. Which nursing statement directed to the patient helps the nurse to assess cognition? a. "Please count backward from 100 by 7s." b. "Tell me what this fable means to you." c. "I will write a word on this paper, and you copy it." d. "Tell me how you were transported to the hospital today."

"Tell me what this fable means to you."

A patient is scheduled for an electromyography (EMG) to evaluate diffuse or localized muscle weakness. What question will the nurse ask the patient before the test? a. "Have you completed your exercise for the day?" b. "Did you take your cyclobenzaprine (Flexeril) this morning?" c. "What herbs and over-the-counter medicines do you take?" d. "When did you last eat or drink?"

"What herbs and over-the-counter medicines do you take?"

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) a. Increased temperature b. Increased hematocrit c. Increased blood pressure d. Increased respiratory rate e. Increased heart rate

- Increased blood pressure - Increased respiratory rate - Increased heart rate

The nurse is caring for a patient with an acoustic neuroma. When preparing to assess the patient further which of the following tests should the nurse anticipate doing? Select all that apply. a. Whisper test b. Weber test c. Rinne test d. Snellen test e. Romberg test

- Whisper test - Weber test - Rinne test

The nurse is assessing for bruits in the renal arteries. What equipment is needed for this? a. Diaphragm side of the stethoscope b. Index and middle finger c. Blood pressure cuff d. Bell side of the stethoscope

Bell side of the stethoscope

When educating your patient about preventing colon cancer, the nurse suggests a healthy diet with fiber. This suggestion would be considered _______________________. a. Secondary Prevention b. Tertiary Prevention c. Primary Prevention

Primary Prevention

Knowing the intended range of motion for joints, which of the following would the nurse anticipate the patient being able to perform using their elbow? Select all that apply. a. Extension b. Supination c. Flexion d. Circumduction e. Abduction

Extension & Flexion

A patient is unable to smile symmetrically. Which cranial nerve is NOT intact? a. Abducens b. Facial c. Trigeminal d. Trochlear

Facial

The nurse draws a number 8 on the palm of a patient's hand and asks to identify what number is drawn. What is this assessment called? a. Stereognosis b. Graphesthesia c. Superficial reflex d. Two-point discrimination

Graphesthesia

Tandem walking is considered which type of gait? a. Normal, usual gait b. Heel only c. Tip toe only d. Heel to toe

Heel to toe

A patient with a history of kidney disease is admitted with acute shoulder pain. Which order should the nurse question? a. Digoxin 0.125 mg by mouth daily b. Metoprolol 50 mg by mouth twice daily c. Ibuprofen 800 mg by mouth every 4 hours as needed for pain d. Pan cultures for a temperature >38.5º C

Ibuprofen 800 mg by mouth every 4 hours as needed for pain

After completing an assessment, the nurse is documenting in the electronic health record. Which of the following would be an example of subjective data? a. Swollen ankles b. Itchy skin c. Pulse strength +1 d. Alert and oriented

Itchy skin

A nurse is attempting to complete a health history on their new admission. The patient easily wakes, but frequently dozes back to sleep. How would the nurse document this level of consciousness? a. Obtunded b. Stupor c. Flat affect d. Lethargic

Lethargic

The nurse is assessing a patient's AV fistula and notes there is not a thrill present. What is the priority action? a. Reschedule dialysis for tomorrow. b. Administer dialysis via the AV fistula. c. Reassess in 1 hour. d. Notify the physician.

Notify the physician

The student nurse is reviewing a patient's chart and notes the previous nurse documented strabismus. What is this referring to? a. Nearsightedness when reading Snellen chart b. Loss of smell unilaterally c. Ocular deviation on the cover/uncover test d. Ocular misalignment on corneal light reflex

Ocular misalignment on corneal light reflex

Falls can lead to complications including fractures and soft tissue injury. Which of the following patient populations are most at risk for these types of complications? a. Older adults b. Middle-aged adults c. Toddlers d. Adolescents

Older adults

Knowing the limitations of practice for a nurse, which of the following would be inappropriate to use when assessing a patient? a. Light palpation b. Opthalmoscope c. Ishihara chart d. Tuning fork

Opthalmoscope

The nurse is caring for an older adult who is usually alert and oriented. When the patient exhibits a change in mental status, which cause does the nurse assess for first? a. Use of sedatives b. Oxygen insufficiency c. Electrolyte imbalance d. Infection

Oxygen insufficiency

A student nurse is documenting their lymphatic assessment of a patient admitted for fever of unknown origin. Which of the following actions by the student nurse would cause the instructor to intervene? a. Assessing the inguinal lymph nodes before the upper lymphatics (pre-auricular, post-auricular, etc.). b. Using the pads of their fingers in a circular motion to assess the lower lymph nodes. c. Palpating the epitrochlear lymph nodes on the medial side by the bend of the arm. d. Documenting lymph nodes as enlarged and fixed.

Palpating the epitrochlear lymph nodes on the medial side by the bend of the arm.

Which of the following patients would you prioritize first? a. Patient with SBP of 130 b. Patient with +2 on the right, 0 on the left c. Patient with bilaterally cool feet d. Patient with a pedal pulse of +1 bilaterally

Patient with +2 on the right, 0 on the left

When assessing a patient with an indwelling catheter the nurse notes the color as brown. Which of the following is most likely the cause of this finding? a. Congestive heart failure b. Severe dehydration c. 10-year history of diabetes mellitus d. Old urinary tract bleed

Severe dehydration

A patient comes in with fluid retention and is given furosemide. To monitor the fluid status, which of the following is the best method? a. Intake & Output b. Edema c. Weight d. Blood pressure

Weight