Deck 20: Health History and Physical Assessment

Question 1

A nurse is assessing a patient's abdomen and hears bowel sounds every 20 to 25 seconds. What action by the nurse is best?

A) Avoid palpating this patient's abdomen.
B) Document the findings in the patient's chart.
C) Have another nurse verify the findings.
D) Ask the patient when the last food intake was.

Answer 1

Document the findings in the patient's chart.

Question 2

The nurse is assessing a patient's cranial nerve III. What technique is best?

A) Have patient identify a common scent with closed eyes.
B) Shine a light into the patient's eyes to assess pupil response.
C) Have the patient read a newspaper or use the Snellen chart.
D) Assess if patient can hear both spoken and whispered words.

Answer 2

Shine a light into the patient's eyes to assess pupil response.

Question 3

A nurse is told in hand-off report that a patient opens eye spontaneously, is confused but able to answer questions, and demonstrates purposeful movement to painful stimuli. What does the nurse calculate the patient's Glasgow Coma Scale to be?

A) 7
B) 9
C) 11
D) 13

Answer 3

13

Question 4

A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What action by the nurse is most appropriate?

A) Offer the patient a small pillow for under his/her head.
B) Provide a method for ensuring the patient stays warm.
C) Raise the head of the bed to about 30 degrees.
D) Ensure there is enough lighting for an adequate examination.

Question 5

A nurse is assisting a patient who is having an examination of the female genitalia. What action by the nurse is best?

A) Get the provider; assist patient into lithotomy position.
B) Assist the patient into lithotomy position; get the provider.
C) Get the provider; assist patient into Sims position.
D) Assist the patient into Sims position; get the provider.

Question 6

A student nurse is preparing to auscultate a patient's lungs. What action by the student leads the instructor to intervene?

A) Student asks to turn the television volume down.
B) Student warms the bell of the stethoscope before use.
C) Student uses the stethoscope bell to listen to bowel sounds.
D) Student places the stethoscope diaphragm on the patient's skin.

Question 7

The nurse is planning to educate four patients on preventing skin cancer and early warning signs. Which patient is the priority for this education?

A) Adolescent who uses a tanning bed
B) Middle-aged adult who walks for fitness
C) Older woman who sits in the sun for 10 minutes daily
D) Person who works indoors under fluorescent lights

Question 8

The student nurse asks if it matters whether a healthy eye or a diseased eye should be examined first. What response by the faculty is best?

A) Diseased eye first because it is the priority
B) Healthy eye first to prevent spread of disease
C) It does not matter if both eyes are examined
D) Start with the eye the patient wants you to start with

Question 9

A clinic nurse is examining an older, confused patient on an examination table and realizes a piece of needed equipment was left outside in the hall. What action by the nurse is best?

A) Tell the patient to lie still and go get the equipment.
B) Call for another staff member to bring the equipment.
C) Have the patient get into a chair and get the equipment.
D) Finish the rest of the exam, get the equipment, and use it.

Question 10

A nurse observes a patient sitting up in bed, leaning forward with the arms braced against the over-the-bed table. What action by the nurse is best?

A) Assess the patient for a barrel-chest appearance.
B) Palpate the patient's abdomen for tenderness.
C) Inspect the patient's spine for deformities.
D) Ask the patient if he/she is experiencing dizziness.

Question 11

A nurse assesses a patient's lungs and notes the presence of low-pitched snoring sounds that clear with coughing. What action by the nurse is best?

A) Prepare to treat the patient for asthma.
B) Prepare to treat the patient for pneumonia.
C) Teach the parent how to prevent croup.
D) Assess the patient for heart failure.

Question 12

A nurse has conducted an Allen's test on a patient and the result was 8 seconds. What action by the nurse is best?

A) Document the findings and continue the assessment.
B) Notify the health care provider immediately.
C) Elevate the patient's arm above the level of the heart.
D) Assess the patient for other signs of circulatory problems.

Question 13

The nurse reads in a chart that a patient has a paronychia. What assessment technique is most appropriate?

A) Auscultate the patient's bowel sounds.
B) Test the cranial nerves for sensory function.
C) Inspect the patient's nails and surrounding skin.
D) Inspect the skin using the ABCDE mnemonic.

Question 14

A new nurse is conducting a patient interview. What behaviors observed by the experienced nurse require education on this process?

A) Typing intently on a keyboard when asking questions
B) Allowing family to accompany the patient as requested
C) Using gestures and eye contact to demonstrate interest
D) Closing the door to the room to ensure privacy
E) Providing nonverbal cues to negative thoughts

Question 15

A patient wishes to review his medical record. What response by the nurse is best?

A) "I'm sorry, we don't allow you to look at your chart."
B) "Let me check to see if we can allow you to do that."
C) "Yes, I can sit with you while you look at it, so you can ask questions."
D) "Yes, all patients can review their charts at any time they wish."

Question 16

A hospitalized patient complains of bilateral leg pain and asks the nurse to massage her legs. One calf is noticeably larger than the other and is warm and slightly reddened. What action by the nurse is best?

A) Only massage the leg with normal assessment findings.
B) Massage the front of both legs and avoid the posterior surfaces.
C) Perform a Homan's test to both legs prior to massaging either of them.
D) Educate the patient on why a massage would be contraindicated.

Question 17

A nurse has assessed a patient's capillary refill, which was 5 seconds. What action by the nurse is most appropriate?

A) Document the findings and continue the examination.
B) Ask the patient about the use of artificial nails.
C) Ask the patient about his/her occupation.
D) Assess the patient for signs of hypoxia.

Question 18

The nurse is assessing a patient's alcohol intake. What question is most appropriate?

A) "Do you drink alcohol at all?"
B) "You don't drink much do you?"
C) "When was your last drink?"
D) "How much alcohol do you drink daily?"

Question 19

The nurse is assessing a patient whose chart indicates a Grade 3 heart murmur. What action is best to hear the murmur?

A) Ensure that the room is extremely quiet.
B) Use a specialized stethoscope with amplification.
C) Auscultate the patient's chest with a stethoscope.
D) Place the stethoscope diaphragm on the patient's back.

Question 20

A nurse is assessing a patient's cranial nerves and notes an abnormal response to testing cranial nerve VI. What action by the nurse is best?

A) Ask the patient about recent facial trauma.
B) Inform the provider immediately.
C) Document findings in the patient's chart.
D) Have the patient frown and lift the eyebrows.

Question 21

The nurse examining a patient's skin correlates which conditions with which underlying pathology?

A) Albinism: Full-thickness burns
B) Peripheral cyanosis: poor circulation
C) Purpura: clotting disorders
D) Jaundice: liver disease
E) Vitiligo: skin infestation

Question 22

A nurse conducting the general survey of a patient includes which items?

A) Hygiene and grooming
B) Affect and mood
C) Sex and gender orientation
D) Sexual preferences and practices
E) Age

Question 23

A nurse is conducting a physical examination using palpation. Which assessments might the nurse note?

A) Rebound tenderness
B) Crepitation
C) Guarding
D) Turgor
E) Consistency
F) None of above

Question 24

A nurse is educating women on breast cancer risk reduction. What topics does the nurse include in the presentation?

A) Exercise
B) Limiting alcohol
C) Low-fat diet
D) Breast self-exams
E) Milk intake

Question 25

A nurse has finished examining a patient. What actions does the nurse take next?

A) Document all findings.
B) Provide privacy for dressing.
C) Provide any hygiene material needed.
D) Tells the patient he/she can leave.
E) Cleans the room after the patient leaves.