Deck 5: Physical Assessment

Question 1

While conducting an assessment of a patient,the nurse recognizes that the initial step is:

A) a body systems review.
B) the nursing health history.
C) biographical data.
D) the present illness.

Answer 1

the nursing health history.

Question 2

The nurse is meeting a patient for the first time.The initial step when initiating a nurse-patient relationship is for the nurse to:

A) appear interested.
B) introduce her/himself.
C) provide support.
D) communicate trust.

Answer 2

introduce her/himself.

Question 3

The nurse uses a systematic method for collecting data on all body systems,including normal functioning and any noted changes.This method is a:

A) nursing interview.
B) review of systems.
C) nursing assessment.
D) health history.

Answer 3

review of systems.

Question 4

When discussing diabetes with a patient,the nurse describes this disease as falling into which group in terms of duration?

A) Acute
B) Organic
C) Chronic
D) Functional

Question 5

The nurse is developing a nursing care plan for a newly admitted patient.The first step in developing this care plan is a:

A) health history.
B) review of systems.
C) family history.
D) nursing assessment.

Question 6

Although the signs and symptoms of both infection and inflammation include erythema,edema,and pain,the major difference is that inflammation:

A) is a result of bacteria.
B) is a protective response.
C) is a disease process.
D) produces tissue damage.

Question 7

A patient was admitted with a complaint of abdominal pain.Later,the nurse observed the patient demonstrating dyspnea.This change in condition requires an assessment called:

A) individualized.
B) focused.
C) specialized.
D) systematic.

Question 8

Any disturbance of a structure or function of the body is a pathological condition.This condition is termed a(n):

A) injury.
B) condition.
C) disease.
D) pathology.

Question 9

There are four categories of factors that increase an individual's vulnerability to developing a disease: genetic,physiological,age,and lifestyle.These are called:

A) risk factors.
B) causative factors.
C) etiological factors.
D) hazardous factors.

Question 10

During the nursing interview,several histories are taken.The history that involves data concerning habits and lifestyle patterns is called:

A) family history.
B) environmental history.
C) past health history.
D) psychosocial history.

Question 11

The nurse is discussing the origin of diabetes with a diabetic patient.The most appropriate explanation is that this disease is caused by a dysfunction of the:

A) pituitary.
B) adrenals.
C) pancreas.
D) thyroid.

Question 12

The patient should be assessed as soon as possible after admission.This initial assessment is done by the:

A) physician.
B) charge nurse.
C) LPN/LVN.
D) RN.

Question 13

The nurse is collecting data during an initial assessment.The data that can be seen,heard,measured,or felt and is objective is called a(n):

A) symptom.
B) observation.
C) sign.
D) assessment.

Question 14

The term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease is:

A) acute.
B) functional.
C) chronic.
D) remission.

Question 15

The nurse is assessing a patient to collect subjective and objective data.These data will provide the basis for making a:

A) care plan.
B) medical diagnosis.
C) nursing assessment.
D) nursing diagnosis.

Question 16

A patient interview being conducted by the nurse should convey to the patient that the nurse has:

A) feelings of concern.
B) plenty of time.
C) a lot of information.
D) the answers to problems.

Question 17

When a disease results in a structural change in an organ that interferes with its functioning,this is a(n):

A) functional disease.
B) organic disease.
C) acute disease.
D) chronic disease.

Question 18

As part of an assessment,the nurse asks the patient for subjective information related to the present illness.Subjective findings that are perceived by the patient are known as:

A) assessments.
B) symptoms.
C) signs.
D) observations.

Question 19

A nursing assessment is a process of collecting data to establish a database.The information contained in the database is the basis for:

A) a complete physical examination.
B) a medical assessment.
C) an individualized plan of care.
D) writing nursing orders.

Question 20

When collecting data related to the present illness,the nurse must obtain detailed and comprehensive data to assist in establishing:

A) a nursing diagnosis.
B) a nursing care plan.
C) appropriate interventions.
D) nursing orders.

Question 21

During a physical assessment,the nurse listens for adventitious lung sounds.Crackles are classified as fine,medium,or coarse and are most often heard:

A) during expiration.
B) following expiration.
C) during inspiration.
D) following inspiration.

Question 22

When performing a physical examination of a patient,the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen.This technique is:

A) auscultation.
B) deep palpation.
C) light palpation.
D) percussion.

Question 23

When auscultating the thorax,the suggested sequence for a systematic approach is to begin with the:

A) anterior thorax.
B) apices.
C) left lateral thorax.
D) right lateral thorax.

Question 24

An older adult patient is being assessed for skin turgor.The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised.The nurse recognizes this could be caused by:

A) dehydration.
B) edema.
C) skin breakdown.
D) malnutrition.

Question 25

The nurse is obtaining a history of a patient's present illness.The PQRST system is used for the interview.In this system,the R stands for:

A) random.
B) region.
C) result.
D) recent.

Question 26

The nurse is performing auscultation of breath sounds on a respiratory patient.The sounds heard on inspiration and expiration are low-pitched,coarse,gurgling,and have a snoring sound.These are identified as:

A) crackles.
B) plural friction rub.
C) rhonchi.
D) sonorous wheezes.

Question 27

During a head-to-toe assessment,the nurse assesses the patient's abdomen.Which area should the nurse assess next?

A) Chest
B) Arms
C) Legs and feet
D) Perineal area

Question 28

Auscultating the heart sounds should result in a "lubb-dupp" sound when using the bell and the diaphragm of the stethoscope.The "lubb" sound is caused by the:

A) opening of the AV valves.
B) opening of the semilunar valves.
C) closing of the AV valves.
D) closing of the semilunar valves.

Question 29

A nurse is gathering subjective data when admitting a patient.Which assessment finding is considered subjective data? The patient:

A) complains of chest pain.
B) is experiencing dyspnea.
C) appears to be anxious.
D) expectorates red-tinged sputum.

Question 30

A nurse is gathering objective data when admitting a patient.Which assessment finding is considered objective? The patient:

A) complains of nausea.
B) states,"I hurt all over."
C) complains of feeling anxious.
D) appears to be anxious.

Question 31

A patient has edema of the lower extremities.The nurse is assessing whether it is pitting and to what degree.After pressing the skin against a bony prominence for 5 seconds,the nurse identifies 2+ pitting edema because the edema disappears in:

A) 10-15 seconds.
B) 20-25 seconds.
C) 30-35 seconds.
D) 40-45 seconds.

Question 32

During a head-to-toe assessment,the nurse assesses the patient's perineal area.Which area should the nurse assess next?

A) Chest
B) Arms
C) Abdomen
D) Legs and feet

Question 33

The nurse assesses a patient for capillary refill.After the fingernail is compressed for 5 seconds,the refill time should be fewer than:

A) 1 second.
B) 2 seconds.
C) 3 seconds.
D) 4 seconds.

Question 34

When performing a nursing physical assessment,the nurse uses a head-to-toe approach.When using this method,the nurse begins with a:

A) skin assessment.
B) neurological assessment.
C) circulatory assessment.
D) respiratory assessment.

Question 35

When performing a head-to-toe assessment,the nurse should begin by assessing the patient's:

A) support system.
B) skin integrity.
C) pain level.
D) neurological status.

Question 36

A nurse is gathering subjective data when admitting a patient.Which assessment finding is considered subjective data? The patient:

A) complains of pruritus.
B) is experiencing erythema.
C) appears to be experiencing pruritus.
D) has a generalized rash.

Question 37

Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope.The normal rate of bowel sounds per minute is:

A) 2-10.
B) 3-20.
C) 4-32.
D) 5-40.

Question 38

Various techniques are used by the nurse when performing a physical assessment.One of these techniques is percussion.Percussion is used to determine:

A) sounds for auscultation.
B) data about physical features.
C) changes in structural integrity.
D) density of underlying tissue.

Question 39

A nurse is gathering subjective data when admitting a patient.Which assessment finding is considered subjective data? The patient:

A) complains of diplopia.
B) is experiencing nystagmus.
C) demonstrates facial grimacing.
D) has a generalized rash.

Question 40

A nurse is gathering objective data when admitting a patient.Which assessment finding is considered objective data?

A) The patient complains of chest pain.
B) The patient states,"I am having trouble breathing."
C) The patient complains of coughing up sputum.
D) The patient expectorates red-tinged sputum.

Question 41

During a physical assessment,the nurse notes that a patient has bright red blood in the feces.The nurse recognizes that the bleeding is most likely caused by:

A) bleeding in the upper intestinal tract.
B) bleeding in the lower intestinal tract.
C) bleeding in the entire intestinal tract.
D) consumption of cranberry juice.

Question 42

A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue.The nurse should document that the patient has:

A) dyspnea.
B) cyanosis.
C) diaphoresis.
D) ecchymosis.

Question 43

A physician needs to assess extension of a patient's hip joint.The nurse should place the patient in what position?

A) Sims'
B) Prone
C) Lithotomy
D) Dorsal recumbent

Question 44

A nurse is caring for a patient with congestive heart failure.During the physical assessment,the nurse notes the patient is experiencing difficulty breathing.The nurse should document that the patient is experiencing:

A) dyspnea.
B) cyanosis.
C) diaphoresis.
D) ecchymosis.

Question 45

A physician needs to assess a patient for a heart murmur.The nurse should place the patient in what position?

A) Sims'
B) Prone
C) Lithotomy
D) Lateral recumbent

Question 46

During a physical assessment,the nurse notes that a patient's heart rate is 56 beats per minute.The nurse should document that the patient is experiencing:

A) dyspnea.
B) cyanosis.
C) diaphoresis.
D) bradycardia.

Question 47

During a physical assessment,the nurse notes a patient has a bluish discoloration of the skin and mucous membranes.The nurse should document that the patient is experiencing:

A) dyspnea.
B) cyanosis.
C) diaphoresis.
D) ecchymosis.

Question 48

During a physical assessment,the nurse notes a patient has a loss of strength and energy.The nurse should document that the patient is experiencing:

A) dyspnea.
B) cyanosis.
C) asthenia.
D) ecchymosis.

Question 49

During a physical assessment,the patient complains of difficulty in passing stools.The nurse should document that the patient is experiencing:

A) dyspnea.
B) cyanosis.
C) constipation.
D) ecchymosis.

Question 50

When assessing a patient with hepatitis,the nurse notes a yellow tingle to the patient's skin.The nurse understands that jaundice most likely results from an obstruction in the flow of bile from the:

A) heart.
B) liver.
C) brain.
D) intestines.

Question 51

When assessing a patient,the nurse notes a yellow tinge to the patient's skin.The nurse should document that the patient has:

A) dyspnea.
B) cyanosis.
C) jaundice.
D) ecchymosis.

Question 52

During a physical assessment,the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs.The nurse should document that the patient is experiencing:

A) dyspnea.
B) cyanosis.
C) coughing.
D) ecchymosis.

Question 53

During a physical assessment,the nurse notes a patient has a lack of appetite resulting in an inability to eat.The nurse should document that the patient is experiencing:

A) dyspnea.
B) asthenia.
C) anorexia.
D) ecchymosis.

Question 54

During a physical assessment,the nurse notes a patient has profuse secretions of sweat.The nurse should document that the patient is experiencing:

A) dyspnea.
B) cyanosis.
C) diaphoresis.
D) ecchymosis.

Question 55

A physician needs to insert a vaginal speculum into a patient for a vaginal examination.The nurse should place the patient in what position?

A) Sims'
B) Prone
C) Lithotomy
D) Dorsal recumbent

Question 56

During a physical assessment,the nurse notes a patient passes frequent loose liquid stools.The nurse should document that the patient is experiencing:

A) dyspnea.
B) cyanosis.
C) diaphoresis.
D) diarrhea.

Question 57

A nurse needs to auscultate a patient's lung sounds.The nurse should place the patient in what position?

A) Sims'
B) Prone
C) Sitting
D) Lithotomy

Question 58

During a neurological assessment,the nurse notes a patient has a unilateral,dilated,and nonreactive pupil.This is a sign that the patient is experiencing pressure on which cranial nerve?

A) I
B) II
C) III
D) IV

Question 59

When admitting a patient to the hospital,the nurse notes the patient has mild sunburn.The nurse should document this finding as:

A) dyspnea.
B) cyanosis.
C) erythema.
D) ecchymosis.

Question 60

A physician needs to assess a patient's rectal area.The nurse should place the patient in what position?

A) Sims'
B) Prone
C) Lithotomy
D) Knee-chest

Question 61

Symptoms that are perceived by the patient are known as _____________ ____________.

Question 62

The nurse observes an older adult patient has no hair on the lower legs.The nurse should assess further for the sufficiency of _________ ________.

Question 63

A circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute is known as _________________.

Question 64

Discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls is known as _________________.

Question 65

A condition is which there is a lack of appetite resulting in the inability to eat is known as _______________.

Question 66

A physician documents that a patient is having purulent drainage from a wound.The nurse understands that this is most likely caused by:

A) ringworm.
B) viral infection.
C) fungal infection.
D) bacterial infection.

Question 67

When auscultating the chest,a nurse hears crackles in both lower lobes.To further assess this finding,the nurse should ask the patient to ______________.

Question 68

A condition in which a patient experiences bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood is known as _________________.

Question 69

Arrange these assessment techniques in correct order of a standard physical examination
1.Auscultation
2.Percussion
3.Inspection
4.Palpation
Put a comma between each answer choice (1,2,3,4,etc.).

Question 70

When assessing a patient,the nurse notes that the patient has an unnatural paleness of color to the skin.The nurse should document this finding as:

A) skin pallor.
B) pruritus.
C) sallow skin.
D) jaundice.

Question 71

The nurse notes that a patient has difficulty breathing in the supine position,and the patient admits that he sleeps in a recliner at home.These are cardinal signs of ____________ disease.

Question 72

When assessing a female for risk factors associated with coronary artery disease,what information should the nurse include? (Select all that apply.)

A) Family history of illness
B) Diet
C) Smoking
D) Exercise
E) Number of pregnancies

Question 73

When assessing a patient,the patient complains of an uncomfortable sensation leading to an urge to scratch.The nurse notes the patient scratching frequently.The nurse should document that the patient is experiencing:

A) dyspnea.
B) cyanosis.
C) jaundice.
D) pruritus.

Question 74

A physician documents that a patient has a scleral icterus.The nurse understands this indicates that the color of the patient's sclera is yellow and is caused by infiltration of:

A) bilirubin.
B) hemoglobin.
C) serum potassium.
D) serum magnesium.

Question 75

Which are infectious diseases? (Select all that apply.)

A) Measles
B) Pneumonia
C) Hay fever
D) Tuberculosis
E)Osteoarthritis
F)Acquired immunodeficiency syndrome

Question 76

Signs that are perceived by an examiner and can be seen,heard,measured,or felt are known as ___________ _________.

Question 77

A physician documents that a patient has a scleral icterus.The nurse understands this indicates that the color of the patient's sclera is:

A) red.
B) blue.
C) green.
D) yellow.

Question 78

When assessing a patient,the nurse notes that the patient is unable to lie flat to breathe.When the nurse assists the patient to a sitting position,the patient is able to breathe more easily.The nurse should document that the patient is experiencing:

A) dyspnea.
B) cyanosis.
C) jaundice.
D) orthopnea.

Question 79

A physician documents that a patient has a sallow complexion.The nurse understands that this means the patient has a:

A) yellow color to the skin.
B) blue color to the skin.
C) red color to the skin.
D) gray color to the skin.

Question 80

A condition of debility,loss of strength and energy,and depleted vitality is known as _________________.