Question 1

Conducting a health assessment involves collecting, validating, and analyzing subjective data and objective data. Which of the following is an example of subjective data?&#10;A) pain&#10;B) rash&#10;C) perspiration&#10;D) fever

Accepted Answer

Pain is an example of subjective data because it is based on the patient's perception and cannot be measured objectively. The other options (rash, perspiration, fever) can be observed and measured objectively.

Question 2

Which of the following positions should not be used to assess the abdomen?&#10;A) supine&#10;B) dorsal recumbent&#10;C) knee-chest&#10;D) Sims'

Accepted Answer

B

Question 3

A nurse is conducting a physical examination and is percussing the gastric area of a patient. What percussion tone is normally heard in this area?&#10;A) flat&#10;B) dull&#10;C) resonant&#10;D) tympany

Accepted Answer

The gastric area is located in the upper left quadrant of the abdomen and is normally filled with air, leading to a tympanic percussion tone. Flat indicates solid tissue or fluid present, dull indicates an organ or mass, and resonant indicates normal lung tissue.

Question 4

A nurse performing physical assessments of residents in a long-term care facility describes to the student nurse common head and neck variations in the older adult. Which of the following accurately defines these variations? Select all that apply.

A) decreased color vision and peripheral vision
B) increased adaptation to light and dark
C) a blue ring around the cornea (arcus senilis)
D) entropion and ectropion
E) impaired conductive hearing
F) larger, more easily palpated lymph glands

Accepted Answer

The answer of A nurse performing physical assessments of residents...

Question 5

A nurse is inspecting the ear canals and tympanic membranes of an 18-month-old child. How would the pinna be moved to achieve better visualization?&#10;A) There is no need to move the pinna.&#10;B) Gently pull the pinna up and back.&#10;C) Gently pull the pinna down and back.&#10;D) Pull the pinna parallel to the side of the head.

Accepted Answer

Gently pulling the pinna down and back is the correct method for visualizing the ear canal and tympanic membrane in an 18-month-old child. This maneuver straightens the canal and allows for better visualization. Pulling the pinna up and back is the correct method for adults and older children.

Question 6

While giving a patient a bath, a student nurse observes the color of the patient's skin as having a yellowish tinge. What term would be used to document this assessment?&#10;A) cyanosis&#10;B) pallor&#10;C) jaundice&#10;D) erythema

Accepted Answer

Jaundice is the term used to describe the yellowing of the skin and sclera due to an accumulation of bilirubin in the blood. Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to decreased oxygenation, pallor refers to paleness of the skin due to decreased blood flow or anemia, and erythema refers to redness of the skin due to inflammation or infection. None of these terms accurately describe the yellowish tinge observed by the student nurse.

Question 7

A nurse is preparing a patient for a barium enema. Which one of the following is a nurse's responsibility for diagnostic procedures and tests?&#10;A) writing the order for the procedure or test&#10;B) delegating care during a procedure to others&#10;C) ensuring results of diagnostic tests are recorded&#10;D) providing emotional and physical preparation

Accepted Answer

It is a nurse's responsibility to provide emotional and physical preparation for diagnostic procedures and tests. Writing the order for the procedure or test is the responsibility of the physician or healthcare provider. Delegating care during a procedure to others may be the responsibility of the nurse, but it is not specifically related to diagnostic procedures and tests. Ensuring results of diagnostic tests are recorded may be a responsibility of the nurse, but again, it is not specific to diagnostic procedures and tests.

Deck 17: Health Assessment