Deck 18: Health Assessment

Question 1

When a client enters the acute care facility, the nurse should perform a:

A) focused health assessment.
B) spiritual health assessment.
C) physical health assessment.
D) comprehensive health assessment.

Answer 1

comprehensive health assessment.

Question 2

A client states, "I have trouble sleeping. I only sleep about 2 hours and then I wake up." This is:

A) subjective data.
B) objective data.
C) focused data.
D) comprehensive data.

Answer 2

subjective data.

Question 3

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of:

A) subjective data.
B) objective data.
C) baseline data.
D) comprehensive data.

Answer 3

objective data.

Question 4

An intensive care unit nurse reports the client's condition to the nurse on the medical unit. This is a(an):

A) primary source.
B) secondary source.
C) general report.
D) informational report.

Question 5

A nurse is using the assistance of an interpreter. When interviewing a client who does not speak English, the nurse should:

A) assess the client's vital signs first.
B) interpret the effect of deep palpation.
C) inspect the symmetry of the facial features.
D) observe the client's body language.

Question 6

When examining a client upon admission to the hospital, it is important to:

A) provide privacy and confidentiality.
B) assess for fear and anxiety.
C) assess in a semiprivate room.
D) have the family present.

Question 7

Upon admission to the hospital, the client states, "I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy." This statement reflects the client's:

A) symptoms.
B) review of systems.
C) chief complaint.
D) objective assessment.

Question 8

A client states during the interview that the client has pain in the lower back. The client states it is a 10 on a scale of 1 to 10 when asked to turn. The nurse should:

A) avoid a position change that requires turning.
B) have the client turn from side to side and assess pain.
C) have the client lay on his or her right side, then palpate the area.
D) elevate the legs, bending at the knee while the client is supine.

Question 9

To gather subjective data on a client's nutrition and metabolic pattern, the nurse should:

A) weigh the client and measure his or her height.
B) ask the client for a 24-hour diet recall.
C) examine the hygiene of the client's teeth.
D) inspect the client's abdomen for symmetry.

Question 10

What percentage of weight change in 6 months is considered abnormal?

A) 1%
B) 2%
C) 5%
D) 10%

Question 11

A client had a cerebrovascular accident yesterday and is currently comatose. What type of scale should the nurse use to weigh the client?

A) Bathroom scale
B) Large floor scale
C) Chair scale
D) Bed scale

Question 12

To assess subjective data related to a client's elimination pattern, the nurse:

A) reviews the latest laboratory report of the urine.
B) asks the client about changes in elimination patterns.
C) notes the frequency, amount, and time the client voids.
D) palpates the abdomen for pain or distention.

Question 13

To obtain subjective data about a newly admitted client's sleep pattern, the nurse:

A) inspects the client's eyes for redness.
B) asks the client what promotes sleep.
C) documents the client's affect and yawning.
D) determines how frequently the client naps.

Question 14

To obtain data about an adult client's sexuality and reproductive pattern, the nurse should ask the client:

A) How often do you have sexual intercourse?
B) What arouses you when you have intercourse?
C) How many children do you have, both living and dead?
D) Has anything changed your sexual performance?

Question 15

A nurse collects objective data on a client during a health assessment that includes the client's:

A) blood pressure.
B) fatigue level.
C) presence of pain.
D) symptoms of nausea.

Question 16

During a health assessment, the nurse uses deep palpation to assess a client's:

A) skin turgor.
B) finger nodules.
C) perspiration.
D) liver.

Question 17

When percussing the liver, the sound should be:

A) resonant
B) hyperresonant
C) dull
D) flat

Question 18

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that his or her vision is:

A) clear
B) blurred
C) clouded
D) 20/20

Question 19

To assess a client's visual accommodation, the nurse has the client:

A) stand 20 feet from the Snellen chart.
B) sit still while a penlight is shined at the pupil.
C) look straight ahead with one eye covered.
D) look at a close object, then at a distant object.

Question 20

When performing a cranial nerve assessment on an adult client, the nurse assesses the trigeminal nerve by:

A) asking the client to smile.
B) eliciting the client's gag reflex.
C) having the client turn the head.
D) eliciting the client's blink reflex.

Question 21

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

A) Inflammation
B) Arthritis
C) Crepitus
D) Fremitus

Question 22

To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the:

A) front of the ear.
B) mastoid process.
C) top of the head.
D) affected ear.

Question 23

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean?

A) It is normal.
B) It is distended.
C) It is dissecting.
D) It is inflamed.

Question 24

Peripheral cyanosis and clubbing of the nails are symptoms of:

A) normal aging.
B) increased cholesterol.
C) hypertension.
D) chronic hypoxia.

Question 25

A parent of a school-age child is told her child has normal vision. The school nurse explains the child's vision is:

A) 20/20 or 6/6
B) 20/40 or 6/12
C) 20/60 or 6/18
D) 20/200 or 6/60