Deck 4: Performing an Assessment

Question 1

What is the best source of subjective data?

A) The medical record
B) The client
C) The client.
D) Assessing the client

Answer 1

The client

Question 2

The nurse is interviewing a client with poor English skills. What action by the nurse is most appropriate?

A) Use a picture board.
B) Ask the family.
C) Act out statements.
D) Use an interpreter.

Answer 2

Use an interpreter.

Question 3

A nurse is performing a rapid head-to-toe assessment. What is the most important advantage of this assessment technique compared to a more comprehensive physical assessment?

A) It can be done faster.
B) It allows prioritization.
C) It is less intrusive.
D) Interpreters are not needed.

Answer 3

It allows prioritization.

Question 4

The nurse has completed a rapid head-to-toe assessment. What action does the nurse take next?

A) Evaluate the patient's laboratory values.
B) Document all assessment findings.
C) Compare findings with a baseline.
D) Inquire into advanced planning.

Question 5

On assessment, the nurse notes the patient's fingernails appear as shown. What statement by the nurse is correct?

A) "I will document this as clubbed nails."
B) "The nail angle is 120 degrees."
C) "The client has a genetic disorder."
D) "The client has a fungal infection."

Question 6

Which assessment technique assesses cranial nerve II?

A) Assess field of gaze.
B) Have client smile.
C) Use an eye chart for visual acuity.
D) Perform the Rinne test.

Question 7

The student nurse brings a client a cup of coffee. The client states "Oh, that smells so good!" What cranial nerve has the student just gotten data about?

A) I
B) III
C) V
D) VII

Question 8

The nurse notices that a client's facial features have become asymmetrical. What cranial nerve appears to have a problem?

A) II
B) IV
C) VII
D) IX

Question 9

Where would the nurse place a stethoscope to assess the Point of Maximal Impulse (PMI)?

A) B
B) D
C) E
D) I

Question 10

The nurse places the stethoscope on location D. What is the nurse assessing?

A) Point of maximal impulse
B) The aortic valve
C) The tricuspid valve
D) The pulmonic valve

Question 11

A client is in the emergency department reporting severe abdominal pain and is being evaluated for an aneurysm. When performing the abdominal exam, which assessment technique would the nurse avoid?

A) Inspection
B) Auscultation
C) Palpation
D) Percussion

Question 12

The nurse needs to auscultate an infant's lungs. What technique is best?

A) Lay the infant flat on an exam table.
B) Listen while baby is asleep in a parent's arms.
C) Document "unable to obtain data."
D) Use distraction to divert his/her attention.

Question 13

The nurse assessing a toddler would incorporate which information into the exam?

A) Engaging the busy toddler may elicit cooperation.
B) Toddlers don't typically have separation anxiety.
C) Let the child play with equipment before using it.
D) Provide privacy by having parents leave the room.

Question 14

The nurse is interviewing an older patient. The client is very slow to answer questions. What action by the nurse is best?

A) Repeat the questions to make sure they were heard.
B) Skip some of the more complicated questions.
C) Simplify the wording of the questions.
D) Allow extra time when planning the interview.

Question 15

A nurse makes this finding when assessing a patient. What does the nurse understand about this assessment?

A) This is a normal finding in postmenopausal women.
B) This is a normal finding for anyone.
C) This signifies an ophthalmologic emergency.
D) This indicates the ophthalmoscope is malfunctioning.

Question 16

What does the nurse understand about this finding, seen in a hospitalized client?

A) This is normal for an older client.
B) This demonstrates jugular venous distention.
C) This shows a carotid bruit.
D) This demonstrates a deviated trachea.

Question 17

How many pairs of lymph nodes does the nurse palpate during a physical assessment?

A) 6
B) 8
C) 10
D) 12

Question 18

The nursing student learns that which term is matched with the correct definition?

A) Accommodation: Muscular contractions of the gastrointestinal tract to allow room for more food
B) Paresthesia: Movement or pulling of an extremity toward the midline of the body
C) Eversion: Movement to tilt the sole of foot away from midline of body
D) Stereognosis: Decrease in size or shape of a body part that can affect its function

Question 19

The nurse is assessing a postpartum teen mother. What considerations does the nurse have for conducting this exam? (Select all that apply.)

A) Allow the teen to voice any concerns or fears related to the exam.
B) Assess the teen's knowledge of the normal postpartum state.
C) To get the best data, palpate the fundus when the patient's bladder is full.
D) Assess the teen's immunization status and update vaccinations.
E) Use the sides of the hands to palpate the fundus.

Question 20

The nurse reviews charting from the last shift on a client. The chart states that the adult client's Babinski reflex is positive. What does the nurse understand from this documentation? (Select all that apply.)

A) This is a normal finding in an adult.
B) The client has good balance.
C) The client's neck movement and strength are normal.
D) The client's great toe is dorsiflexed.
E) This could indicate upper motor neuron defect.

Question 21

A student watches a nurse interact with a client. After shaking the client's hand, the nurse and client converse about the weather outside and the news on the television. After the interaction, the nurse asks the student how much assessment data was collected. What are correct answers by the student? (Select all that apply.)

A) Orientation
B) Perfusion
C) Motor strength
D) Respiratory function
E) Cognition
F) Sensory perception
G) Hygiene

Question 22

The nurse receives report from the nurse going off shift who relates that one client has 4+ pitting pedal edema. On assessment, what does the incoming nurse expect to find? (Select all that apply.)

A) Swelling around the eyes
B) Limited ability to open the eyes
C) Swelling around the feet and ankles
D) Superficial indentations when palpated
E) 8 mm pit in palpated tissues
F) Rebound time >30 seconds

Question 23

The nurse is assessing a client. Which assessment techniques are correctly matched with a possible finding? (Select all that apply.)

A) Inspection: a skin lesion
B) Palpation: tissue density
C) Percussion: wheezes
D) Auscultation: heart murmur
E) Percussion: kidney inflammation
F) Palpation: bounding pulses

Question 24

The student nurse is preparing to weigh a client. What actions by the student are most appropriate? (Select all that apply.)

A) Ensures the scale is zeroed and calibrated per policy
B) Uses the same scale for clients on daily weights
C) Orders a bed with a built-in scale for clients on bedrest
D) Reminds the client not to eat or drink before getting weighed
E) Assesses the client's mobility for a standing weight

Question 25

A nurse is preparing to interview a client just admitted to the hospital. What actions by the nurse are most appropriate? (Select all that apply.)

A) Ask the client to turn down the TV.
B) Introduce him- or herself.
C) Make culturally appropriate eye contact.
D) Ask closed-ended questions.
E) Repeat client information for validation.