Deck 28: The Complete Health Assessment: Putting It All Together

Question 1

Which does the nurse do first during a physical assessment when examining the head and neck of a patient?

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

Answer 1

Inspection

Question 2

When the nurse performs the confrontation test,the nurse has assessed:

A)EOMs.
B)PERRLA.
C)near vision.
D)visual fields.

Answer 2

visual fields.

Question 3

The nurse has just completed an examination of a patient's extraocular muscles.When documenting the findings,the nurse would note the assessment of which cranial nerves?

A)II,III,VI
B)II,IV,V
C)III,IV,V
D)III,IV,VI

Answer 3

III,IV,VI

Question 4

The nurse documents that a patient has coarse,thickened skin and brown discoloration over the lower legs.Pulses are present.This finding is probably the result of:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)lymphedema.
B)Raynaud's disease.
C)chronic arterial insufficiency.
D)chronic venous insufficiency.

Question 5

During inspection of the posterior chest,the nurse should assess for:

A)symmetrical expansion.
B)symmetry of the shoulders and muscles.
C)tactile fremitus.
D)diaphragmatic excursion.

Question 6

An 85-year-old man has come into the clinic for a physical examination,and the nurse notes that he uses a cane.When documenting general appearance,the nurse will document this information under the section that covers:

A)posture.
B)mobility.
C)mood and affect.
D)physical deformity.

Question 7

Gloves should be worn for which of the following examinations?

A)Measurement of vital signs
B)Palpation of the sinuses
C)Palpation of the mouth and tongue
D)Inspection of the eye with an ophthalmoscope

Question 8

During an examination,a patient has successfully completed the finger-to-nose and the rapid-alternating-movements tests,and is able to run each heel down the opposite shin.The nurse will conclude that the patient's:

A)occipital function is intact.
B)cerebral function is intact.
C)temporal function is intact.
D)cerebellar function is intact.

Question 9

A 5-year-old child is in the clinic for a check-up.The nurse would expect him to:

A)have to be held on his mother's lap.
B)be able to sit on the examination table.
C)be able to stand on the floor for the examination.
D)be able to remain alone in the examination room.

Question 10

A patient states,"whenever I open my mouth real wide,I feel this popping sensation in front of my ears." To further examine this,the nurse would:

A)place the stethoscope over the temporomandibular joint and listen for bruits.
B)place the hands over his ears,and ask him to open his mouth "really wide."
C)place one hand on his forehead and the other on his jaw,and ask him to try to open his mouth.
D)place a finger on his temporomandibular joint and ask him to open and close his mouth.

Question 11

When assessing the neonate,the nurse should use which of the following methods to test for hip stability?

A)Elicit the Moro reflex.
B)Perform Romberg's test.
C)Check for the Ortolani sign.
D)Assess the stepping reflex.

Question 12

Which of the following is an appropriate location for eliciting deep tendon reflexes?

A)Achilles
B)Femoral
C)Scapular
D)Abdominal

Question 13

A patient's uvula rises midline when she says "ahh," and she has a positive gag reflex.The nurse has just tested which cranial nerves?

A)IX,X
B)IX,XII
C)X,XII
D)XI,XII

Question 14

During an examination,the nurse notices that a patient is unable to stick out his tongue.Which cranial nerve is involved with the successful performance of this action?

A)I
B)V
C)XI
D)XII

Question 15

During inspection of a patient's face,the nurse notes that the facial features are symmetrical.This finding indicates that which cranial nerve is intact?

A)VII
B)IX
C)XI
D)XII

Question 16

After the health history has been obtained,and before beginning the physical examination,the nurse should ask the patient to first:

A)empty the bladder.
B)completely disrobe.
C)lie on the examination table.
D)walk around the room.

Question 17

A patient is unable to shrug her shoulders against the nurse's resistant hands.What cranial nerve is involved with successful shoulder shrugging?

A)VII
B)IX
C)XI
D)XII

Question 18

Which of the following is included in assessment of general appearance?

A)Height
B)Weight
C)Skin colour
D)Vital signs

Question 19

Which of the following statements is true regarding the recording of data from the health history and physical examination?

A)Use long,descriptive sentences to document findings.
B)Record the data as soon as possible after the interview and physical examination.
C)If the information is not documented,it can be assumed that it was done as a standard of care.
D)The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient.

Question 20

During an examination,the nurse notes that a patient's legs turn white when they are raised above her head.The nurse would suspect:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)lymphedema.
B)Raynaud's disease.
C)chronic arterial insufficiency.
D)chronic venous insufficiency.

Question 21

After the examination of an infant,the nurse notes opisthotonos.The nurse recognizes that this finding often occurs with:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)cerebral palsy.
B)meningeal irritation.
C)lower motor neuron lesion.
D)upper motor neuron lesion.

Question 22

The nurse has just recorded a positive obturator test on a patient who has abdominal pain.This test is used to confirm a(n):
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)inflamed liver.
B)perforated spleen.
C)perforated appendix.
D)enlarged gallbladder.

Question 23

MATCHING
Place the following abdominal assessment techniques in the correct order,with 1 being performed first,and 5 being performed last.

First perform:

A)Deep palpation,all quadrants
B)Light palpation,all quadrants
C)Auscultation of bowel sounds
D)Inspection of abdomen for contour,skin characteristics,and pulsations
E)Percussion of all quadrants

Question 24

The nurse notes that a patient has ulcerations on the tips of the toes and on the lateral ankles.This finding would indicate:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)lymphedema.
B)Raynaud's disease.
C)arterial insufficiency.
D)venous insufficiency.

Question 25

The nurse will use which of the following tools to measure a patient's near vision?
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)A Snellen eye chart with letters
B)A Snellen "E" chart
C)A Jaeger card
D)An ophthalmoscope

Question 26

A patient tells the nurse that "sometimes I wake up at night,and I have real trouble breathing.I have to sit up in bed to get a good breath." When documenting this information,the nurse would note:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)orthopnea.
B)acute emphysema.
C)paroxysmal nocturnal dyspnea.
D)acute shortness-of-breath episode.

Question 27

If the nurse records the results to the Hirschberg test,the nurse has:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)tested the patellar reflex.
B)assessed for appendicitis.
C)tested the corneal light reflex.
D)assessed for thrombophlebitis.

Question 28

When the nurse flexes the patient's knee and gently compresses the gastrocnemius muscle anteriorly against the tibia,the patient indicates that he is having calf pain.The nurse would document:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)positive Allen's sign.
B)negative Allen's sign.
C)positive Homan's sign.
D)negative Homan's sign.

Question 29

While examining a 48-year-old patient's eyes,the nurse notes that he has to move the handheld vision screener farther away from his face.The nurse would suspect:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)myopia.
B)omniopia.
C)hyperopia.
D)presbyopia.

Question 30

MATCHING
Place the following abdominal assessment techniques in the correct order,with 1 being performed first,and 5 being performed last.

Fourth perform:

A)Deep palpation,all quadrants
B)Light palpation,all quadrants
C)Auscultation of bowel sounds
D)Inspection of abdomen for contour,skin characteristics,and pulsations
E)Percussion of all quadrants

Question 31

Which of the following assessments is most appropriate to perform on a 9-month-old well child?
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)Assessment for the Ortolani sign
B)Assessment for stereognosis
C)Assessment of blood pressure
D)Assessment for the presence of the startle reflex

Question 32

While recording in a patient's chart,the nurse notes that a patient's hematest results have been positive.This means that:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)there are crystals in his urine.
B)there are parasites in his stool.
C)there is occult blood in his stool.
D)there are bacteria in his sputum.

Question 33

During an examination,the patient tells the nurse that she sometimes feels as if objects are spinning around her.The nurse would note that she occasionally experiences:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)vertigo.
B)tinnitus.
C)syncope.
D)dizziness.

Question 34

The nurse is documenting the assessment of an infant.During the abdominal assessment,the nurse notes a very loud splash auscultating over the upper abdomen when the nurse rocks her from side to side.This finding would indicate:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)epigastric hernia.
B)pyloric obstruction.
C)hypoactive bowel sounds.
D)hyperactive bowel sounds.

Question 35

MATCHING
Place the following abdominal assessment techniques in the correct order,with 1 being performed first,and 5 being performed last.

Second perform:

A)Deep palpation,all quadrants
B)Light palpation,all quadrants
C)Auscultation of bowel sounds
D)Inspection of abdomen for contour,skin characteristics,and pulsations
E)Percussion of all quadrants

Question 36

During the examination of a patient,the nurse notes that the patient has several small,flat macules on her posterior thorax.These macules are less than 1 cm wide.Another name for these macules is:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)warts.
B)bullas.
C)freckles.
D)papules.

Question 37

During an examination,the nurse finds that a patient is unable to distinguish objects placed in his hand.The nurse would document:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)stereognosis.
B)astereognosis.
C)graphesthesia.
D)agraphesthesia.

Question 38

After assessing a female patient,the nurse notes flesh-coloured,soft,pointed,moist papules in a cauliflower-like patch around her introitus.This finding is most likely:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)a urethral caruncle.
B)a syphilitic chancre.
C)herpes.
D)human papillomavirus infection.

Question 39

During the examination of a patient's mouth,the nurse observes a nodular,bony ridge down the middle of the hard palate.The nurse would chart this finding as:
(This question reflects the results an examiner may find during a complete physical examination.Content in this question is not necessarily addressed directly in Jarvis' Physical Examination & Health Assessment. )

A)cheilosis.
B)leukoplakia.
C)ankyloglossia.
D)torus palatinus.

Question 40

MATCHING
Place the following abdominal assessment techniques in the correct order,with 1 being performed first,and 5 being performed last.

Third perform:

A)Deep palpation,all quadrants
B)Light palpation,all quadrants
C)Auscultation of bowel sounds
D)Inspection of abdomen for contour,skin characteristics,and pulsations
E)Percussion of all quadrants

Question 41

MATCHING
Place the following abdominal assessment techniques in the correct order,with 1 being performed first,and 5 being performed last.

Fifth perform:

A)Deep palpation,all quadrants
B)Light palpation,all quadrants
C)Auscultation of bowel sounds
D)Inspection of abdomen for contour,skin characteristics,and pulsations
E)Percussion of all quadrants