Deck 7: Health Assessment

Question 1

An older patient is being assessed by the nurse.Which finding does the nurse consider abnormal when assessing the patient's risk for fall?

A) Use of an assistive device
B) Wearing glasses
C) Failure of the Get Up and Go test
D) Negative Romberg's test

Answer 1

Failure of the Get Up and Go test

Question 2

The nurse is assessing an older patient and finds the heart rate to be 62 and irregular.Suddenly the patient complains of dizziness and "feeling faint." Which action should the nurse take next?

A) Ask the patient about valve replacement surgery.
B) Apply 3 L of oxygen via nasal cannula.
C) Notify the healthcare provider.
D) Explain that this is a normal finding in older adults.

Answer 2

Notify the healthcare provider.

Question 3

Nursing assistive personnel (NAP)are part of the patient care team.Which aspect of obtaining health information can the nurse delegate to NAP?

A) Auscultate apical pulse of a patient with acute angina.
B) Take vital signs of a patient who might be discharged.
C) Complete lung assessment of a patient with pneumonia.
D) Clarify effects of antihypertensive therapy for a patient.

Answer 3

Take vital signs of a patient who might be discharged.

Question 4

A male patient with back pain asks why the nurse needs so many details about his history.What is the most effective response by the nurse?

A) "You seem reluctant to provide information."
B) "We need complete data to plan nursing care."
C) "It will take a short time to answer all questions."
D) "We need to determine contributors to your pain."

Question 5

The patient has an irregular,elevated,localized area of edema on the left forearm.Which term should the nurse use when documenting?

A) Tumor
B) Wheal
C) Macule
D) Vesicle

Question 6

A patient has the following intake: a cup of oatmeal,a half cup of ice,3 ounces of apple juice,and 6 ounces of coffee.What is the total intake the nurse should document on the intake portion?

A) 210 mL
B) 390 mL
C) 600 mL
D) 630 mL

Question 7

The nurse assesses an adult patient with a cardiopulmonary illness and hears a grating sound over the lower lateral lung during inspiration that does not clear with coughing.What would the nurse most likely document as a result of the assessment findings?

A) Rhonchi
B) A pleural friction rub
C) Wheezes
D) Crackles

Question 8

The nurse assesses the patient with altered musculoskeletal function.Which is the best reason supporting the nurse's motive for asking probing questions?

A) Explore how the patient's family reacts to the disability.
B) Evaluate patient concerns about the problem at this time.
C) Determine how the alteration affects the patient's lifestyle.
D) Validate the amount of physical rehabilitation completed.

Question 9

The nurse is instructing a patient how to breathe during auscultation of the lungs.Instruction by the nurse has been effective if the patient breathes in which manner?

A) Takes rapid shallow breaths
B) Breathes with the mouth open
C) Coughs and then takes a deep breath
D) Takes a deep breath and holds it

Question 10

The nurse is performing a neurological assessment.Which patient behaviors demonstrate a level of consciousness within normal limits?

A) States name, age, and date but not location
B) Is lethargic; responds logically to questions
C) Responds verbally, but words are unintelligible
D) Responds to questions spontaneously; is alert and oriented

Question 11

The nurse assesses a patient with arterial occlusive disease in the lower extremities.Which activity should the nurse implement in the patient's plan of care?

A) Use a Doppler device to locate pulses.
B) Massage the feet and ankles twice daily.
C) Elevate the legs slightly when in the chair.
D) Measure the circumference of the thighs daily.

Question 12

The nurse is preparing to assess the patient's abdomen.Nursing care is appropriate if which maneuver is seen?

A) The abdomen is auscultated after percussion.
B) The nurse instructs the patient to extend the legs.
C) The nurse inspects the abdomen before auscultation.
D) The assessment begins with palpation, followed by auscultation.

Question 13

How often should the nurse perform a general assessment of the patient?

A) At least every 4 hours
B) As often as it is needed
C) When the patient requests it
D) At the rate set by agency policy

Question 14

The nurse assesses the patient admitted with constipation.Which assessment finding warrants further investigation?

A) No aortic bruit
B) Firm liver edge
C) Bowel sounds audible
D) Abdomen distended and taut

Question 15

The nurse is listening to the patient's lungs.Which information should the nurse use to document normal patient lung sounds?

A) Rales in the right lower lobe
B) No adventitious breath sounds
C) Pleural friction rub in the left lung
D) Inspiratory wheezing in the upper lobes

Question 16

The nurse is teaching a nursing student the correct technique for assessing an apical pulse.Which method when used by the student demonstrates she knows the correct location to take an adult patient's apical pulse?

A) Percusses the left ventricular wall
B) Palpates along the left sternal border
C) Directs the patient to lie in a supine position
D) Listens at the fifth intercostal space at the point of maximal impulse (PMI)

Question 17

The nurse is assessing a patient with a cast extending from just below the left knee to the toes.Which assessment contains a desirable patient outcome?

A) The toes are pink bilaterally.
B) The cast is warm at the ankle.
C) Paresthesia is present in the left foot.
D) The cast is snug at the knee.

Question 18

The nurse assesses a patient with light skin and observes normally shaped nail beds exhibiting pallor and a slight bluish color.Which should the nurse implement?

A) Provide a warm heating pad.
B) Collaborate with the healthcare provider.
C) Assess patient oxygen saturation.
D) Check for restricted venous return.

Question 19

The nurse admits the patient with mild chest pain from the emergency department.Which should the nurse implement first to gain patient cooperation during a physical assessment?

A) Explain the procedure and its purpose.
B) Perform assessment in stages over the day.
C) Complete assessment within 3 to 5 minutes.
D) Assess painful areas before nontender areas.

Question 20

The nurse is concerned with possible impaired peripheral perfusion after performing a patient's assessment.Which assessment datum about the patient's lower extremities supports the nurse's suspicion?

A) The ankle bones are prominent.
B) The skin is warm and pink bilaterally.
C) The legs ache when in a dependent position.
D) The peripheral pulses are absent on both legs.

Question 21

The nurse documents the patient's swollen lower extremities and measures the depth of a 4-mm indentation made 1 minute ago.Which is the best description for the nurse to use to describe the patient's lower extremities?

A) 4+ pitting edema
B) Mild pitting edema
C) 4+ nonpitting edema
D) Severe nonpitting edema

Question 22

The patient has iron deficiency anemia.Which is the nurse's priority for prevention with suitably planned nursing care?

A) Pallor
B) Jaundice
C) Cyanosis
D) Erythema

Question 23

The patient is being assessed for a possible respiratory problem.In which position should the patient be placed to facilitate chest expansion during a thoracic assessment?

A) Prone
B) Side-lying
C) High-Fowler's
D) Dorsal recumbent

Question 24

The school nurse alerts parents to observe for chickenpox.Which clinical indicator does the nurse instruct the parents to observe for chickenpox?

A) Wheals
B) Nodules
C) Pustules
D) Vesicles

Question 25

The nurse admitted a patient with clear lungs and 2 days later determines that the patient has fluid in the left lung.Which should the nurse implement next?

A) Place the patient in high-Fowler's position.
B) Obtain a stat portable chest x-ray film.
C) Notify the healthcare provider immediately.
D) Complete a full respiratory assessment.

Question 26

The nurse is preparing to auscultate the pulmonic area.At which site should the nurse place the stethoscope?

A) At the costovertebral angle
B) Over the costochondral junction
C) At Erb's point
D) On the left side at the second intercostal space

Question 27

The nurse begins to assess the patient's respiratory system.Which assessment by the nurse best determines the patient's diaphragmatic excursion?

A) Observation of respiratory effort
B) Percussion over air-filled regions
C) Auscultation of thorax symmetrically
D) Palpation of chest inspiratory movement

Question 28

The nurse assesses the patient's lungs to find high-pitched musical sounds on inspiration and expiration.Which description does the nurse use to document the findings?

A) Rhonchi
B) Wheezes
C) Crackles
D) Friction rub

Question 29

The nurse assesses peripheral perfusion.Which does the nurse find in a patient with arterial insufficiency?

A) Edema
B) Warm skin
C) Palpable pulses
D) Pain with exercise

Question 30

The nurse assesses the adult patient's spine.Which expected finding does the nurse identify about the patient's alignment and posture?

A) Upper spine bent slightly
B) Spine in straight alignment
C) Slumping to nondominant side
D) Dominant side of patient favored

Question 31

The nurse is performing an abdominal assessment.The technique is appropriate if the nurse uses which method?

A) Assesses the painful areas first
B) Auscultates each quadrant for 5 minutes
C) Palpates lightly to locate painful and tender areas
D) Positions the patient with the arms behind the head

Question 32

The nurse is assessing the temperature of the lower legs.Which method should the nurse use to best assess the patient's skin temperature subjectively?

A) Oral thermometer
B) Dorsum of the hand
C) Tympanic thermometer
D) Thumb and index finger

Question 33

The nurse is preparing to begin the thoracic assessment of a patient.What is the initial step of the thoracic assessment?

A) Percussion of the lateral thorax
B) Palpation of the anterior thorax
C) Measurement of the respiratory rate
D) Inspection of the posterior thorax

Question 34

The nurse assesses the oral mucosa for pathological color changes.Which finding does the nurse expect to see in the patient's mouth,and why does the nurse expect to find it?

A) Ecchymosis, because it often is bluish green
B) Cyanosis, because it can occur as an ashen tongue
C) Petechiae, because they are easily visible in all patients
D) Erythema, because the gums should be pink and moist

Question 35

The nurse has been assessing the patient's bowel sounds.Which action should the nurse implement before notifying the healthcare provider if the bowel sounds are absent?

A) Obtain an abdominal radiograph.
B) Ambulate the patient.
C) Assess related factors.
D) Use an amplifying instrument.

Question 36

The nurse observes yellow sclerae while assessing the patient's eyes.What does the nurse look for to validate this finding?

A) A history of pallor
B) Jaundice
C) Cyanosis
D) Ecchymosis

Question 37

The nurse assesses a possible melanoma on the patient's skin.Which characteristic does the lesion have that is consistent with a melanoma?

A) Regular borders
B) Larger than 6 mm
C) Symmetrical borders
D) Reddened coloration

Question 38

The nurse is performing a neuromuscular assessment.Which method should the nurse use to evaluate muscle strength?

A) Measure the muscle size.
B) Perform range of motion.
C) Apply pressure against resistance.
D) Observe the patient's gait and transfers.

Question 39

The nurse assesses the pupils of an older patient.What unexpected finding might the nurse identify about the patient's pupils?

A) They are 3 mm in size.
B) Both of them are round.
C) There is a slight opacity.
D) They respond to light spontaneously.

Question 40

The nurse is performing a cardiovascular assessment at the fifth intercostal space at the midclavicular line.What would the nurse be attempting to check?

A) S₃
B) Point of maximal impulse (PMI)
C) Murmur
D) Visible pulsations