Deck 27: The Complete Health Assessment: Putting It All Together

Question 1

During inspection of a patient's face,the nurse notes that the facial features are symmetric.This finding indicates that which cranial nerve is intact?
1)VII
2)IX
3)XI
4)XII

Answer 1

1
Cranial nerve VII is responsible for facial symmetry.

Question 2

Which of the following is an appropriate location for eliciting deep tendon reflexes?
1)Achilles
2)Femoral
3)Scapular
4)Abdominal

Answer 2

1
Deep tendon reflexes are elicited in the following areas: biceps,triceps,brachioradialis,patella,and Achilles.

Question 3

During an examination,a patient has just 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:
1)occipital function is intact.
2)cerebral function is intact.
3)temporal function is intact.
4)cerebellar function is intact.

Answer 3

4
Test cerebellar function of the upper extremities by using the finger-to-nose test or rapid-alternating-movements test.Test cerebellar function of the lower extremities by asking the person to run each heel down the opposite shin.

Question 4

After the health history has been obtained,and before beginning the physical examination,the nurse should ask the patient to first:
1)empty the bladder.
2)completely disrobe.
3)lie on the examination table.
4)walk around the room.

Question 5

Which of the following is included in assessment of General Appearance?
1)Height
2)Weight
3)Skin color
4)Vital signs

Question 6

The nurse is performing a vision examination.Which of the following charts is most widely used for vision examinations?
1)Snellen
2)Shetllen
3)Smoollen
4)Schwellon

Question 7

While the nurse palpates the maxillary sinuses,the patient tells the nurse that he has some tenderness in that area.The nurse should proceed by:
1)tapping on the sinus area.
2)auscultating the sinus area.
3)asking him to blow his nose.
4)transilluminating the sinuses.

Question 8

When assessing the neonate,the nurse should test for hip stability with which method?
1)Eliciting the Moro reflex
2)Performing Romberg's test
3)Checking for Ortolani's sign
4)Assessing the stepping reflex

Question 9

An 85-year-old man has come in 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:
1)posture.
2)mobility.
3)mood and affect.
4)physical deformity.

Question 10

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?
1)II,III,VI
2)II,IV,V
3)III,IV,V
4)III,IV,VI

Question 11

Gloves should be worn for which of the following examinations?
1)Measuring vital signs
2)Palpation of the sinuses
3)Palpation of the mouth and tongue
4)Inspection of the eye with an ophthalmoscope

Question 12

Which of the following statements is true regarding the recording of data from the history and physical examination?
1)Use long,descriptive sentences to document findings.
2)Record the data as soon as possible after the interview and physical examination.
3)If the information is not documented,it can be assumed that it was done as a standard of care.
4)The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient.

Question 13

A 5-year-old child is in the clinic for a checkup.The nurse would expect him to:
1)have to be held on his mother's lap.
2)be able to sit on the examination table.
3)be able to stand on the floor for the examination.
4)be able to remain alone in the examination room.

Question 14

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:
1)place the stethoscope over the temporomandibular joint and listen for bruits.
2)place the hands over his ears and ask him to open his mouth "really wide."
3)place one hand on his forehead and the other on his jaw and ask him to try to open his mouth.
4)place a finger on his temporomandibular joint and ask him to open and close his mouth.

Question 15

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?
1)IX,X
2)IX,XII
3)X,XII
4)XI,XII

Question 16

A patient is unable to shrug her shoulders against the nurse's resistant hands.What cranial nerve is involved with successful shoulder shrugging?
1)VII
2)IX
3)XI
4)XII

Question 17

During an examination,the nurse notices that a patient is unable to stick out his tongue.Which cranial nerve is involved with successful performance of this action?
1)I
2)V
3)XI
4)XII

Question 18

Which of the following statements is true regarding the complete physical assessment?
1)The male genitalia should be examined in the supine position.
2)The patient should be in the sitting position for examination of the head and neck.
3)The vital signs,height,and weight should be obtained at the end of the exam for convenience.
4)To promote consistency between patients,the examiner should not vary the order of the assessment.

Question 19

During inspection of the posterior chest,the nurse should assess for:
1)symmetric expansion.
2)symmetry of shoulders and muscles.
3)tactile fremitus.
4)diaphragmatic excursion.

Question 20

When the nurse performs the confrontation test,the nurse has assessed:
1)EOMs.
2)PERRLA.
3)near vision.
4)visual fields.

Question 21

While recording in a patient's chart,the nurse notes that a patient's hematest results have been positive.This means that:
1)there are crystals in his urine.
2)there are parasites in his stool.
3)there is occult blood in his stool.
4)there are bacteria in his sputum.

Question 22

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:
1)vertigo.
2)tinnitus.
3)syncope.
4)dizziness.

Question 23

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:
1)warts.
2)bullas.
3)freckles.
4)papules.

Question 24

The nurse has just recorded a positive obturator test on a patient who has abdominal pain.This test is used to confirm:
1)inflamed liver.
2)perforated spleen.
3)perforated appendix.
4)enlarged gallbladder.

Question 25

If the nurse records the results to the Hirschberg test,the nurse has:
1)tested the patellar reflex.
2)assessed for appendicitis.
3)tested the corneal light reflex.
4)assessed for thrombophlebitis.

Question 26

A female patient tells the nurse that she has four children and has had three pregnancies.How should the nurse document this?
1)Gravida 3/para 4
2)Gravida 4/para 3
3)This information cannot be documented using the terms gravida and para.
4)"The patient seems to be confused about how many times she has been pregnant."

Question 27

Which of the following is most appropriate to perform on a 9-month-old well child?
1)Testing for Ortolani's sign
2)Assessment for stereognosis
3)Blood pressure measurement
4)Assessment for the presence of the startle reflex

Question 28

The nurse will measure a patient's near vision with which tool?
1)Snellen eye chart with letters
2)Snellen "E" chart
3)Jaeger card
4)Ophthalmoscope

Question 29

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:
1)lymphedema.
2)Raynaud's disease.
3)chronic arterial insufficiency.
4)chronic venous insufficiency.

Question 30

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:
1)positive Allen's sign.
2)negative Allen's sign.
3)positive Homan's sign.
4)negative Homan's sign.

Question 31

While examining a 48-year-old patient's eyes,the nurse notes that he had to move the hand-held vision screener farther away from his face.The nurse would suspect:
1)myopia.
2)omniopia.
3)hyperopia.
4)presbyopia.

Question 32

After the examination of an infant,the nurse notes opisthotonos.The nurse recognizes that this finding often occurs with:
1)cerebral palsy.
2)meningeal irritation.
3)lower motor neuron lesion.
4)upper motor neuron lesion.

Question 33

The nurse notes that a patient has ulcerations on the tips of the toes and on the lateral ankles.This finding would indicate:
1)lymphedema.
2)Raynaud's disease.
3)arterial insufficiency.
4)venous insufficiency.

Question 34

After assessing a female patient,the nurse notes flesh-colored,soft,pointed,moist,papules in a cauliflower-like patch around her introitus.This finding is most likely:
1)urethral caruncle.
2)syphilitic chancre.
3)herpes.
4)human papillomavirus.

Question 35

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:
1)cheilosis.
2)leukoplakia.
3)ankyloglossia.
4)torus palatinus.

Question 36

The nurse is documenting the assessment of an infant.During the abdominal assessment,the nurse noted a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side.This finding would indicate:
1)epigastric hernia.
2)pyloric obstruction.
3)hypoactive bowel sounds.
4)hyperactive bowel sounds.

Question 37

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:
1)orthopnea.
2)acute emphysema.
3)paroxysmal nocturnal dyspnea.
4)acute shortness of breath episode.