Deck 29: Complete Health Assessment

Question 1

The nurse is performing a physical assessment for the client and identifies a venous hum while auscultating the client's abdomen. Which statement by the nurse is the most consistent with this type of vascular sound?

A) "The sound is a blowing, pulsing sound."
B) "The sound is soft and constant. The pitch of the sound is low."
C) "It is grating, rough sound."
D) "It is tinkling and has a high pitch. The sound is sort of gurgling and irregular."

Answer 1

"The sound is soft and constant. The pitch of the sound is low."

Question 2

The nurse is performing a physical assessment on a client in an outpatient clinic. The nurse is inspecting and palpating the client's face, skin folds, axillae, palms, and soles of the feet. The nurse determines the client is diaphoretic. Which client statement supports this finding?

A) "Your elevator is out and I had to climb three flights of stairs."
B) "I've been running a fever for the last few days."
C) "I think I have hypothyroidism."
D) "I'm in a lot of pain today."
E) "I heard a rumor at work yesterday that layoffs were inevitable."

Answer 2

"Your elevator is out and I had to climb three flights of stairs."
"I've been running a fever for the last few days."
"I'm in a lot of pain today."
"I heard a rumor at work yesterday that layoffs were inevitable."

Question 3

The nurse is interviewing the client and learns that the client has an open leg wound that has been draining a moderate amount of yellowish drainage over the last 3 days. Prior to assessing the client's wound, which piece of personal protective equipment is most important for the nurse to wear based on the principles of standard precautions?

A) Fluid-resistant gown.
B) Shoe covers.
C) Mask.
D) Gloves.

Answer 3

Gloves.

Question 4

The student nurse is preparing to insert the otoscope into the adult client's ear. Which statement by the student nurse indicates the need for further education?

A) "I'm going to use the largest speculum that will fit easily into the ear canal."
B) "I'm going to prepare to insert the otoscope by pulling the pinna down and back."
C) "The tympanic membrane should look gray and translucent."
D) "I will ask the client to perform the Valsalva maneuver so that I can see how well the tympanic membrane moves."

Question 5

The nurse is performing an assessment of the female client's genitalia. The nurse has inserted a speculum and notices that the client has a frothy greenish-yellowish discharge present within the vagina. Based on this data, which condition does the nurse suspect?

A) Trichomoniasis.
B) Gonorrhea.
C) Chlamydia.
D) Candidiasis.

Question 6

The nurse has palpated an abnormal mass within the client's scrotum. Which assessment activity is appropriate for the nurse to perform next?

A) The nurse should percuss the client's scrotum.
B) The nurse should attempt to transilluminate behind the area in which the abnormal mass was palpated.
C) The nurse should inspect the inguinal area.
D) The nurse should gently squeeze the mass between the fingers.

Question 7

The nurse is assessing the client's cardiovascular system. The nurse is preparing to assess the client for the presence of a lift or heave. Which directions should the nurse provide for the client?

A) "I am going to put you into a position where your feet are actually above your head."
B) "I need you to turn to your left side."
C) "Can you please turn onto your stomach?"
D) "I need you to sit up straight."
E) "I am going to elevate your head to a 30-degree angle while you lie on your back."

Question 8

The nurse percusses the client's abdomen. Which piece of information accurately reflects that tympany is present?

A) "The sound is low-pitched, loud, and hollow-sounding."
B) "It is a high-pitched, soft sound that doesn't last very long."
C) "The sound is very loud and has a low tone. The sound has a long duration."
D) "It sounds like a drum, is loud, and high-pitched."

Question 9

The nurse is performing a physical assessment of the client. Which is the location for the costovertebral angle?

A) A.
B) B.
C) C.
D) D.

Question 10

The nurse is preparing to perform an interview to obtain information about the client. Which are classified as secondary sources of information?

A) The client's wife.
B) The client's medical record from his last hospital admission.
C) The client.
D) The client's daughter.
E) The client's physical therapist.

Question 11

The nurse is interviewing the client. Which interaction could lead to a communication breakdown between the nurse and client?

A) The client is a Native American and the nurse is of Northern European descent.
B) During the interview, the nurse is trying to remember what the healthcare provider asked her to do earlier in the day.
C) The young nurse creates an informal atmosphere to discuss safe sexual practices with a teenaged client.
D) The young nurse uses a serious and respectful tone to discuss erectile dysfunction with an older client.
E) The nurse states, "So, you experience pain with micturition."

Question 12

The nurse is assessing the client's neurologic system. The nurse tests the client's ability to perform stereognosis. Which activity will accurately test this?

A) The nurse places a vibrating tuning fork over the client's ankle and asks the client to indicate when the vibration can no longer be felt.
B) The nurse asks the client to close her eyes and writes the number '7' in the client's palm with the base of the nurse's pen. The nurse asks the client to identify what was written.
C) The nurse asks the client to close her eyes and places a pen in the client's hand. The nurse asks the client to name the object in her hand.
D) The nurse asks the client to close her eyes and indicate where the nurse is touching the client.

Question 13

The nurse is auscultating the client's lungs and is able to auscultate bronchovesicular sounds over the client's left lung. Which location would the nurse use when auscultating this type of lung sound?

A) A.
B) B.
C) C.
D) D.

Question 14

During the physical assessment of the client, the nurse notes that the client is able to shrug the shoulders bilaterally. Based on this data, which nerve is intact?

A) Cranial nerve I (olfactory).
B) Cranial nerve II (optic).
C) Cranial nerve VII (facial).
D) Cranial nerve XI (spinal accessory).

Question 15

The nurse is assessing the client's cardiovascular system during the physical assessment. Which location will the nurse use to palpate the point of maximal impulse/apical pulse?

A) A.
B) B.
C) C.
D) D.

Question 16

The nurse is performing a physical assessment of a male client. The nurse must assess the client's sacrococcygeal area. Which position will allow the nurse to assess this area adequately?

A) Orthopneic position.
B) Semi-Fowler's position.
C) Lithotomy.
D) On his left side with his knees drawn up.

Question 17

Which location w

A) A.
B) B.
C) C.
D) D.

Question 18

The nurse holds the tuning fork by the handle and gently strikes the fork on the palm of the hand. Then, the nurse places the base of the fork on the client's mastoid process. The nurse requests that the client indicate when the sound can no longer be heard. Which test is the nurse performing?

A) Weber.
B) Whisper.
C) Rinne.
D) Romberg.

Question 19

The student nurse is preparing to assess the client while the more experienced nurse assists. Prior to the physical assessment, the client complains of left lower quadrant abdominal pain. Which statement by the student nurse indicates that the student nurse requires further education prior to performing this part of the assessment?

A) "I'm going to start by percussing and palpating the client's left lower quadrant first."
B) "I will start the abdominal assessment by inspecting the client's abdomen."
C) "I'm going to auscultate the abdomen prior to percussing the abdomen."
D) "I need to ask the client about the characteristics of his pain."

Question 20

The nurse is assessing the function of the client's cranial nerve XII (hypoglossal). Which activity will allow the nurse to assess this nerve during the client's physical assessment?

A) "Can you stick out your tongue?"
B) "I'm going to ask you to taste something and tell me what you think it is."
C) "Close your eyes and tell me when you feel me touch your face with this wisp of cotton."
D) "I'm going to lightly touch the back of your throat with this tongue depressor."

Question 21

When conducting a health history for a pediatric client, which action by the nurse is appropriate?

A) Asking the client which grade they are in.
B) Monitoring the client's vital signs.
C) Assessing the cardiovascular system.
D) Documenting immunizations administered during the visit.

Question 22

The nurse is assessing a client's musculoskeletal system. Which action will the nurse perform first?

A) Assist the client to a standing position.
B) Assess the skin on the posterior legs.
C) Perform the Romberg.
D) Test range of motion and strength in the hips, knees, ankles, and feet.

Question 23

Which action is appropriate for the nurse to include in the client's health history portion of the nursing assessment?

A) Monitoring blood pressure.
B) Assessing lung sounds.
C) Discussing cultural traditions.
D) Monitoring temperature.

Question 24

The nurse is providing care to an adolescent female who seeks care due to experiencing a change in vaginal discharge. The client is not sexually active, but states, "There is white stuff in my panties that looks like cottage cheese." Based on this data, which condition does the nurse suspect?

A) Gonorrhea.
B) Chlamydia.
C) Yeast infection.
D) Pelvic inflammatory disease.

Question 25

The nurse is discussing the results of recent laboratory tests with a female client, who tested positive for a sexually transmitted infection. Which statement by the nurse is the most therapeutic?

A) "If you did not sleep around, this would not be happening."
B) "The best way to prevent this from happening again is to not have sex until you are married."
C) "I understand that this result is concerning. I would like to discuss how to prevent this from occurring again."
D) "You may never be able to have children because of this diagnosis."

Question 26

The nurse is preparing to conduct an abdominal assessment for a client who is denying abdominal pain. Which assessment will the nurse perform first?

A) Auscultate the abdomen for bowel sounds.
B) Palpate the abdomen for masses or tenderness.
C) Palpate for hernias.
D) Percuss the abdomen in all quadrants.