Deck 12: Physical Assessment

Question 1

A patient was admitted with a complaint of abdominal pain.Later,the nurse observed the patient demonstrating dyspnea.What type of assessment does this change in condition require?

A)Individualized
B)Focused
C)Specialized
D)Systematic

Answer 1

Focused

Question 2

The patient should be assessed as soon as possible after admission.Who performs this initial assessment?

A)Physician
B)Charge nurse
C)LPN/LVN
D)RN

Answer 2

RN

Question 3

Any disturbance of a structure or function of the body is a pathologic condition.What is the term for this condition?

A)Injury
B)Condition
C)Disease
D)Pathology

Answer 3

Disease

Question 4

What should a patient interview being conducted by the nurse convey to the patient?

A)The nurse has feelings of concern.
B)The nurse has limited time.
C)The nurse is very intelligent.
D)The nurse has answers to problems.

Question 5

What type of disease results in a structural change in an organ that interferes with its functioning?

A)Functional disease
B)Organic disease
C)Acute disease
D)Chronic disease

Question 6

The nurse is assessing a patient for collection of subjective and objective data.What will this data provide the basis for making?

A)Care plan
B)Medical diagnosis
C)Nursing assessment
D)Nursing diagnosis

Question 7

The nurse is collecting data during an initial assessment.What can be seen,heard,measured,or felt and is objective?

A)Symptom
B)Observation
C)Sign
D)Assessment

Question 8

What does the nurse recognize as the initial step in conducting an assessment of a patient?

A)A body systems review
B)The nursing health history
C)Biographical data
D)The present illness

Question 9

The nurse is developing a nursing care plan for a newly admitted patient.What is the first step the nurse will take in developing this care plan?

A)Health history
B)Review of systems
C)Family history
D)Nursing assessment

Question 10

The nurse is meeting a patient for the first time.What is the first thing the nurse will do to initiate a nurse-patient relationship?

A)Appear interested
B)Introduce herself/himself
C)Provide support
D)Communicate trust

Question 11

There are four categories of factors that increase an individual's vulnerability to develop a disease: genetic,physiological,age,and lifestyle.What is the term for these factors?

A)Risk factors
B)Causative factors
C)Etiologic factors
D)Hazardous factors

Question 12

A nursing assessment is a process of collecting data to establish a database.The information contained in the database is a basis for:

A)a complete physical examination.
B)a medical assessment.
C)an individualized plan of care.
D)writing nursing orders.

Question 13

As part of an assessment,the nurse asks the patient for subjective information related to the present illness.What are the subjective findings perceived by the patient?

A)Assessments
B)Symptoms
C)Signs
D)Observations

Question 14

When collecting data related to the present illness,the nurse must obtain detailed and comprehensive data.What does this data help to establish?

A)A nursing diagnosis
B)A nursing care plan
C)Appropriate interventions
D)Nursing orders

Question 15

The nurse is discussing the origin of diabetes with a diabetic patient.What will the nurse discuss as the most appropriate explanation for the cause of this disease?

A)Pituitary
B)Adrenals
C)Pancreas
D)Thyroid

Question 16

The signs and symptoms of both infection and inflammation include erythema,edema,and pain.What is considered the major difference between infection and inflammation?

A)Inflammation is a result of bacteria.
B)Inflammation is a protective response.
C)Inflammation is a disease process.
D)Inflammation produces tissue damage.

Question 17

The nurse uses a systematic method for collecting data on all body systems,including normal functioning and any noted changes.What is this method?

A)Nursing interview
B)Review of systems
C)Nursing assessment
D)Health history

Question 18

During the nursing interview,several histories are taken.What is the history that involves data concerning habits and lifestyle patterns?

A)Family history
B)Environmental history
C)Past health history
D)Psychosocial history

Question 19

When discussing diabetes with a patient,the nurse describes this disease as falling into which group in terms of duration?

A)Acute
B)Organic
C)Chronic
D)Functional

Question 20

What is the term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease?

A)Acute
B)Functional
C)Chronic
D)Remission

Question 21

An older adult patient is being assessed for skin turgor.The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised.What can the nurse conclude is responsible for this assessment?

A)Dehydration
B)Edema
C)Skin breakdown
D)Malnutrition

Question 22

A nurse is gathering subjective data when admitting a patient.Which assessment finding reported by the patient is considered subjective data?

A)Complains of chest pain
B)Is experiencing dyspnea
C)Appears to be anxious
D)Expectorates red-tinged sputum

Question 23

During a head-to-toe assessment,the nurse assesses the patient's abdomen.Which area should the nurse assess next?

A)Chest
B)Arms
C)Legs and feet
D)Perineal area

Question 24

Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope.What is the normal rate of bowel sounds per min-ute?

A)2-10
B)3-20
C)4-32
D)5-40

Question 25

During a physical assessment,the nurse listens for adventitious lung sounds.Crackles are classified as fine,medium,or coarse.When are these sounds most often auscultated?

A)During expiration
B)Following expiration
C)During inspiration
D)Following inspiration

Question 26

A nurse is gathering subjective data when admitting a patient.Which assessment finding reported by the patient is considered subjective data?

A)Complains of pruritus
B)Is experiencing erythema
C)Appears to be experiencing pruritus
D)Has a generalized rash

Question 27

A patient has edema of the lower extremities.The nurse is assessing whether it is pitting and to what degree.After pressing the skin against a bony prominence for 5 seconds,the nurse identifies 2+ pitting edema.When did the edema disappear?

A)10-15 seconds
B)20-25 seconds
C)30-35 seconds
D)40-45 seconds

Question 28

The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds.What should the nurse expect the refill time to be?

A)1 second
B)2 seconds
C)3 seconds
D)4 seconds

Question 29

When performing a nursing physical assessment,the nurse uses a head-to-toe approach.Where will the nurse begin when using this method?

A)Skin assessment
B)Neurologic assessment
C)Circulatory assessment
D)Respiratory assessment

Question 30

A nurse is gathering objective data when admitting a patient.Which assessment finding is considered objective data?

A)The patient complains of chest pain.
B)The patient states, "I am having trouble breathing."
C)The patient complains of coughing up sputum.
D)The patient expectorates red-tinged sputum.

Question 31

When performing a physical examination of a patient,the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen.What is this technique?

A)Auscultation
B)Deep palpation
C)Light palpation
D)Percussion

Question 32

Auscultating the heart sounds should result in a "lubb-dupp" sound when using the bell and the diaphragm of the stethoscope.What causes the "lubb" sound?

A)Opening of the AV valves
B)Opening of the semilunar valves
C)Closing of the AV valves
D)Closing of the semilunar valves

Question 33

The nurse is performing auscultation of breath sounds on a respiratory patient.The sounds heard on inspiration and expiration are low-pitched,coarse,gurgling,and have a snoring sound.What best identifies these sounds?

A)Crackles
B)Plural friction rub
C)Rhonchi
D)Sonorous wheezes

Question 34

A nurse is gathering subjective data when admitting a patient.Which assessment finding reported by the patient is considered subjective data?

A)Complains of diplopia
B)Is experiencing nystagmus
C)Demonstrates facial grimacing
D)Has a generalized rash

Question 35

The nurse is obtaining a history of a patient's present illness.The PQRST system is used for the interview.What does the R stand for in this system?

A)Random
B)Region
C)Result
D)Recent

Question 36

Various techniques are used by the nurse when performing a physical assessment.One of these techniques is percussion.What is percussion used to determine?

A)Sounds for auscultation
B)Data about physical features
C)Changes in structural integrity
D)Density of underlying tissue

Question 37

A nurse is gathering objective data when admitting a patient.Which assessment finding reported by the patient is considered objective?

A)Complains of nausea
B)States, "I hurt all over."
C)Complains of feeling anxious
D)Appears to be anxious

Question 38

What should the nurse begin by assessing when performing a head-to-toe assessment?

A)Support system
B)Skin integrity
C)Pain level
D)Neurologic status

Question 39

What is the suggested sequence for a systematic approach to begin auscultating the thorax?

A)Anterior thorax
B)Apices
C)Left lateral thorax
D)Right lateral thorax

Question 40

During a head-to-toe assessment,the nurse assesses the patient's perineal area.Which area should the nurse assess next?

A)Chest
B)Arms
C)Abdomen
D)Legs and feet

Question 41

During a physical assessment,the nurse notes a patient has a loss of strength and energy.What should the nurse document that the patient is experiencing?

A)Dyspnea
B)Cyanosis
C)Asthenia
D)Ecchymosis

Question 42

A nurse is caring for a patient with congestive heart failure.During the physical assessment,the nurse notes the patient is experiencing difficulty breathing.What should the nurse document that the patient is experiencing?

A)Dyspnea
B)Cyanosis
C)Diaphoresis
D)Ecchymosis

Question 43

A physician needs to assess a patient's rectal area.In what position should the nurse place the patient?

A)Sims
B)Prone
C)Lithotomy
D)Knee-chest

Question 44

A nurse needs to auscultate a patient's lung sounds.In what position should the nurse place the patient?

A)Sims
B)Prone
C)Sitting
D)Lithotomy

Question 45

During a physical assessment,the nurse notes that a patient's heart rate is 56 beats per minute.What should the nurse document that the patient is experiencing?

A)Dyspnea
B)Cyanosis
C)Diaphoresis
D)Bradycardia

Question 46

During a physical assessment,the nurse notes that a patient has bright red blood in the feces.What does the nurse recognize as the most likely cause of this bleeding?

A)Bleeding in the upper intestinal tract
B)Bleeding in the lower intestinal tract
C)Bleeding in the entire intestinal tract
D)Consumption of cranberry juice

Question 47

During a neurologic assessment,the nurse notes a patient has a unilateral,dilated,and nonreactive pupil.This is a sign that the patient is experiencing pressure on which cranial nerve?

A)I
B)II
C)III
D)IV

Question 48

A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue.What should the nurse document that the patient has?

A)Dyspnea
B)Cyanosis
C)Diaphoresis
D)Ecchymosis

Question 49

A physician needs to insert a vaginal speculum into a patient for a vaginal examination.In what position should the nurse place the patient?

A)Sims
B)Prone
C)Lithotomy
D)Dorsal recumbent

Question 50

When assessing a patient,the nurse notes a yellow tinge to the patient's skin.How should the nurse document this finding?

A)Dyspnea
B)Cyanosis
C)Jaundice
D)Ecchymosis

Question 51

A physician needs to assess extension of a patient's hip joint.In what position should the nurse place the patient?

A)Sims
B)Prone
C)Lithotomy
D)Dorsal recumbent

Question 52

When admitting a patient to the hospital,the nurse notes the patient has mild sunburn.How should the nurse document this finding?

A)Dyspnea
B)Cyanosis
C)Erythema
D)Ecchymosis

Question 53

During a physical assessment,the nurse notes a patient has profuse secretions of sweat.What should the nurse document that the patient is experiencing?

A)Dyspnea
B)Cyanosis
C)Diaphoresis
D)Ecchymosis

Question 54

During a physical assessment,the nurse notes a patient has a bluish discoloration of the skin and mucous membranes.How should the nurse document this finding?

A)Dyspnea
B)Cyanosis
C)Diaphoresis
D)Ecchymosis

Question 55

During a physical assessment,the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs.What should the nurse document that the patient is experiencing?

A)Dyspnea
B)Cyanosis
C)Coughing
D)Ecchymosis

Question 56

During a physical assessment,the nurse notes a patient passes frequent loose liquid stools.What should the nurse document that the patient is experiencing?

A)Dyspnea
B)Cyanosis
C)Diaphoresis
D)Diarrhea

Question 57

A physician needs to assess a patient for a heart murmur.In what position should the nurse place the patient?

A)Sims
B)Prone
C)Lithotomy
D)Lateral recumbent

Question 58

When assessing a patient with hepatitis,the nurse notes a yellow tinge to the patient's skin.What does the nurse understand as the most likely cause of the jaundice?

A)Heart
B)Liver
C)Brain
D)Intestines

Question 59

During a physical assessment,the nurse notes a patient has a lack of appetite resulting in an inability to eat.What should the nurse document that the patient is experiencing?

A)Dyspnea
B)Asthenia
C)Anorexia
D)Ecchymosis

Question 60

During a physical assessment,the patient complains of difficulty in passing stools.What should the nurse document that the patient is experiencing?

A)Dyspnea
B)Cyanosis
C)Constipation
D)Ecchymosis

Question 61

A physician documents that a patient has a sallow complexion.How does the nurse interpret this information?

A)Yellow color to the skin
B)Blue color to the skin
C)Red color to the skin
D)Gray color to the skin

Question 62

A condition of debility,loss of strength and energy,and depleted vitality is known as _________________.

Question 63

The nurse notes that a patient has difficulty breathing in the supine position,and the patient admits that he sleeps in a recliner at home.These are cardinal signs of ____________ disease.

Question 64

Discoloration of an area of the skin or mucous membrane that is caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls is known as _________________.

Question 65

A physician documents that a patient has a scleral icterus.What is the cause of this coloring?

A)Bilirubin
B)Hemoglobin
C)Serum potassium
D)Serum magnesium

Question 66

When assessing a patient,the nurse notes that the patient has an unnatural paleness of color to the skin.How should the nurse document this finding?

A)Skin pallor
B)Pruritus
C)Sallow skin
D)Jaundice

Question 67

Symptoms that are perceived by the patient are known as _____________ ____________.

Question 68

Which are infectious diseases? (Select all that apply.)

A)Measles
B)Pneumonia
C)Hay fever
D)Tuberculosis
E)Osteoarthritis
F) Acquired immunodeficiency syndrome

Question 69

The nurse is preparing to perform a physical assessment.What essential supplies should this nurse gather? (Select all that apply.)

A)Flashlight
B)Gloves
C)Red pen
D)Thermometer
E)Scissors

Question 70

When assessing a patient,the nurse notes that the patient is unable to lie flat to breathe.When the nurse assists the patient into a sitting position,the patient is able to breathe more easily.What should the nurse document that the patient is experiencing?

A)Dyspnea
B)Cyanosis
C)Jaundice
D)Orthopnea

Question 71

When assessing a patient,the patient complains of an uncomfortable sensation leading to an urge to scratch.The nurse notes the patient scratches frequently.How should the nurse document this finding?

A)Dyspnea
B)Cyanosis
C)Jaundice
D)Pruritus

Question 72

Signs that are perceived by an examiner and can be seen,heard,measured,or felt are known as ___________ _________.

Question 73

A physician documents that a patient is having purulent drainage from a wound.What does the nurse understand is most likely the cause?

A)Ringworm
B)Viral infection
C)Fungal infection
D)Bacterial infection

Question 74

When auscultating the chest,a nurse hears crackles in both lower lobes.To further assess this finding,the nurse should ask the patient to ______________.

Question 75

A physician documents that a patient has a scleral icterus.How does the nurse describe the color of the patient's sclera?

A)Red
B)Blue
C)Green
D)Yellow

Question 76

The nurse observes that an older adult patient has no hair on the lower legs.The nurse should assess further for the sufficiency of _________ ________.

Question 77

A circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute is known as _________________.

Question 78

A condition in which a patient experiences bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood is known as _________________.

Question 79

When assessing a female for risk factors associated with coronary artery disease,what information should the nurse include? (Select all that apply.)

A)Family history of illness
B)Diet
C)Smoking
D)Exercise
E)Number of pregnancies

Question 80

A condition in which there is a lack of appetite resulting in the inability to eat is known as _______________.