Deck 6: Health Assessment

Question 1

The assessment technique that involves striking the body surface directly with one of two fingers is known as:

A) Indirect percussion
B) Deep palpation
C) Direct percussion
D) Light palpation

Answer 1

Direct percussion

Question 2

An expected outcome for a patient after cardiac assessment is:

A) Apical pulse rate = 58 beats per minute
B) Carotid bruits present
C) PMI palpable at left fifth intercostal space at midclavicular line
D) Jugular veins distended with patient in sitting position

Answer 2

PMI palpable at left fifth intercostal space at midclavicular line

Question 3

The patient is admitted with fever and acute lower abdominal pain.He has taken Tylenol but says he still feels feverish.Before taking the patient's temperature,the nurse may:

A) Touch the patient's skin with the dorsum of her hand
B) Touch the patient's skin with the pads of her fingers
C) Palpate the skin using the bimanual method
D) Tap the patient's skin using the fingertips

Answer 3

Touch the patient's skin with the dorsum of her hand

Question 4

To hear low-pitched sounds,the best position in which to place the patient is:

A) Supine
B) Sitting up
C) Dorsal recumbent
D) Left lateral recumbent

Question 5

The nurse is examining a patient who she suspects is having right-sided heart failure.Which finding would most strongly support her suspicion?

A) 4⁺ edema in the left foot
B) A jugular venous pulsation of less than 2.5 cm
C) A capillary refill time less than 4 seconds
D) Bilateral pedal edema when the patient is sitting

Question 6

Petechiae are noted on the patient as a result of the nurse's finding:

A) Bluish-black patches
B) Tenting
C) Pinpoint-sized red dots
D) Large areas of raised, irritated skin

Question 7

The nurse is assessing the patient by grasping a fold of skin on his forearm.She notices that the skin remains suspended for a longer than normal period.This could possibly indicate:

A) A stage I pressure ulcer
B) Increased blood flow to the area
C) Localized vasodilation
D) Dehydration

Question 8

An unexpected finding after a cardiac assessment is:

A) A pulse rate of 72 beats per minute
B) Jugular vein pulsation with the patient supine
C) PMI found at the midclavicular line
D) A sustained swishing sound during systole or diastole

Question 9

The nurse is preparing to examine a patient who has chronic lung disease.She realizes that the patient most likely will need to be in which position for the examination?

A) Sitting upright
B) Supine
C) Side-lying
D) Prone

Question 10

In providing a physical assessment of an 88-year-old patient,the nurse should:

A) Do it as quickly as possible to prevent fatigue
B) Assume that the patient will have disabilities
C) Prepare to perform a mental status examination
D) Always do the exam in the small exam room to prevent chills

Question 11

The nurse is visiting the patient for the first time this shift.She introduces herself and asks the patient several questions related to his condition.While doing so,and without being obvious,she is looking at the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth.The nurse is using the assessment technique known as:

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

Question 12

When preparing to complete an assessment for a 16-year-old patient,a nurse should:

A) Focus on illness behaviors
B) Plan for a diminished energy level
C) Treat the patient as an individual
D) Have the parents present throughout

Question 13

The patient has had chronic lung disease for many years.This would lead the nurse to expect his anteroposterior (AP)ratio to be:

A) 2:1
B) The same as a child's
C) Twice as wide as it is deep
D) Normal

Question 14

The general survey begins a review of the patient's primary health problems and evaluation of the patient's vital signs,height and weight,general behavior,and appearance.It also provides information about the patient's illness,hygiene,skin condition,body image,and emotional state.Which of the following cannot be delegated to nursing assistive personnel?

A) Reporting subjective signs and symptoms
B) Measuring the patient's height and weight
C) Monitoring I&O
D) Obtaining initial vital signs

Question 15

What technique should the nurse implement for assessment of the carotid artery?

A) Massaging the arteries briskly
B) Using the diaphragm of the stethoscope
C) Palpating each carotid artery separately
D) Placing the patient in a supine position

Question 16

A nursing assistant may be responsible for determining:

A) Vital signs
B) Cranial nerve function
C) Neck vein distention
D) Auscultation of bowel sounds

Question 17

An unexpected finding during the assessment of the pupils of the eyes is:

A) A round shape
B) Slight opacity
C) A brisk response to light
D) Consensual constriction

Question 18

The pulmonic area for auscultation is found at the:

A) Second intercostal space on the right side
B) Second intercostal space on the left side
C) Third intercostal space (Erb's point)
D) Fourth intercostal space along the sternum

Question 19

The nurse is caring for a patient who is recovering from an acute myocardial infarction.While providing cardiac education,the nurse realizes that the patient needs more education when he:

A) Describes changes in his behavior that may improve cardiovascular function
B) Describes the schedule, dosage, and purpose of his medication
C) States that he will take his medication when he has chest pain or when his heart rate is greater than 100
D) Describes the benefits of taking his medication regularly

Question 20

While performing a cardiovascular assessment on a patient with suspected left sided congestive heart failure,the nurse is unable to palpate the PMI with the patient lying supine.Her next step might be to:

A) Have the patient turn onto his left side
B) Have the patient lean forward
C) Have the patient move to a sitting position
D) Palpate the PMI to the right of the midclavicular line

Question 21

How should the nurse document an exaggeration of the posterior curvature of the thoracic spine found during the assessment of a 90-year-old patient?

A) Lordosis
B) Osteoporosis
C) Scoliosis
D) Kyphosis

Question 22

Which condition puts patients at risk for increased fluid retention?

A) Addison's disease
B) Cushing's disease
C) Diabetic ketoacidosis
D) Febrile conditions

Question 23

The patient has come to the clinic complaining of bleeding from what she calls a "mole" on her neck.She states that her mother died from skin cancer at a fairly early age because she was fair skinned and had a lot of exposure to the sun.Because of this,the patient has been going for tanning sessions regularly for several years to keep her dark and to protect her from the sun.The nurse prepares to examine the "mole," being especially watchful for: (Select all that apply.)

A) Uneven shape of the mole (asymmetry)
B) Ragged or blurred edges of the mole border
C) Pigmentation that is not uniform
D) Size of the mole
E) None of above

Question 24

Which patient position maximizes the nurse's ability to assess the patient's body for symmetry?

A) Sitting
B) Supine
C) Prone
D) Dorsal recumbent

Question 25

How does a nurse appropriately measure intake and output?

A) Recording 50% of ice chip consumption
B) Checking urinary output every 24 hours
C) Emptying the chest tube drainage every 2 hours
D) Subtracting liquid medications from the total intake

Question 26

The purpose of the physical assessment is to: (Select all that apply.)

A) Compare the patient's status with previous findings
B) Help the nurse gather additional data
C) Help select the best nursing measures
D) Teach patients about better health promotion
E) None of above

Question 27

In teaching the patient about prevention of cervical cancer,the nurse teaches the patient about the risk factors for cervical cancer.Risk factors for cervical cancer include which of the following? (Select all that apply.)

A) History of human papillomavirus (HPV) infection
B) Multiple sex partners
C) Smoking
D) Multiple pregnancies
E) None of above

Question 28

During assessment of a patient with anemia,a nurse is alert for the presence of:

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

Question 29

The patient is diagnosed with Bell's palsy.The nurse assesses the patient and notices drooping of the patient's right eye and the right side of his mouth.When the functions of the following nerves are compared,the most likely cause of these symptoms would be a dysfunction of:

A) The seventh cranial nerve
B) The trigeminal nerve (CN V)
C) The oculomotor nerve (CN III)
D) The glossopharyngeal nerve (CN IX)

Question 30

A nurse is documenting a patient's breath sounds.Crackles are heard as:

A) Loud, low-pitched, coarse sounds
B) High-pitched, musical squeaks
C) Dry, grating sounds on inspiration
D) High-pitched, fine sounds at the end of inspiration

Question 31

While performing a physical examination,the nurse incorporates health promotion by teaching the patient about how to reduce the risk of lung cancer.Besides cigarette smoke,the nurse explains that exposure to other substances may lead to this disease.Some of these substances are: (Select all that apply.)

A) Arsenic
B) Asbestos
C) Radiation
D) Air pollution
E) None of above

Question 32

Which skin condition would cause a nurse to suspect chickenpox?

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

Question 33

Which technique is most appropriate for a nurse to implement during the assessment of the abdomen?

A) Assessing painful areas first
B) Auscultating for 5 minutes over each quadrant
C) Positioning the patient in a supine position with the arms behind or over the head
D) Palpating painful masses or organ enlargement deeply and firmly

Question 34

A student nurse is working with a patient who has asthma.The primary nurse tells the student that wheezes can be heard on auscultation.The student expects to hear:

A) Coarse crackles and bubbling
B) High-pitched musical sounds
C) Dry, grating noises
D) Loud, low-pitched rumbling

Question 35

The patient is 3 days post abdominal surgery.The nurse utilizes her stethoscope to listen for bowel sounds.This assessment technique is known as ______________________.

Question 36

The female nurse is preparing to assess and possibly change a scrotal dressing on a 34-year-old patient.Before changing the dressing,she should ______________.

Question 37

The nurse is preparing to examine a comatose patient on a ventilator.Before beginning the procedures,she: (Select all that apply.)

A) Speaks to the patient to minimize anxiety
B) Drapes the body parts not being examined
C) Encourages the patient to ask questions
D) Uses medical terms to let the patient know that she is professional

Question 38

Measurement of the patient's ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?

A) Abducens
B) Facial
C) Trigeminal
D) Oculomotor

Question 39

The nurse is assessing the neurological status of a patient.She uses the handle end of a reflex hammer to stroke the lateral aspect of the sole of the foot.She notes that the great toe dorsiflexes and the other toes spread out like a fan.What does this indicate?

A) A positive Romberg's test
B) A negative Babinski's reflex
C) A hyperactive patellar tendon reflex
D) A normal reflex in a child younger than age 2

Question 40

A nurse is documenting a patient's breath sounds.Rhonchi are heard as:

A) Loud, low-pitched, coarse sounds
B) High-pitched, musical squeaks
C) Dry, grating sounds on inspiration
D) High-pitched, fine sounds at the end of inspiration

Question 41

When performing an assessment of the cardiovascular system,the nurse evaluates the skin and nails of the patient.Inadequate tissue perfusion is known as ______________.

Question 42

Increased visibility of oxyhemoglobin caused by dilation or increased blood flow is known as ________________.

Question 43

The patient is noted to have difficulty swallowing.The nurse realizes that the most probable cause of this difficulty is damage to cranial nerve ______.

Question 44

The patient has been in the ICU following an acute myocardial infarction 3 days earlier.During the nurse's initial assessment of the patient,she detects a heart murmur that the patient did not have previously.The nurse should __________________.

Question 45

The nurse is caring for an infant on the pediatric unit who is to have intake and output (I&O)recorded.To determine the infant's output,she weighs the patient's diapers.She does this knowing that 1 g of diaper is equal to _______ of urine.

Question 46

The patient has been immobile at home after having had leg trauma in an automobile accident and is now being admitted with calf pain and localized swelling of the calf muscle.One test that is contraindicated in assessment of this patient is testing for _____________.

Question 47

The patient is admitted to the hospital with a hematocrit of 60%.This level indicates __________________.

Question 48

The nurse is providing health education to a group of adolescent females.The topic is "Preventing Skin Cancer." As part of the health promotion education,the nurse recommends that they avoid tanning under direct sun at midday and avoid _________________.

Question 49

Breast self-examination should be done once a month.For women who menstruate,the best time is ______________.

Question 50

________________ is a major cause of lung cancer,cerebrovascular disease,heart disease,and chronic lung disease.

Question 51

An increased amount of deoxygenated hemoglobin may cause a change in skin color known as _____________.