Deck 25: Health Assessment

Question 1

A nurse is conducting a health assessment. How will the information collected from the client be used?

A) As a basis for the nursing process
B) To illustrate nursing competence
C) To facilitate nurse-client caring
D) As one component of medical care

Answer 1

As a basis for the nursing process

Question 2

Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

A) Ongoing partial assessment
B) Comprehensive assessment
C) Focused assessment
D) Emergency assessment

Answer 2

Ongoing partial assessment

Question 3

An older adult asks the nurse about the appearance of flat brown age spots on the hands. After examining the client's hands, the nurse recognizes these skin characteristics as a common skin variation in the older adult and documents the variations as which of the following?

A) Senile lentigines
B) Lanugo
C) Senile keratosis
D) Cherry angiomas

Answer 3

Senile lentigines

Question 4

The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment that should be documented and reported to the physician?

A) Decreased heart rate
B) Visible pulsation through a thin chest wall
C) Sinus dysrhythmia that increases with inspiration and decreases with expiration
D) Presence of an S heart sound

Question 5

The nurse is conducting an assessment on the integumentary system of a client age 74 years. Which of the following findings should the nurse document as an anomaly that may warrant follow-up?

A) The client states that a mole on his forehead has become larger in recent months.
B) Decreased skin turgor is evident when the skin is folded and then released.
C) Small, round, red spots are present on the client's forearms bilaterally.
D) There are some raised, brown areas on the backs of the client's hands.

Question 6

An adolescent comes to a community health clinic with complaints of vaginal itching and discharge. She believes it is from having sex with her boyfriend. Which response should the nurse use during the health history to elicit information?

A) "Tell me about the sexual activity with your boyfriend."
B) "Why did you ever have sex with someone you don't know?"
C) "You are old enough to know to use condoms."
D) "I don't understand how you could be so careless."

Question 7

A nurse working in a clinic is planning to conduct vision screenings for a group of low-income women. What equipment would be needed to test vision?

A) Snellen chart
B) Stethoscope
C) Ophthalmoscope
D) Otoscope

Question 8

As a component of a head to toe assessment, the nurse is preparing to assess convergence of the client's eyes. How should the nurse conduct this assessment?

A) Ask the client to follow her finger as she slowly moves it towards the client's nose.
B) Ask the client to look ahead while slowly bringing a pen light in from the side and to the client's pupil.
C) Ask the client to hold his head stationary while following a pencil from left to right.
D) Ask the client to read a Snellen chart from a distance of 20 feet.

Question 9

A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct?

A) Comprehensive
B) Ongoing partial
C) Focused
D) Emergency

Question 10

A nurse is performing a general survey of a client admitted to the hospital. Which of the following actions is an element of this procedure?

A) Taking vital signs
B) Palpating the integument
C) Identifying risk factors for altered health
D) Assessing the head and neck

Question 11

A school nurse is preparing to test the auditory function of grade school students. What equipment will be needed for this examination?

A) Tuning fork
B) Percussion hammer
C) Speculum
D) Ophthalmoscope

Question 12

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate?

A) "This is nothing to worry about. I won't hurt you."
B) "Some of the examination may be painful, but I will be gentle."
C) "Let me tell you what I will be doing. It should not be painful."
D) "I have to do this, so just relax and it won't last long."

Question 13

What would a nurse ensure before beginning a health assessment?

A) That the time needed for the assessment fits into the nurse's work schedule
B) That the room is private, quiet, warm, and has adequate light
C) That family members are present to answer specific questions
D) That there is a written physician's order for the assessment

Question 14

When using assessment equipment that will touch the client, what should the nurse do before conducting the assessment?

A) Describe the equipment and how it works.
B) Show pictures of functions of the equipment.
C) Draw pictures of the anatomy to be assessed.
D) Warm the equipment with hands or warm water.

Question 15

The nurse palpating the skin of a client documents a firm 1.5 cm mass on the lower right leg. What type of skin lesion does this describe?

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

Question 16

A nurse is using inspection as an assessment technique. What does the nurse use during inspection?

A) Equipment such as a stethoscope
B) Both hands to produce sounds
C) Light palpation to detect surfaces
D) Senses of vision, hearing, smell

Question 17

A nurse is preparing to examine the breasts of a client. In what position should the nurse place the client?

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

Question 18

When auscultating a client's abdomen, a nurse notes gurgling sounds. What characteristic of sound would the nurse document?

A) Resonance
B) Turgor
C) Quality
D) Texture

Question 19

Which of the following can a nurse assess by palpation?

A) Heart sounds, lung sounds, blood pressure
B) Temperature, turgor, moisture
C) Vision, hearing, cranial nerves
D) Tissue density, gait, reflexes

Question 20

When inspecting the skin of a client, the nurse notes a bluish tinge to the skin. What condition would the nurse document?

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

Question 21

The nurse preparing to perform an abdominal assessment on a client places the client in which of the following positions?

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

Question 22

While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds?

A) Air in the lungs
B) A narrowing of the upper airway
C) Narrowed small air passages
D) Moisture in air passages

Question 23

A nurse assesses a client's eyes by testing the cardinal fields of vision for coordination and alignment. What eye characteristic is being assessed by this process?

A) Visual acuity
B) Extraocular movements
C) Peripheral vision
D) Existence of cataracts

Question 24

Which framework is used during the focused assessment?

A) Functional health assessment
B) Head-to-toe framework
C) Conceptual framework
D) Body systems framework

Question 25

The nurse is preparing to assess a client's cranial nerves. Which of the following techniques should you use to assess cranial nerve III?

A) Shine a bright light in the client's eye and observe for bilateral pupillary response.
B) Ask the client to close the eyes, occlude a nostril, then identify the smell of different substances.
C) Determine visual acuity using a Snellen chart
D) Occlude the patient's right ear, whisper a word into the left ear, and ask the patient to repeat it.

Question 26

While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these?

A) Bronchial
B) Bronchovesicular
C) Vesicular
D) Adventitious

Question 27

A nurse is assessing the spine of a client with kyphosis. Which of the following would the nurse expect to observe about the client's posture?

A) The shoulder and upper back curves forward
B) The lumbar region tends to curve inward
C) The sacral region tends to turn outward
D) A portion of the spine is curved to the side laterally

Question 28

When assessing the abdomen, which assessment technique is used last?

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

Question 29

An African American client with jaundice has been admitted to the health care facility. Which of the following body areas is the best place to assess jaundice?

A) Sclera
B) Nailbeds
C) Lips
D) Palm

Question 30

During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. What nerve is being tested by this action?

A) Cranial nerve I
B) Cranial nerves II and III
C) Cranial nerve VII
D) Cranial nerve VIII

Question 31

When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts?

A) Actual measurements in centimeters
B) Symmetry (comparison of bilateral body parts)
C) Indications of general health status
D) Vital signs of all extremities (arms and legs)

Question 32

During a nurse's visit to the client's home, the client states, "I have pain in my right knee." The nurse assesses the client's right knee. What kind of assessment is this?

A) Focused assessment
B) Spiritual assessment
C) Social assessment
D) Comprehensive assessment

Question 33

How would a nurse assess a client for pupillary accommodation?

A) Using an ophthalmoscope, check the red reflex.
B) Ask the client to focus on a finger and move the client's eyes through the six cardinal positions of gaze.
C) Ask the client to focus on an object as it is brought closer to the nose.
D) Ask the client to read the smallest possible line of letters on the Snellen chart.

Question 34

What is one purpose of documentation of the health assessment?

A) To identify the nurse's role in health care
B) To identify actual and potential health problems
C) To expand nursing knowledge and skills
D) To provide a basis for evidence-based nursing

Question 35

A nurse is conducting a health assessment for an African American client. What should the nurse consider in terms of cultural sensitivity?

A) All individuals, regardless of culture, have the same anatomy and physiology.
B) Asking specific questions about race during the health history
C) Cultural risk factors for alterations in health and normal racial variations
D) Differences in emotional, social, and spiritual basic human needs