Deck 31: Health Assessment

Question 1

The nurse is performing a lung assessment on a client with suspected pneumonia. Which of the following assessments should the nurse report to the physician immediately?

A) Bilateral symmetric vocal fremitus.
B) Asymmetric chest expansion.
C) Chest symmetrical.
D) Breath sounds equal bilaterally.

Answer 1

Asymmetric chest expansion.

Question 2

The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him, however, he is unable to respond by speech or writing. What is this form of aphasia called?

A) Sensory aphasia.
B) Acoustic aphasia.
C) Auditory aphasia.
D) Expressive aphasia.

Answer 2

Expressive aphasia.

Question 3

The nurse is undertaking a general assessment on a new client. Which of the following assessments should the nurse perform?

A) Appearance.
B) Mental status.
C) Height and weight.
D) Assess vital signs.
E) Assess peripheral pulses.

Answer 3

Appearance.
Mental status.
Height and weight.
Assess vital signs.

Question 4

The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. The nurse would expect the physician to perform which of the following?

A) Rectal exam.
B) Pap test.
C) Breast exam.
D) Abdominal exam.

Question 5

While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins?

A) 60-degree angle.
B) 15-degree angle.
C) 30- to 45-degree angle.
D) 90-degree angle.

Question 6

The nurse is preparing to perform an eye assessment. Which of the following equipment will the nurse need to gather?

A) Penlight.
B) Snellen's chart.
C) Sterile gloves.
D) Gauze square.
E) Millimetre ruler.

Question 7

Assessment of mental status reveals the client's general cerebral function. These include which of the following?

A) Cognitive and effective functions.
B) Affective and knowledge functions.
C) Cognitive and affective functions.
D) Affective and memory functions.

Question 8

The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse would document this as which of the following?

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

Question 9

The nurse is preparing to perform a physical examination. Which of the following is the correct order to perform the assessment?

A) Inspect, percuss, auscultate, palpate.
B) Palpate, percuss, auscultate, inspect.
C) Auscultate, percuss, palpate, inspect.
D) Inspect, auscultate, palpate, percuss.

Question 10

The nurse is performing a musculoskeletal assessment on a client admitted with a possible cerebrovascular accident (stroke). When testing for muscle grip strength, the nurse should ask the client to:

A) grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out.
B) hold an arm up and resist while the nurse tries to push it down.
C) shrug the shoulders against the resistance of the nurse's hands.
D) flex each arm and then try to extend it against the nurse's attempt to keep the arm in flexion.

Question 11

A nurse is conducting a physical examination of a client who has abdominal pain. One of the methods of assessment the nurse will use to determine pain with pressure is:

A) inspection.
B) palpation.
C) percussion.
D) auscultation.

Question 12

The nurse is preparing to conduct an assessment of the heart. On which of the following areas would the nurse place the stethoscope for auscultation?

A) Aortic.
B) Pulmonic.
C) Tricuspid.
D) Abdomen.
E) Mitral.

Question 13

The nurse is preparing to administer a cardiac drug to a client. Which of the following assessments should the nurse perform before administering the medication?

A) Apical pulse.
B) Popliteal pulse.
C) Respiratory rate.
D) Capillary blanch test.

Question 14

The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which of the following should the nurse report to the medical practitioner immediately?

A) Thready pulses.
B) Pulses equal bilaterally.
C) Pulses present bilaterally.
D) Full pulsations.

Question 15

The nurse is preparing for morning rounds. Which of the following may not be delegated to the Assistant in Nursing?

A) Fill water jugs.
B) Vital signs.
C) Health assessment.
D) Ambulate surgical clients.

Question 16

A nurse is auscultating a client's abdomen and hears rough grating sounds like two pieces of leather rubbing together. This sound alerted the nurse to the possibility of:

A) vascular sounds or bruits.
B) peritoneal friction rub from infection.
C) hyperactive bowel sounds or borborygmi.
D) hypoactive bowel sounds of an obstruction.

Question 17

A blanch test is undertaken for which of the following?

A) Temperature assessment.
B) Capillary refill assessment.
C) Female genital assessment.
D) Musculoskeletal assessment.

Question 18

When undertaking a physical assessment, hyperresonance and tympany are features of:

A) heart sounds.
B) ear and nose sounds.
C) percussion.
D) palpation.

Question 19

The nurse is assessing a female's breasts. The nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What is the nurse's next action?

A) Notify the physician.
B) Notify the nurse unit manager.
C) Document the findings in the nurse's notes as normal.
D) Document the findings in the nurse's notes as abnormal.

Question 20

While performing an assessment of the integument system, the nurse notes the client's eyeballs are protruding and the upper eyelids are elevated. What term would the nurse use to document this finding?

A) Cyanosis.
B) Exophthalmos.
C) Erythema.
D) Normocephalic.

Question 21

The nurse is preparing a client for an abdominal examination. Which of the following should be performed before the examination?

A) Assess heart rate.
B) Ask client to urinate.
C) Ask client to drink 250mL of water.
D) Assess vital signs.

Question 22

The nurse is conducting a neurological assessment on a client by asking the client to stand with his feet together with arms resting at the sides, first with eyes open, then closed. This test is called:

A) Abducens test.
B) Kinesthetic sensation test.
C) Romberg test.
D) Stereognosis test.

Question 23

The nurse is preparing to assess a client's reflexes. Which of the following equipment should the nurse gather before entering the room?

A) Sterile gloves.
B) Penlight.
C) Percussion hammer.
D) Clean gloves.

Question 24

The Glasgow Coma Scale is used for assessing level of consciousness. It tests in which of the following areas?

A) Eye response.
B) Motor response.
C) Verbal response.
D) Orientation.
E) Musculoskeletal response.

Question 25

The midwife is assisting a mother with her newborn baby to establish breast feeding. The midwife strokes the side of the baby's face near the mouth to help with attachment. The nurse is using which of the normal reflexes?

A) Palmar.
B) Moro.
C) Rooting.
D) Sucking.