Deck 27: The Complete Health Assessment: Adult

Question 1

During an inspection of a patient's face,the nurse notices that the facial features are symmetric.This finding indicates which cranial nerve is intact?

A)VII
B)IX
C)XI
D)XII

Answer 1

VII

Question 2

A patient's uvula raises midline when she says "ahh," and she has a positive gag reflex.The nurse has just tested which cranial nerves?

A)IX and X
B)IX and XII
C)X and XII
D)XI and XII

Answer 2

IX and X

Question 3

During an examination,the patient tells the nurse that she sometimes feels as if objects are spinning around her.The nurse would document that she occasionally experiences:

A)Vertigo.
B)Tinnitus.
C)Syncope.
D)Dizziness.

Answer 3

Vertigo.

Question 4

The nurse has just completed an examination of a patient's extraocular muscles.When documenting the findings,the nurse should document the assessment of which cranial nerves?

A)II, III, and VI
B)II, IV, and V
C)III, IV, and V
D)III, IV, and VI

Question 5

During an examination,the nurse notices that a patient is unable to stick out his tongue.Which cranial nerve is involved with the successful performance of this action?

A)I
B)V
C)XI
D)XII

Question 6

The nurse should use which location for eliciting deep tendon reflexes?

A)Achilles
B)Femoral
C)Scapular
D)Abdominal

Question 7

A patient tells the nurse,"Sometimes I wake up at night and I have real trouble breathing.I have to sit up in bed to get a good breath." When documenting this information,the nurse would note:

A)Orthopnea.
B)Acute emphysema.
C)Paroxysmal nocturnal dyspnea.
D)Acute shortness of breath episode.

Question 8

The nurse is performing a vision examination.Which of these charts is most widely used for vision examinations?

A)Snellen
B)Shetllen
C)Smoollen
D)Schwellon

Question 9

During the examination of a patient,the nurse notices that the patient has several small,flat macules on the posterior portion of her thorax.These macules are less than 1 cm wide.Another name for these macules is:

A)Warts.
B)Bullae.
C)Freckles.
D)Papules.

Question 10

After the health history has been obtained and before beginning the physical examination,the nurse should first ask the patient to:

A)Empty the bladder.
B)Completely disrobe.
C)Lie on the examination table.
D)Walk around the room.

Question 11

Which of these is included in an assessment of general appearance?

A)Height
B)Weight
C)Skin color
D)Vital signs

Question 12

A patient states,"Whenever I open my mouth real wide,I feel this popping sensation in front of my ears." To further examine this,the nurse would:

A)Place the stethoscope over the temporomandibular joint, and listen for bruits.
B)Place the hands over his ears, and ask him to open his mouth "really wide."
C)Place one hand on his forehead and the other on his jaw, and ask him to try to open his mouth.
D)Place a finger on his temporomandibular joint, and ask him to open and close his mouth.

Question 13

The nurse should wear gloves for which of these examinations?

A)Measuring vital signs
B)Palpation of the sinuses
C)Palpation of the mouth and tongue
D)Inspection of the eye with an ophthalmoscope

Question 14

When the nurse performs the confrontation test,the nurse has assessed:

A)Extraocular eye muscles (EOMs).
B)Pupils (pupils equal, round, reactive to light, and accommodation [PERRLA]).
C)Near vision.
D)Visual fields.

Question 15

During an examination,a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin.The nurse will conclude that the patient's __________ function is intact.

A)Occipital
B)Cerebral
C)Temporal
D)Cerebellar

Question 16

An 85-year-old man has come in for a physical examination,and the nurse notices that he uses a cane.When documenting general appearance,the nurse should document this information under the section that covers:

A)Posture.
B)Mobility.
C)Mood and affect.
D)Physical deformity.

Question 17

During inspection of the posterior chest,the nurse should assess for:

A)Symmetric expansion.
B)Symmetry of shoulders and muscles.
C)Tactile fremitus.
D)Diaphragmatic excursion.

Question 18

A patient is unable to shrug her shoulders against the nurse's resistant hands.What cranial nerve is involved with successful shoulder shrugging?

A)VII
B)IX
C)XI
D)XII

Question 19

Which statement is true regarding the complete physical assessment?

A)The male genitalia should be examined in the supine position.
B)The patient should be in the sitting position for examination of the head and neck.
C)The vital signs, height, and weight should be obtained at the end of the examination.
D)To promote consistency between patients, the examiner should not vary the order of the assessment.

Question 20

During a complete health assessment,how would the nurse test the patient's hearing?

A)Observing how the patient participates in normal conversation
B)Using the whispered voice test
C)Using the Weber and Rinne tests
D)Testing with an audiometer

Question 21

During the examination of a patient's mouth,the nurse observes a nodular bony ridge down the middle of the hard palate.The nurse would chart this finding as:

A)Cheilosis.
B)Leukoplakia.
C)Ankyloglossia.
D)Torus palatinus.

Question 22

The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles.This finding indicates:

A)Lymphedema.
B)Raynaud disease.
C)Arterial insufficiency.
D)Venous insufficiency.

Question 23

After the examination of an infant,the nurse documents opisthotonos.The nurse recognizes that this finding often occurs with:

A)Cerebral palsy.
B)Meningeal irritation.
C)Lower motor neuron lesion.
D)Upper motor neuron lesion.

Question 24

If the nurse records the results to the Hirschberg test,the nurse has:

A)Tested the patellar reflex.
B)Assessed for appendicitis.
C)Tested the corneal light reflex.
D)Assessed for thrombophlebitis.

Question 25

The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain.This test is used to confirm a(n):

A)Inflamed liver.
B)Perforated spleen.
C)Perforated appendix.
D)Enlarged gallbladder.

Question 26

During examination,the nurse finds that a patient is unable to distinguish objects placed in his hand.The nurse would document:

A)Stereognosis.
B)Astereognosis.
C)Graphesthesia.
D)Agraphesthesia.

Question 27

The nurse documents that a patient has coarse,thickened skin and brown discoloration over the lower legs.Pulses are present.This finding is probably the result of:

A)Lymphedema.
B)Raynaud disease.
C)Chronic arterial insufficiency.
D)Chronic venous insufficiency.

Question 28

During an examination,the nurse notices that a patient's legs turn white when they are raised above the patient's head.The nurse should suspect:

A)Lymphedema.
B)Raynaud disease.
C)Chronic arterial insufficiency.
D)Chronic venous insufficiency.

Question 29

The nurse will measure a patient's near vision with which tool?

A)Snellen eye chart with letters
B)Snellen "E" chart
C)Jaeger card
D)Ophthalmoscope

Question 30

After assessing a female patient,the nurse notices flesh-colored,soft,pointed,moist,papules in a cauliflower-like patch around her introitus.This finding is most likely:

A)Urethral caruncle.
B)Syphilitic chancre.
C)Herpes simplex virus.
D)Human papillomavirus.

Question 31

While examining a 48-year-old patient's eyes,the nurse notices that he had to move the handheld vision screener farther away from his face.The nurse would suspect:

A)Myopia.
B)Omniopia.
C)Hyperopia.
D)Presbyopia.

Question 32

While recording in a patient's medical record,the nurse notices that a patient's Hematest results are positive.This finding means that there is(are):

A)Crystals in his urine.
B)Parasites in his stool.
C)Occult blood in his stool.
D)Bacteria in his sputum.