Deck 31: Health Assessment and Physical Examination

Question 1

If a low-pitched murmur is suspected with prior assessment,which of the following is the best position for the patient when the nurse auscultates the apical site?

A) Sitting up
B) Standing
C) Lying on the left side
D) Dorsal recumbent

Answer 1

C

Question 2

Measurement of the patient's sensation of light pain and touch across the skin of the face tests which of the following cranial nerves?

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

Answer 2

C

Question 3

The nurse is examining a patient with dark skin.In assessing for pallor,at which of the following will it be best for the nurse to specifically look?

A) Lips and tongue
B) Skin creases and folds
C) Hard palate
D) Sclera

Answer 3

A

Question 4

How would the nurse document adventitious breath sounds that were loud,low-pitched,rumbling,coarse sounds?

A) Crackles
B) Rhonchi
C) Wheezes
D) Pleural friction rub

Question 5

The nurse suspects that the patient may have cardiovascular disease.During the examination,the nurse is alert to which of the following complaints from the patient?

A) Headache, dizziness, and tingling of body parts
B) Diplopia, floaters, and headaches
C) Cough, leg cramps, and orthopnea
D) Pain and cramping in the lower extremities relieved by walking

Question 6

The nurse is auscultating the patient's lungs and notes normal vesicular sounds as being which of the following?

A) Medium-pitched blowing sounds with inspiration equalling expiration
B) Loud, high-pitched, hollow sounds with expiration longer than inspiration
C) Soft, breezy, low-pitched sounds with longer inspiration
D) Sounds created by air moving through small airways

Question 7

The patient has an enlarged thyroid gland and is currently admitted to a medical nursing unit.Which of the following is accurate regarding the procedure for a thyroid assessment for this patient?

A) Deep palpation should be used anterior and posterior.
B) Swallowing sips of water causes the isthmus of the thyroid gland to rise.
C) The posterior approach is used with the fingers placed over the trachea.
D) The diaphragm of the stethoscope is best for auscultation of bruits.

Question 8

Part of the neurological examination involves evaluating the response of the cranial nerves.To test cranial nerve VIII,which of the following actions should the nurse take?

A) Ask the patient to read printed material.
B) Assess the directions of the gaze.
C) Assess the patient's ability to hear the spoken word.
D) Ask the patient to say "ah," and observe movement of the palate and pharynx.

Question 9

Which abnormality of the nail bed can be caused by iron deficiency anemia?

A) Beau's lines
B) Paronychia
C) Koilonychia
D) Splinter hemorrhages

Question 10

The student nurse is working with a patient who has asthma.The primary nurse tells the student that wheezes can be heard on auscultation.Which of the following should the student expect to hear?

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

Question 11

A female patient is seen in the outpatient clinic for numerous cuts,bruises,and apparent burns.In a discussion with the patient,the nurse finds that the injuries are inconsistent with the stated cause.The patient also states that she is having trouble sleeping,and she appears anxious.Based on these findings,which of the following does the nurse suspect the patient may be experiencing?

A) Substance abuse
B) Domestic violence
C) Vascular disease
D) Mental illness

Question 12

Which of the following positions maximizes the nurse's ability to assess the patient's upper body for symmetry?

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

Question 13

In preparing to examine a patient's abdomen,which of the following actions does the nurse plan to take?

A) Leave painful areas for the end of the examination.
B) Place a pillow under the patient's head, and extend his legs.
C) Keep the TV or radio on to distract the patient throughout the examination.
D) Assess only the side of the body where the pain occurs.

Question 14

The nurse will be assessing position sense with cerebellar tests.Which of the following tests relates to testing cerebellar function?

A) Weber test
B) Allen test
C) Romberg test
D) Rinne test

Question 15

In which of the following locations could the nurse best auscultate the point of maximum impulse (PMI)in an adult patient?

A) Fourth intercostal space, left of the midclavicular line
B) Fifth intercostal space, medial to the left midclavicular line
C) Second intercostal space, right of the midclavicular line
D) Third intercostal space, right of the midclavicular line

Question 16

Assessment of the patient's skin reveals a serous fluid-filled circumscribed elevation of 0.4 cm.The nurse documents this as which one of the following?

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

Question 17

During an assessment of the patient's integument,the nurse notes a flat,nonpalpable change in skin colour that is smaller than 1 cm.How is this finding documented by the nurse?

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

Question 18

A 21-year-old female patient asks the nurse what is the best time for performing breast self-examination (BSE).Which of the following should the nurse tell the patient?

A) "Any time you think of it."
B) "At the same time each month."
C) "On the first day of your menstrual period."
D) "Two to three days after your menstrual period ends."

Question 19

During the assessment of a 90-year-old patient,the nurse documents an exaggeration of the posterior curvature of the thoracic spine as which of the following?

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

Question 20

What is the expected appearance of the oral mucosa in a light-skinned adult?

A) Pinkish red, smooth, and moist
B) Light pink, rough, and dry
C) Cyanotic, with rough nodules
D) Deep red, with rough edges

Question 21

The nurse uses a goniometer to assess which of the following?

A) Abdominal tone
B) Muscle strength
C) The degree of motion in a joint
D) The angle of wrist flexion and hyperextension

Question 22

Which of the following is a congenital condition commonly referred to as "lazy eye"?

A) Myopia
B) Hyperopia
C) Presbyopia
D) Amblyopia

Question 23

The nurse instructs the male patient that which one of the following is the protocol for testicular self-examination?

A) Perform the examination annually after age 35 years.
B) Using both hands, roll the testicles and feel the consistency.
C) Perform the examination before bathing or showering.
D) Contact the physician if a cordlike structure is felt on the top and back of the testicle.

Question 24

An inspection of the lower extremities is being performed.The observation of which of the following causes the nurse to suspect the presence of arterial insufficiency?

A) Increased hair growth
B) Cooler skin temperatures
C) Marked edema
D) Brown pigmentation

Question 25

The nurse is preparing to perform a physical examination on a patient who has cardiopulmonary disease.Knowing this about the patient,the nurse is alert for the presence of which of the following when checking the patient's nails?

A) Clubbing
B) Bands in nail beds
C) Yellow discoloration
D) Splinter hemorrhages

Question 26

What is the correct technique to assess teeth occlusion?

A) Use a tongue depressor.
B) Clench the teeth and smile.
C) Open mouth with the lips relaxed.
D) Retract lower lip with the patient's mouth open.

Question 27

A pregnant patient is seen by the nurse in the antenatal clinic.On inspection,which of the following changes does the nurse expect to see in the patient's breasts?

A) Softer tissue
B) Flatter nipples
C) Darkened areolae
D) Diminished superficial veins

Question 28

The nurse is using the Weber test to evaluate the patient for conduction deafness in the right ear.Which one of the following occurs when the nurse appropriately places the tuning fork and confirms this type of deafness?

A) Sound is not heard in either ear.
B) Sound is heard best by the patient in the left ear.
C) Sound is heard best by the patient in the right ear.
D) Sound is reduced and heard longer through air conduction.

Question 29

A school-age child is brought to the clinic after experiencing a nosebleed during a soccer practice.During the health history,which of the following is the most appropriate question for the nurse to ask the patient?

A) "Do you use nasal sprays?"
B) "Do you snore or experience breathing difficulties during sleep?"
C) "Have you ever experienced nosebleeds before?"
D) "Are you allergic to anything?"

Question 30

The nurse uses olfaction during a patient assessment.If a sweet,fruity smell is noticed in the patient's oral cavity,which of the following should the nurse suspect?

A) Diabetic acidosis
B) Gum disease
C) Urinary tract infection
D) Malabsorption syndrome

Question 31

An older adult patient is visiting the physician's office for a checkup.The patient asks the nurse at what age yearly prostate-specific antigen blood tests should begin.Which of the following should be the nurse's response?

A) 20 years
B) 30 years
C) 40 years
D) 50 years

Question 32

During the physical examination,the nurse should use which part of the hand to assess characteristics such as consistency,contour,and texture in the patient's glands?

A) Dorsum of the hand
B) Pads of the fingers
C) Palmar surface of the hand
D) Fingertip grasp of the tissue