Deck 28: The Complete Health Assessment: Adult, Infant, Child, and Adolescent

Question 1

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

Answer 1

Freckles

Question 2

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

Answer 2

Empty the bladder

Question 3

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)Peripheral vision

Answer 3

Peripheral vision

Question 4

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

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

Question 5

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

Question 6

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 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

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

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

Question 9

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 10

Which statement regarding the complete physical assessment is true?

A)The male genitalia should be examined with the patient 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 among patients, the examiner should not vary the order of the assessment.

Question 11

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 12

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 13

Which of these is included when the nurses assesses the general appearance of the patient?

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

Question 14

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

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

Question 15

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)Snell

Question 16

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 17

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

Question 18

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 19

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

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

Question 20

An 85-year-old man has come in for a physical examination, and the nurse observes 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 21

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 22

The nurse is documenting the assessment of an infant.During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side.This finding would indicate:

A)Epigastric hernia
B)Pyloric obstruction
C)Hypoactive bowel sounds
D)Hyperactive bowel sounds

Question 23

When 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 24

The nurse is conducting an abdominal assessment on a 52-year-old patient with ascites and a history of extensive alcohol use.During inspection what should the nurse expect to observe?

A)Scaphoid abdomen with visible fine veins
B)Abdominal distension with visible dilated abdominal veins
C)Flat abdomen with bulging hernia
D)Abdominal contraction with sunken umbilicus

Question 25

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 26

Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup?

A)Performing the Ortolani manoeuvre
B)Assessment for stereognosis
C)Blood pressure measurement
D)Assessment for the presence of the startle reflex

Question 27

While reviewing a patient's medical record, the nurse notices that a patient's Hematest results are positive.This finding indicates 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

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's disease
C)Chronic arterial insufficiency
D)Chronic venous insufficiency

Question 29

During assessment, the nurse notes an old vertical scar across the patient's lower abdomen.How should the nurse best document this finding?

A)With a full-scale drawing of patient and location of the scar
B)By using a comprehensive drawing to detail the type of scar
C)By using a line drawing of the abdomen with the location and length of the scar
D)With a detailed narrative description of how the scar was acquired

Question 30

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 31

Which statement regarding the recording of data from the history and physical examination is true?

A)Use long, descriptive sentences to document findings.
B)Record the data as soon as possible after the interview and physical examination.
C)If the information is not documented, then it can be assumed that it was done as a standard of care.
D)The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient.

Question 32

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's disease
C)Chronic arterial insufficiency
D)Chronic venous insufficiency

Question 33

A female patient tells the nurse that she has four children and has had three pregnancies.How should the nurse document this?

A)Gravida 3, para 4
B)Gravida 4, para 3
C)This information cannot be documented using the terms gravida and para.
D)"The patient seems to be confused about how many times she has been pregnant."

Question 34

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 35

When assessing the neonate, the nurse should test for hip stability with which method?

A)Eliciting the Moro reflex
B)Checking the Romberg test
C)Performing the Ortolani manoeuvre
D)Assessing the stepping reflex

Question 36

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's disease
C)Arterial insufficiency
D)Venous insufficiency

Question 37

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 38

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

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

Question 39

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 40

A 5-year-old child is in the clinic for a checkup.The nurse would expect him to:

A)Need to be held on his mother's lap.
B)Be able to sit on the examination table.
C)Be able to stand on the floor for the examination.
D)Be able to remain alone in the examination room.