Question 1

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

Accepted Answer

A) symmetric expansion. 
B) symmetry of shoulders and muscles. 
C) tactile fremitus. 
D) diaphragmatic excursion. 
A) symmetric expansion. 
B) symmetry of shoulders and muscles. 
C) tactile fremitus. 
D) diaphragmatic excursion.

Question 2

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

Accepted Answer

A) empty the bladder. 
B) completely disrobe. 
C) lie on the examination table. 
D) walk around the room. 
A) empty the bladder. 
B) completely disrobe. 
C) lie on the examination table. 
D) walk around the room.

Question 3

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

Accepted Answer

A) urethral caruncle. 
B) syphilitic chancre. 
C) herpes. 
D) human papillomavirus. 
A) urethral caruncle. 
B) syphilitic chancre. 
C) herpes. 
D) human papillomavirus.

Question 4

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

Accepted Answer

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

Question 5

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

Accepted Answer

A) cerebral palsy. 
B) meningeal irritation. 
C) lower motor neuron lesion. 
D) upper motor neuron lesion. 
A) cerebral palsy. 
B) meningeal irritation. 
C) lower motor neuron lesion. 
D) upper motor neuron lesion.

Question 6

While the nurse palpates the maxillary sinuses,the patient tells the nurse that he has some tenderness in that area.The nurse should proceed by:

Accepted Answer

A) tapping on the sinus area. 
B) auscultating the sinus area. 
C) asking him to blow his nose. 
D) transilluminating the sinuses. 
A) tapping on the sinus area. 
B) auscultating the sinus area. 
C) asking him to blow his nose. 
D) transilluminating the sinuses.

Question 7

When the nurse flexes the patient's knee and gently compresses the gastrocnemius muscle anteriorly against the tibia,the patient indicates that he is having calf pain.The nurse would document:

Accepted Answer

A) positive Allen's sign. 
B) negative Allen's sign. 
C) positive Homan's sign. 
D) negative Homan's sign. 
A) positive Allen's sign. 
B) negative Allen's sign. 
C) positive Homan's sign. 
D) negative Homan's sign.

Question 8

Which of the following statements is true regarding the complete physical assessment?

Accepted Answer

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 exam for convenience. 
D) To promote consistency between patients,the examiner should not vary the order of the 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 exam for convenience. 
D) To promote consistency between patients,the examiner should not vary the order of the assessment.

Question 9

Which of the following is most appropriate to perform on a 9-month-old well child?

Accepted Answer

A) Testing for Ortolani's sign 
B) Assessment for stereognosis 
C) Blood pressure measurement 
D) Assessment for the presence of the startle reflex 
A) Testing for Ortolani's sign 
B) Assessment for stereognosis 
C) Blood pressure measurement 
D) Assessment for the presence of the startle reflex

Question 10

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:

Accepted Answer

A) lymphedema. 
B) Raynaud's disease. 
C) chronic arterial insufficiency. 
D) chronic venous insufficiency. 
A) lymphedema. 
B) Raynaud's disease. 
C) chronic arterial insufficiency. 
D) chronic venous insufficiency.

Question 11

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

Accepted Answer

A) EOMs. 
B) PERRLA. 
C) near vision. 
D) visual fields. 
A) EOMs. 
B) PERRLA. 
C) near vision. 
D) visual fields.

Question 12

A patient tells the nurse that "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:

Accepted Answer

A) orthopnea. 
B) acute emphysema. 
C) paroxysmal nocturnal dyspnea. 
D) acute shortness of breath episode. 
A) orthopnea. 
B) acute emphysema. 
C) paroxysmal nocturnal dyspnea. 
D) acute shortness of breath episode.

Question 13

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

Accepted Answer

A) tested the patellar reflex. 
B) assessed for appendicitis. 
C) tested the corneal light reflex. 
D) assessed for thrombophlebitis. 
A) tested the patellar reflex. 
B) assessed for appendicitis. 
C) tested the corneal light reflex. 
D) assessed for thrombophlebitis.

Question 14

Which of the following is included in assessment of General Appearance?

Accepted Answer

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

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:

Accepted Answer

A) occipital function is intact. 
B) cerebral function is intact. 
C) temporal function is intact. 
D) cerebellar function is intact. 
A) occipital function is intact. 
B) cerebral function is intact. 
C) temporal function is intact. 
D) cerebellar function is intact.

Question 16

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

Accepted Answer

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

Question 17

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

Accepted Answer

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." 
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."

Exam 27: The Complete Health Assessment: Putting It All Together

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

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

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

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

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

While the nurse palpates the maxillary sinuses,the patient tells the nurse that he has some tenderness in that area.The nurse should proceed by:

When the nurse flexes the patient's knee and gently compresses the gastrocnemius muscle anteriorly against the tibia,the patient indicates that he is having calf pain.The nurse would document:

Which of the following statements is true regarding the complete physical assessment?

Which of the following is most appropriate to perform on a 9-month-old well child?

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:

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

A patient tells the nurse that "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:

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

Which of the following is included in assessment of General Appearance?

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:

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

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

Critical Thinking in Health Assessment

Developmental Tasks and Health Promotion Across the Life Cycle

Cultural Competence: Cultural Care

The Interview

The Complete Health History

Mental Status Assessment

Domestic Violence Assessment

Assessment Techniques and the Clinical Setting

General Survey, measurement, vital Signs

Pain Assessment: the Fifth Vital Sign

Nutritional Assessment

Skin, hair, and Nails

Head, face, and Neck, including Regional Lymphatics

Eyes

Ears

Nose, mouth, and Throat

Breasts and Regional Lymphatics

Thorax and Lungs

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Musculoskeletal System

Neurologic System

Male Genitourinary System

Anus,rectum,and Prostate

Female Genitourinary System

Reassessment of the Hospitalized Adult

The Pregnant Female

Functional Assessment of the Older Adult

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