Deck 3: Health Assessment

Question 1

The nurse is caring for a client in chronic renal failure who is admitted to the hospital to begin peritoneal dialysis.Which manifestation would the nurse need to report to the health care provider immediately?

A)Urine output of 10 mL over the past 4 hours
B)Potassium level of 5.9 mg/dL
C)Edema of the ankles bilaterally with 1+ pitting
D)Slight rales in the base of the right lung

Answer 1

Potassium level of 5.9 mg/dL

Question 2

The nurse performing an assessment of the client's abdomen uses which of the four techniques of examination in order to collect data?

A)Inspection and auscultation
B)Inspection,auscultation,and palpation
C)Inspection,auscultation,palpation,and percussion
D)Auscultation,percussion,and inspection

Answer 2

Inspection,auscultation,palpation,and percussion

Question 3

The nurse is performing a health history,and the client relates a history of drug abuse,saying he has been drug free for 15 years.Which action by the nurse is the most appropriate?

A)Record this information under lifestyle.
B)Record this information under social data.
C)Do not record this information,because it is too old to be relevant.
D)Record this information under patterns of health care.

Answer 3

Record this information under lifestyle.

Question 4

The nurse is assessing an infant's nose and sinuses.Which tool will the nurse require to complete this exam?

A)A nasal speculum
B)A flashlight
C)A water-soluble lubricant
D)Tongue blades

Question 5

The nurse is assigned to accept a new admission expected from the emergency department.As the client is wheeled off the elevator,which action by the nurse is the most appropriate?

A)Waiting for the client to be placed in bed,then orienting the client to the unit
B)Accompanying the client and making introductions while assessing the client's mental status and appearance
C)Entering the client's room as soon as possible to obtain data for admission history
D)Asking the unlicensed assistive personnel to assist the client into bed

Question 6

The nurse is reading the client's medical history,and learns that the client has a history of alopecia,exophthalmos,and right leg paresthesia.When performing a thorough assessment,the nurse confirms that the client has which manifestations?

A)Hair loss,protruding eyes,and reduced sensation in the right leg
B)Facial hair,deeply sunken eyes,and an abnormal sensation in the right leg
C)Hair loss,exceptionally clear vision,and more sensation than normal in the right leg
D)Hair loss,protruding eyes,and an abnormal sensation in the right leg

Question 7

After completing a health assessment of the client,which information would the nurse need to document in the progress notes as opposed to on the assessment form?

A)Any findings that deviate from expected or normal findings
B)Detailed follow-up examination of findings that deviate from expected or normal findings
C)All findings of the health assessment
D)Nothing,because everything would be documented on the assessment form

Question 8

The nurse is examining the client's eyes and vision,and notes the client is unable to see items clearly that are close up.Which term will the nurse use when documenting this finding?

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

Question 9

The nurse is performing a head-to-toe assessment.Organize the areas that need to be assessed into the order in which the nurse would examine them.

A)Ears and eyes Response
B)General appearance Response
C)Respiratory and cardiac systems Response
D)Neurologic status Response
E)Abdomen and GI system

Question 10

Which assessment skills could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

A)Assessment of abdomen
B)Collection of nursing history
C)Assessment of client's allergies
D)Measurement of vital signs

Question 11

The nurse is assessing the client's cardiorespiratory system.Which tool will the nurse require to perform these examinations?

A)Stethoscope
B)Percussion hammer
C)Nasal speculum
D)Lubricant

Question 12

The nurse admits a client to the oncology unit diagnosed with metastatic breast cancer.Why does the nurse )the client about social history?

A)To determine the cause of breast cancer
B)To determine what type of support the client will have
C)To determine any habits that might interfere with treatment
D)To determine what health resources are available to the client

Question 13

Which client would normally have a rounded abdomen?

A)Infant
B)Toddler
C)School-age child
D)Adolescent
E)Older adult

Question 14

The nurse percusses a client's lung and hears a dull sound throughout the left lung.What does the nurse suspect based on this assessment finding?

A)Emphysema
B)Pneumothorax
C)Pneumonia
D)Hyperinflation of the lung

Question 15

Which action by the nurse is appropriate when examining an infant's neck?

A)Palpating the trachea
B)Positioning the infant upright on the parent's shoulder
C)Lifting the head and turning it from side to side while the infant is lying supine
D)Documenting the short neck as abnormal for development

Question 16

When examining an older adult client's sense of smell,which finding would the nurse anticipate?

A)Heightened sense of smell
B)Normal sense of smell
C)Diminished sense of smell
D)Development does not impact the sense of smell

Question 17

The unlicensed assistive personnel (UAP),a student nurse working as a certified nursing assistant,informs the nurse that the client is dyspneic,has crackles throughout the lung fields bilaterally,has an oxygen saturation of 94%,has a respiratory rate of 52,and is in respiratory distress.Which action by the nurse is the most appropriate?

A)Notify the health care provider.
B)Call the rapid response team.
C)Instruct the UAP to administer oxygen.
D)Assess the client.

Question 18

The nurse is performing an assessment of the skin.Which statements regarding this assessment are correct?

A)Assessment of the skin involves inspection,palpation,and auscultation.
B)Assessment of the skin involves using the sense of smell.
C)The nurse assesses the client for edema.
D)The nurse may assess the client's nails and hair while assessing the skin.
E)When assessing the skin,the nurse recognizes the effect of developmental stage on findings.

Question 19

Which item is not included in a health history?

A)Health promotion
B)Biographic data
C)Chief complaint
D)Patterns of health care

Question 20

Which definitions appropriately identify the four examination techniques used by nurses during the assessment process?

A)Palpation is visualizing,inspection is feeling or touching,percussion is hearing,and auscultation is tapping and listening.
B)Palpation is touching,inspection is feeling,percussion is tapping and listening,and auscultation is listening.
C)Palpation is touching,inspection is looking,percussion is tapping,and auscultation is listening.
D)Palpation is tapping and listening,inspection is listening,percussion is touching,and auscultation is smelling.

Question 21

The nurse is explaining to the client the need to do a more detailed assessment.This type of assessment involves obtaining which type of information?

A)Information regarding the client's overall assessment
B)Information of a specific medical condition
C)Information specific to the client's current condition
D)Information regarding past medical history

Question 22

The nurse is explaining to the student nurses the different heart sounds that are assessed during the cardiac assessment.Which statement made by a student indicates understanding of the expected normal heart sounds?

A)"If I hear the S1 as lub and S2 as dub,then that is normal and means that the valves are working."
B)" If I hear a 'lub-dub-ee' it means the client has a ventricular gallop."
C)"If I hear 'dee-lub-dub' then the client may have an atrial gallop.This occurs near the very end of diastole just before S1 and creates the sound."
D)"If I hear the 'dee-lub-dub' sound in an older adult,then I should know that is considered normal for the older client."

Question 23

The nurse is admitting an early-adolescent client.Which strategies would the nurse use when assessing the genitalia,anus,and inguinal area?

A)Maintain a very professional,matter-of-fact approach.
B)If possible,arrange for a nurse of the same sex as the client to perform the assessment.
C)Assess the areas only if necessary.
D)Provide a detailed explanation,and encourage the parents to be present during the exam.
E)Use of humor to relax the client.

Question 24

The nurse is explaining to the client that part of the assessment includes inspection.The nurse would know that the client understands inspection when the client makes which statement?

A)"So,you are going to listen to my heart."
B)"So,you will be touching my abdomen."
C)"So,you will be looking at my skin."
D)"So,you are going tap my abdomen."

Question 25

The nurse is observing a student nurse performing a respiratory assessment on a client.Which statement indicates that the student nurse is performing the assessment correctly?

A)The student nurse has the client in either a sitting or lying position.
B)The client is placed in a sitting position and uncovered to the waist.
C)The client is placed in a sitting position with gown and blanket.
D)The client is placed in the semi-Fowler's position with gown removed.

Question 26

The nurse is going to perform light palpation.Which statement regarding light palpation is true?

A)It is a gentle downward movement of the hand in a circular fashion.
B)It is done by using two hands to apply pressure.
C)It is only done by the health care provider.
D)It should cause the client pain.