Deck 28: Health Assessment

Question 1

Which of the following neurological assessment findings would be considered normal for a 4-year-old child?

A)Balance on one foot for 5 seconds
B)Heel-toe walk backward
C)Heel-toe walk forward
D)Presence of a stepping reflex

Answer 1

Balance on one foot for 5 seconds

Question 2

Mrs.Rein,43,is in the clinic for her annual physical exam.She is considered average risk for breast cancer.Based on the latest evidence published by the Canadian Cancer Society,what health teaching would the nurse offer to her regarding breast cancer screening?

A)No routine screening or mammogram necessary at this time
B)Annual clinical breast exam until the age of 50
C)Continue with self breast exam until 45 then annual mammogram
D)Every other year mammogram until the age of 69

Answer 2

No routine screening or mammogram necessary at this time

Question 3

The nurse is preparing a client for an abdominal examination.Which of the following should be performed before the examination?

A)Ask client to urinate
B)Ask client to drink 8 ounces of water
C)Instruct the client to relax
D)Ask the client to lie prone on the examination bed

Answer 3

Ask client to urinate

Question 4

The nurse is assessing a female's breasts.The nurse finds both breasts rounded,slightly unequal in size,skin smooth and intact,and nipples without discharge.What is the nurse's next action?

A)Notify the charge nurse
B)Notify the physician
C)Document the findings as normal
D)Document the findings as abnormal

Question 5

The Canadian Cancer Society has identified which population as at-risk for developing prostate cancer?

A)Males over the age of 40 years
B)Males having a history of working with asbestos
C)Older males with a history of smoking
D)Males over 65 with a family history

Question 6

The nurse is preparing to perform a health assessment of the abdomen.Which of the following is the correct order to perform the assessment?

A)Auscultate,percuss,palpate,inspect
B)Inspect,auscultate,palpate,percuss
C)Inspect,auscultate,percuss,palpate
D)Palpate,percuss,auscultate,inspect

Question 7

Which of the following data would be noted during the general survey?

A)Skin turgor
B)Absent pedal pulse
C)Lung crackles
D)Dyspnea

Question 8

The nurse is preparing to conduct a cardiovascular assessment of a 5-year-old.Which of the following heart sounds would be considered normal?

A)S3
B)Bruit
C)Thrill
D)Click

Question 9

What considerations should the nurse take when completing a physical exam on an elderly female client?

A)Have her spouse present during the examination
B)Speak slower and louder than usual
C)Allow extra time for the client to answer questions
D)Do not require her to remove her clothes

Question 10

The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye.The nurse would document this as which of the following?

A)Cyanosis
B)Jaundice
C)Pallor
D)Erythema

Question 11

Which of the following assessment techniques would be used to determine the size and shape of internal organs by establishing their borders?

A)Inspection
B)Palpation
C)Percussion
D)Auscultation

Question 12

Maya is a 16-year-old that presents to the clinic with what appears to be a herpes simplex viral infection.She presents with a small (< .5 cm)round fluid filled translucent mass on her upper lip.What is the correct term the nurse would use when documenting this mass?

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

Question 13

The nurse is preparing to perform an eye assessment.To facilitate an organized examination,which of the following equipment will the nurse need to gather prior to starting the exam?

A)Penlight
B)Seldman's chart
C)Sterile gloves
D)Pachymeter

Question 14

The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease.Which of the following should the nurse record as an abnormal finding?

A)Pulses equal bilaterally
B)Dorsalis pedis pulse palpable with absent popliteal
C)Thready pulses
D)Pulses only palpable with a doppler

Question 15

While performing a health assessment,in which position should the nurse place the client for inspection of the jugular veins?

A)90-degree angle
B)30- to 45-degree angle
C)15-degree angle
D)60-degree angle

Question 16

Mrs.Beacon,78 years old,presents to the emergency department.The RN completes the general survey and finds that the client has a productive cough,is short of breath,and febrile.Which of the following questions asked while taking the health history would elicit the most meaningful response from Mrs.Beacon?

A)What caused you to come to the hospital today?
B)Has anyone in your family ever had pneumonia?
C)How would you describe your health up to today?
D)Does anyone in your family have a breathing problem?

Question 17

Mr.Cruz is at the physicians' office for his annual physical.When assessing his chest,the nurse notes that the ratio of anteroposterior to transverse diameter of his chest is 1:1.Which of the following terms would the nurse use to describe this condition?

A)Normal
B)Scoliosis
C)Barrel chest
D)Pigeon chest

Question 18

The nurse is performing a lung assessment on a client with suspected pneumonia.Which of the following assessments should the nurse report to the physician immediately?

A)Presence of mydriasis
B)Breath sounds equal bilaterally
C)Asymmetric chest expansion
D)Bilateral vocal fremitus

Question 19

While completing a physical examination,the nurse positions a female patient supine during palpation of the breasts.What information should the nurse provide for the patient regarding the positioning?

A)Your breast exam will be less painful when you are lying down.
B)It is easier to feel the breast tissue when you are lying on your back.
C)The examination will take a few minutes and you will be more comfortable lying down.
D)Breast abnormalities are easier to visualize with the client in the supine position.

Question 20

Josh is a 5-year-old coming in to the clinic for his preschool physical.Which of the following considerations would the RN implement before beginning his assessment?

A)Allow Josh to touch some of the equipment used for his exam
B)Ask his mother to leave while he is being examined
C)Ask his mother to hold him for the examination
D)Instruct him to leave his clothes on for the examination

Question 21

The nurse is caring for a client following a cerebrovascular accident (CVA).While the client is able to follow simple directions,he is experiencing difficulty communicating verbally to the nurse.What term does the nurse use to document this?

A)Disorientation
B)Glasgow coma scale of 7
C)Sensory aphasia
D)Expressive aphasia

Question 22

The Glasgow coma scale is used to determine which of the following?

A)Vision
B)Motor strength
C)Verbal response
D)Orientation

Question 23

The nurse should expect the adult male testicle to have which of the following characteristics when palpated?

A)2 cm by 4 cm,texture rubbery and smooth
B)1 cm by 3 cm,texture soft with smooth curvature
C)2 cm by 2 cm,texture soft with an uneven but smooth shape
D)2 cm by 4 cm,may be asymmetrical in shape if the examination area is cold

Question 24

Which cranial nerve is being tested when the nurse asks the client to clench his teeth?

A)Facial
B)Hypoglossal
C)Trigeminal
D)Trochlear

Question 25

When performing a vaginal examination,what is the usual required position for the patient?

A)Sims
B)Prone
C)Lithotomy
D)Trendelenburg

Question 26

Which of the following tests would be part of a screening for cervical cancer?

A)Rectal exam
B)Tanner staging
C)Papanicolaou (Pap)test
D)Vaginal digital exam

Question 27

What equipment should the nurse gather to prepare to assess a client's reflexes?

A)Penlight
B)Clean gloves
C)Sterile gloves
D)Percussion hammer

Question 28

A 14-month-old child has been walking for two months.Which assessment finding is within normal expectations?

A)Asymmetry of the legs
B)Pronation and "toeing in"
C)Asymmetrical gluteal folds
D)Dorsiflexion of one or both feet