Deck 16: Health Assessment and Physical Examination

Question 1

On examination of an 18-month-old child,the nurse found the right eardrum pink and bulging.How should a normal eardrum appear?

A) Pink
B) Red
C) Pearly gray
D) White

Answer 1

Pearly gray

Question 2

The nursing student is performing a physical examination on a 6-year-old patient who is being admitted to the pediatric unit with abdominal pain.When would be the most appropriate time in the examination to palpate the patient's abdomen?

A) Palpate tender areas last.
B) Palpate tender areas first to get it over.
C) Palpate tender areas before inspection.
D) Palpate before auscultation.

Answer 2

Palpate tender areas last.

Question 3

The patient recently had a cast applied to his left lower leg after a football injury in which he broke his tibia.After the application of the cast,the nurse felt the toes of his left and right feet.To assess circulation in the left foot,the nurse should do which of the following?

A) Use the tips of her fingers to assess temperature.
B) Expect that the temperature in the left leg will be lower than that in the right.
C) Expect that the temperature of the left foot to be the same as the right foot.
D) Expect that the left foot will be warmer than the left.

Answer 3

Expect that the temperature of the left foot to be the same as the right foot.

Question 4

A student nurse is helping admit a 77-year-old man to the surgical floor of an acute care hospital.The patient has an abdominal tumor that is scheduled to be removed.He has had nothing by mouth (NPO)since midnight in preparation for his surgery.The student nurse notes that the patient's skin is very dry and scaly.Which of the following should the student nurse investigate further as the most likely cause for the patient's dry skin?

A) Excess humidity in the patient's living environment
B) The use of excessive soap when bathing
C) Lack of sun exposure leading to decreased stimulation of sweat glands
D) Decreased levels of stress

Question 5

While auscultating a patient with pneumonia,a nurse hears low-pitched,rumbling coarse sounds during inspiration and expiration.These sounds can best be described as which of the following?

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

Question 6

An older adult patient complains of thirst,headache,and weight loss.The patient appears emaciated.On physical assessment the nurse finds that the patient's skin does not return to normal shape after being assessed.This finding is consistent with which of the following?

A) Pallor
B) Cyanosis
C) Erythema
D) Poor skin turgor

Question 7

The registered nurse is precepting a first-year nursing student.She is demonstrating how to appropriately auscultate.Auscultation is defined as which of the following?

A) Listening with a stethoscope to sounds produced by the body
B) Tapping the body with the fingertips to produce a vibration
C) Becoming familiar with the nature and source of body odors
D) Using the hands to touch body parts to make a sensitive assessment

Question 8

A nurse is preparing to perform a physical exam on a patient.She has found that it is best to perform the physical with a head-to-toe approach.Why is this important?

A) The head-to-toe format excludes unnecessary body systems.
B) It is a methodical way to include all body systems.
C) It reduces time by allowing examination of only one side.
D) It requires that painful procedures be done first.

Question 9

A registered nurse is preparing to perform a physical examination on a 5-year-old child.To make the child feel safer during the examination the nurse should do which of the following?

A) Examine the child's fingernails before listening to his breath sounds.
B) Question only the child so as to avoid unwanted parental influence.
C) Perform palpation before visual inspection.
D) Calls the parents by their first names to establish a more trusting bond.

Question 10

An RN is assessing an 87-year-old patient who has gone to the clinic to see the health care provider for a follow-up appointment.The nurse notes that the patient looks tired and has dark circles under her eyes.She assesses her skin turgor,which is poor.She is concerned because she knows that poor skin turgor can predispose the patient to which of the following?

A) Dehydration
B) Edema
C) Skin breakdown
D) Direct trauma

Question 11

The nurse is assessing an elderly patient and notices a significant drooping of the eyelid.The nurse recognizes this as which of the following?

A) Ectropion of the eyelid
B) Entropion of the eyelid
C) Impairment of the fourth cranial nerve
D) Ptosis of the eyelid

Question 12

A nurse is preparing to perform a physical examination on a patient who has mobility issues.In preparing for the examination,the nurse should do which of the following?

A) Be sure that a well-equipped examination room is available.
B) Tune the radio to the nurse's favorite station to relax the patient.
C) Perform thorough hand hygiene before preparing equipment.
D) Instruct the patient on the safest way to transfer onto the examination table.

Question 13

A 47-year-old patient is being treated for hyperthyroidism.When she goes to the health care provider for a check-up,the nurse in the clinic expects to see which of the following physical symptoms?

A) Exophthalmos
B) Strabismus
C) Photophobia
D) Diplopia

Question 14

A 17 year old was taken to the emergency department when his mother found him unresponsive.Upon examination,his pupils were found to be pinpoints.This is a common sign of which of the following?

A) Opioid intoxication
B) Arcus senilis
C) Cataracts
D) Opioid withdrawal

Question 15

The student nurse has been assigned to the pediatric unit for her clinical training this semester.She is assisting with the admission of a 5-month-old infant admitted with pneumonia.The student nurse is responsible for taking the child's vital signs and weighing and measuring the child.The infant's mother is very concerned when the student nurse tells her that the baby weighs 14 pounds.The mother states that the baby has lost a significant amount of weight because the previous week she weighed 16 pounds at home.What is the student nurse's best response to the mother's concern?

A) "To get an accurate weight, babies are weighed at different times of the day."
B) "Variations occur because we place our hand firmly on the child."
C) "Even if we use the same scale, the variation can be 1 to 2 pounds."
D) "Weight measurements can vary with different scales."

Question 16

An older adult African-American woman has gone to the clinic where a RN volunteers twice a week.She is a diabetic and has some skin breakdown on the calf of her right leg.Her skin is very darkly pigmented.To best examine the patient's skin,the nurse should use which of the following?

A) Halogen lighting
B) Artificial warming to increase room temperature
C) Natural sunlight
D) Air conditioning to lower room temperature

Question 17

A patient is being seen in the health clinic for abdominal pain.The nurse will be doing a physical assessment.After using light palpation to examine the patient,the nurse uses deep palpation.With deep palpation the nurse does which of the following?

A) Performs a completely safe method of examination
B) Should use two hands only
C) Uses the upper hand to exert an upward pressure
D) Can examine the condition of organs

Question 18

A nurse is admitting a 79-year-old woman with a fractured hip to the orthopedic unit.Her husband states that she broke her hip when she tripped in her garden.Upon examination,the nurse notes purple,green,and yellow bruises on the back and arms.The patient states that those were received when she fell.The nurse should do which of the following?

A) Ask the husband to wait in the waiting room.
B) Ignore the bruises because the patient has provided an explanation.
C) Realize that the patient may be abused, but that is a family issue.
D) Prepare to discharge the patient home once treatment is complete.

Question 19

A single mother with three school-age children has recently noticed that the second child has been scratching his head and complains that it itches.She asks the school nurse to examine him.The school nurse notes that the child has head lice.Which of the following is the best description of head lice?

A) Lice are easy to see and look like little white crabs.
B) Lice are difficult to see, but their eggs are small oval particles.
C) Lice and their eggs are on the hair shafts and look like dandruff.
D) Treatment for lice can wait until the entire family can be checked.

Question 20

The nurse is assessing an older adult who has smoked for the past 47 years and has been diagnosed with chronic obstructive pulmonary disease.Which of the following would the nurse expect to see upon physical examination of the patient?

A) Pallor and hardening of the nail bed
B) Jaundice in the nail bed
C) An angle greater than 160 degrees between the nail and nail bed
D) An angle less than 160 degrees between the nail and nail bed

Question 21

A nurse is meeting a patient for the first time.The importance of establishing baseline data is that it will enable the nurse to assess which of the following? (Select all that apply.)

A) Know the baseline information about the patient's health status.
B) Supplement, confirm, or refute information learned during the history taking.
C) Identify or confirm nursing diagnoses.
D) Assess the patient's understanding of the disease process.
E) Focus on a specific body system.

Question 22

A 45-year-old gay man who lives with a partner of 19 years recently has developed a persistent cough and night sweats from which he wakes up soaked.The nurse who is caring for the man should be most concerned about which of the following conditions?

A) Lung cancer
B) Tuberculosis
C) Orthopnea
D) Cardiopulmonary disease

Question 23

A nurse uses four basic skills during a physical assessment.While assessing the abdomen the nurse must begin with which of the following skills?

A) Light palpation
B) Inspection
C) Deep palpation
D) Auscultation

Question 24

Risk factors for breast cancer in women include which of the following? (Select all that apply.)

A) Age greater than 40
B) BRCA 1 and 2 gene mutations
C) Late onset menarche
D) Early menopause
E) Use of contraceptives

Question 25

A nurse inspects the thorax of an older adult patient who has chronic lung disease.An expected finding would be a(n):

A) round shape of the chest.
B) barrel-shaped chest.
C) AP diameter greater than the transverse diameter.
D) AP diameter less than the transverse diameter.

Question 26

A nurse is assisting with a female genitalia examination.The nurse will assist the patient to which position?

A) Supine
B) Lithotomy
C) Knee-chest
D) Dorsal recumbent

Question 27

At a point during the admission process of a young female patient,the nurse asks the patient about whether or not she performs self-breast examinations.The patient asks about the best time of the month to perform this examination.What is the best response?

A) "Usually the first day of your menstrual period is best."
B) "At the same time every month."
C) "If you're pregnant there is no need to do it."
D) "A few days after your menstrual period ends."

Question 28

The nurse is caring for a 22-year-old woman who has come in for a routine examination.The patient asks about how often she should perform breast self-examinations and get a mammogram.The nurse should inform the patient of which of the following?

A) Monthly breast self-examinations are optional for women in their twenties and thirties.
B) Women less than 40 need a clinical breast exam by a health care provider yearly.
C) Asymptomatic women need mammograms yearly until age 40.
D) Women greater than age 40 need mammograms every 6 months.

Question 29

A patient is admitted from the emergency department.The nurse notices that the patient and family are anxious.During the admission process the nurse should do which of the following? (Select all that apply.)

A) Continue with the examination even if the patient is anxious to get it done.
B) Disregard cultural differences to gather therapeutic data.
C) Provide a thorough explanation of the purpose of each assessment.
D) Provide a thorough explanation of the steps of each assessment.
E) Maintain a formal professional approach.

Question 30

A nurse can best auscultate the point of maximum impulse (PMI)in a teenager at the _____ intercostal space,_____ midclavicular line.

A) fifth; left
B) fourth; left
C) fifth; right
D) fourth; right

Question 31

A woman went to the public health clinic with a fever that had persisted for several days.Upon palpation of the neck,a registered nurse found several large lymph nodes.What is the nurse's best response to this patient upon palpating her lymph nodes?

A) "There is no need to worry; enlarged lymph nodes are normal findings."
B) "Lymph nodes are not really significant because they really have no function."
C) "Most people have a few enlarged lymph nodes."
D) "Enlarged lymph nodes sometimes indicate an infection."

Question 32

A patient is complaining of nonspecific abdominal pain.What is the technique the nurse uses to assess tenderness?

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

Question 33

An adolescent is examined and told that she has a sexually transmitted disease (STI).The patient is shocked and states,"How can that be.I would know if I had a problem down there wouldn't I?" What is the most appropriate response by the nurse?

A) "You should have known. It's pretty hard to miss."
B) "Usually STIs show up within 2 to 3 days of exposure."
C) "If you'd like, we can teach you some self-examination techniques."
D) "It's just bad luck. We'll clear this up and that will be the end of it."