Deck 22: Assessing Health Status

Question 1

It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

A) admission to the unit.
B) discharge.
C) the beginning of each shift.
D) the patient's wakening in the morning.

Answer 1

the beginning of each shift.

Question 2

The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurse's best reply is:

A) "You stand 50 feet away from the chart while I test each of your eyes."
B) "I will be testing your vision with your reading glasses on."
C) "You stand 20 feet away from the chart while I test each of your eyes."
D) "The number beside the largest print read is your visual acuity score."

Answer 2

"You stand 20 feet away from the chart while I test each of your eyes."

Question 3

The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of:

A) 7.
B) 10.
C) 12.
D) 15.

Answer 3

15.

Question 4

The nurse taking a blood pressure should:

A) place the arm so that the brachial artery is at waist level.
B) position the patient so that the arm is level with the shoulder.
C) request that the patient put feet flat on the floor.
D) chat with the patient to reduce any anxiety in the patient.

Question 5

When the heart is assessed for the point of maximal impulse (PMI), the stethoscope should be placed on the:

A) fifth intercostal space, left midclavicular line.
B) fifth intercostal space, left anterior axillary line.
C) second intercostal space, right midclavicular line.
D) fourth intercostal space, left lateral sternal border.

Question 6

A nurse caring for a patient on bed rest with a history of respiratory health problems should:

A) monitor for skin turgor every shift.
B) monitor peripheral pulses once a shift.
C) auscultate lung sounds at the beginning of a shift.
D) auscultate for bowel sounds once a shift.

Question 7

When performing deep palpation, the nurse should:

A) use one hand and exert pressure to depress tissue about one half to three fourths of an inch.
B) use either one or two hands to depress the tissue about 1 inch.
C) use either one or two hands to depress the tissue about 1.5 to 2 inches.
D) use two hands and exert pressure to depress the tissue about 3 to 4 inches.

Question 8

A nurse records absence of bowel sounds after assessing the abdomen:

A) in the two lower quadrants for 2 minutes each.
B) in the two upper quadrants for 5 minutes.
C) in all quadrants for 3 minutes each.
D) in each quadrant for 1 minute.

Question 9

Prior to preparing a female patient for a pelvic examination, the nurse should:

A) encourage her to void in the bathroom.
B) provide a pillow for the head and the hips.
C) hand the patient a sheet and allow her to drape herself.
D) cleanse the external genitalia with soap and water.

Question 10

When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:

A) consensual reflex
B) brisk reflex.
C) accommodation.
D) dilation reflex.

Question 11

An 8-year-old patient is due for height measurement during a routine examination. For an accurate measurement to be obtained, the child should be asked to stand:

A) with back toward the rod and the feet 6 inches apart.
B) with back toward the rod and the feet centered together.
C) with front toward the rod and the feet 8 inches apart.
D) with front toward the rod and the feet 4 inches apart.

Question 12

The nurse weighing an infant in an outpatient clinic should:

A) place a towel on the scale prior to weighing the baby.
B) place the baby in a prone position on the scale to reduce the infant's movement.
C) keep one hand hovering over the infant during the weighing procedure.
D) rest a hand lightly on the infant's abdomen during weighing to prevent a fall.

Question 13

To correctly determine the strength of a patient's lower extremities during a neurological examination, the nurse asks the patient to:

A) wiggle the toes of both feet at the same time.
B) push against his hand with the sole of one foot and then the other.
C) pull both feet up at the same time to stretch the Achilles tendons.
D) stand up independently.

Question 14

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

A) bell of the stethoscope directly on the patient's skin.
B) bell of the stethoscope on top of the patient's gown.
C) diaphragm of the stethoscope directly on the patient's skin.
D) diaphragm of the stethoscope on top of the patient's gown.

Question 15

The nurse lightly palpates the abdomen of a patient during a physical examination. On palpation to the right side of the abdomen, the patient cries out and draws the knees to the chest. The nurse should:

A) discontinue the examination and report findings to the primary care provider.
B) palpate the abdominal skin 1.5 to 2 inches to determine the cause of pain.
C) continue the examination and have the patient take deep breaths.
D) proceed to percuss the abdomen with a quick snap of the wrist.

Question 16

The nurse assessing a patient's capillary refill finds that it took 5 seconds for the color to return. The most appropriate intervention to do following this assessment is to:

A) assess the radial pulse and the blood pressure.
B) document the results as normal.
C) repeat the assessment.
D) notify the charge nurse.

Question 17

The nurse is aware that the best way to assess dependent pitting edema in a patient with congestive heart failure is to:

A) measure the circumference of the ankles daily.
B) inquire whether the patient's shoes fit tightly.
C) auscultate lung sounds every shift.
D) press fingers into the tissue over the tibia, just above the ankle.

Question 18

To the breath sounds of a patient correctly, the nurse should:

A) inspect the chest wall for characteristics of movements and respirations.
B) use a stethoscope and properly position the earpieces and diaphragm.
C) percuss the chest by quickly tapping on the chest wall surface to produce sounds.
D) touch the chest wall and note the texture, temperature, and moisture of the skin.

Question 19

During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

A) repeat the questions at the end of the visit to cross check for accuracy of data.
B) reassure the patient that forgetfulness is a normal part of the aging process.
C) gather information from a family member accompanying the patient.
D) omit the interview and proceed to a physical examination.

Question 20

To perform the Weber test, the tuning fork is struck and placed:

A) at the nape of the neck.
B) in the middle of the bridge of the nose.
C) behind the right and then the left ear.
D) in the middle of the forehead or skull.

Question 21

A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?

A) "When I shine a light into the patient's eyes, the pupils should constrict."
B) "When I shine a light into the patient's eyes, the pupils should dilate."
C) "It is normal for the pupils to react sluggishly to light."
D) "Pupil checks should be performed with the room lights on."

Question 22

A female patient of Asian descent was admitted to the medical-surgical unit with possible lung cancer. A male nurse is preparing to perform a physical assessment. It is best for the male nurse to:

A) ask the family members to leave the room to ensure patient privacy.
B) perform the procedure accurately and quickly to lessen patient anxiety.
C) examine only the affected body systems to decrease patient discomfort.
D) ask the patient for permission to perform the assessment before starting.

Question 23

The nurse who is assessing a patient for heart sounds anticipates that the S₂ sound (the "dub" sound") can be heard best at the ________ area.

Question 24

The nurse notes that a patient has an exaggerated lumbar curve. This is indicative of __________.

Question 25

The nurse is assessing a patient's heart sounds and hears a "swish" that is recorded as a ___________.

Question 26

Percussion is a technique by which the nurse can assess sounds relative to the underlying structures that indicate the presence of: (Select all that apply.)

A) air.
B) infection.
C) fluid.
D) the inflammatory process.
E) a solid organ.

Question 27

A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

A) monitor intake and output.
B) auscultate lung and abdominal sounds.
C) check for verbal and motor response.
D) monitor daily weight.

Question 28

The nurse is assessing a patient's lung sounds and hears a wheeze in the lower left lobe. This wheeze is categorized as a(n) ______________ sound.

Question 29

When the nurse asks the neurologically impaired patient to follow the motion of the nurse's fingers, the patient's eyes track the fingers with jerky movements, which should be documented as ______________________.

Question 30

The nurse is aware that the most accurate quick method to check hydration status in the older adult is to evaluate the moisture of the ______.

Question 31

When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)

A) Difficulty in swallowing
B) Persistent cough
C) Hyperactive bowel sounds
D) Vesicular breath sounds
E) Changes in pulse rate
F) Obvious change in a mole

Question 32

The nurse uses the technique of inspection to initially assess: (Select all that apply.)

A) skin tone.
B) skin turgor.
C) body contours.
D) color.
E) characteristics of movement.

Question 33

Before starting the initial morning care or the physical assessment of the patient, the first intervention the nurse would perform would be:

A) putting down the side rails.
B) washing his or her hands.
C) placing the bed at working height.
D) turning on the overhead light.

Question 34

The nurse takes special care in the draping of a patient in the lithotomy position in order to diminish ____________________________.

Question 35

Prior to assessing a patient's blood pressure in both arms, the nurse will instruct the patient to lie down for at least __________ minutes.

Question 36

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a:

A) psychological history.
B) financial history.
C) cultural assessment.
D) literacy assessment.