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

Question 1

A patient is unable to shrug her shoulders against the nurse's resistant hands.What cranial nerve is involved with successful shoulder shrugging?

A) VII
B) IX
C) XI
D) XII

Answer 1

XI

Question 2

When assessing the neonate,the nurse should test for hip stability with which method?

A) Eliciting the Moro reflex
B) Performing the Romberg's test
C) Checking for the Ortolani's sign
D) Assessing the stepping reflex

Answer 2

Checking for the Ortolani's sign

Question 3

Which of these statements is true regarding the complete physical 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 examination.
D) To promote consistency between patients, the examiner should not vary the order of the assessment.

Answer 3

The patient should be in the sitting position for examination of the head and neck.

Question 4

The nurse is performing a vision examination.Which of these charts is most widely used for vision examinations?

A) Snellen
B) Shetllen
C) Smoollen
D) Schwellon

Question 5

Which of these statements is true regarding the recording of data from the history and physical examination?

A) Use long, descriptive sentences to document findings.
B) Record the data as soon as possible after the interview and physical examination.
C) If the information is not documented, then it can be assumed that it was done as a standard of care.
D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient.

Question 6

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

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

Question 7

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) I
B) V
C) XI
D) XII

Question 8

During inspection of a patient's face,the nurse notices that the facial features are symmetric.This finding indicates that which cranial nerve is intact?

A) VII
B) IX
C) XI
D) XII

Question 9

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

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

Question 10

Which of these is included in assessment of general appearance?

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

Question 11

A 5-year old child is in the clinic for a checkup.The nurse would expect him to:

A) have to be held on his mother's lap.
B) be able to sit on the examination table.
C) be able to stand on the floor for the examination.
D) be able to remain alone in the examination room.

Question 12

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 ____ function is intact.

A) occipital
B) cerebral
C) temporal
D) cerebellar

Question 13

During a complete health assessment,how would the nurse test the patient's hearing?

A) By observing how the patient participates in normal conversation
B) Using the whispered voice test
C) Using the Weber and Rinne tests
D) Testing with an audiometer

Question 14

The nurse should wear gloves for which of these examinations?

A) Measuring vital signs
B) Palpation of the sinuses
C) Palpation of the mouth and tongue
D) Inspection of the eye with an ophthalmoscope

Question 15

The nurse should use which location for eliciting deep tendon reflexes?

A) Achilles
B) Femoral
C) Scapular
D) Abdominal

Question 16

An 85-year-old man has come in for a physical examination,and the nurse notices that he uses a cane.When documenting general appearance,the nurse should document this information under the section that covers:

A) posture.
B) mobility.
C) mood and affect.
D) physical deformity.

Question 17

The nurse has just completed an examination of a patient's extraocular muscles.When documenting the findings,the nurse should document the assessment of which cranial nerves?

A) II, III, VI
B) II, IV, V
C) III, IV, V
D) III, IV, VI

Question 18

A patient states,"Whenever I open my mouth real wide,I feel this popping sensation in front of my ears." To further examine this,the nurse would:

A) place the stethoscope over the temporomandibular joint and listen for bruits.
B) place the hands over his ears and ask him to open his mouth "really wide."
C) place one hand on his forehead and the other on his jaw and ask him to try to open his mouth.
D) place a finger on his temporomandibular joint and ask him to open and close his mouth.

Question 19

A patient's uvula rises midline when she says "ahh" and she has a positive gag reflex.The nurse has just tested which cranial nerves?

A) IX, X
B) IX, XII
C) X, XII
D) XI, XII

Question 20

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

A) extraocular eye muscles (EOMs).
B) pupils (PERRLA).
C) near vision.
D) visual fields.

Question 21

During the examination of a patient's mouth,the nurse observes a nodular bony ridge down the middle of the hard palate.The nurse would chart this finding as:

A) cheilosis.
B) leukoplakia.
C) ankyloglossia.
D) torus palatinus.

Question 22

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

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

Question 23

While examining a 48-year-old patient's eyes,the nurse notices that he had to move the handheld vision screener farther away from his face.The nurse would suspect:

A) myopia.
B) omniopia.
C) hyperopia.
D) presbyopia.

Question 24

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:

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

Question 25

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:

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

Question 26

The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles.This finding indicates:

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

Question 27

During an examination,the patient tells the nurse that she sometimes feels as if objects are spinning around her.The nurse would document that she occasionally experiences:

A) vertigo.
B) tinnitus.
C) syncope.
D) dizziness.

Question 28

During the examination of a patient,the nurse notices that the patient has several small,flat macules on the posterior portion of her thorax.These macules are less than 1 cm wide.Another name for these macules is:

A) warts.
B) bullae.
C) freckles.
D) papules.

Question 29

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

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

Question 30

The nurse is documenting the assessment of an infant.During the abdominal assessment,the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side.This finding would indicate:

A) epigastric hernia.
B) pyloric obstruction.
C) hypoactive bowel sounds.
D) hyperactive bowel sounds.

Question 31

For the abdominal assessment,place these assessment techniques in the correct order,with A being performed first and E being performed last.

A)Deep palpation, all quadrants
B)Light palpation, all quadrants
C)Auscultate bowel sounds
D)Inspect abdomen for contour, skin characteristics, and pulsations
E)Percuss all quadrants

Question 32

During an examination,the nurse notices that a patient's legs turn white when they are raised above the patient's head.The nurse should suspect:

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

Question 33

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 should document _____ sign.

A) positive Allen's
B) negative Allen's
C) positive Homans'
D) negative Homans'

Question 34

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

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."

Question 35

While recording in a patient's medical record,the nurse notices that a patient's Hematest results are positive.This means that there:

A) are crystals in his urine.
B) are parasites in his stool.
C) is occult blood in his stool.
D) are bacteria in his sputum.

Question 36

The nurse has just recorded a positive obturator test on a patient who has abdominal pain.This test is used to confirm a(n):

A) inflamed liver.
B) perforated spleen.
C) perforated appendix.
D) enlarged gallbladder.

Question 37

Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup?

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

Question 38

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

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

Question 39

During examination,the nurse finds that a patient is unable to distinguish objects placed in his hand.The nurse would document:

A) stereognosis.
B) astereognosis.
C) graphesthesia.
D) agraphesthesia.

Question 40

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

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