Deck 30: Health Assessment and Physical Examination

Question 1

A nurse is a preceptor for a nurse who just graduated from nursing school.When caring for a patient,the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment.Which of the following statements made by the new graduate nurse requires the preceptor to intervene?

A) "I will use the information from my assessment to figure out if your antihypertensive medication is working effectively."
B) "Nursing assessment data are used only to provide information about the effectiveness of your medical care."
C) "Nurses use data from their patient's physical assessment to determine a patient's educational needs."
D) "Information gained from physical assessment helps nurses better understand their patients' emotional needs."

Answer 1

"Nursing assessment data are used only to provide information about the effectiveness of your medical care."

Question 2

A male student comes to the college health clinic.He hesitantly describes that his testis has lumps.The nurse recognizes this as a potential sign of which of the following?

A) Inguinal hernia
B) Sexually transmitted infection
C) Testicular cancer
D) Diuretic use

Answer 2

Testicular cancer

Question 3

On admission,a patient weighs 250 pounds.The weight is recorded as 256 pounds on the second inpatient day.The nurse should evaluate the patient for

A) Fluid retention.
B) Fluid loss.
C) Decreased nutritional reserves.
D) Anorexia.

Answer 3

Fluid retention.

Question 4

A head and neck physical examination is completed on a 50-year-old female patient.All physical findings are normal except for fine brittle hair.Based on the physical findings,which of the following laboratory tests would the nurse expect to be ordered?

A) Liver function test
B) Lead level
C) Thyroid-stimulating hormone test
D) Complete blood count

Question 5

An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old American woman of Chinese descent.Which of the following nursing actions does the nurse do first?

A) Place the patient in the lithotomy position.
B) Drape the patient to enhance patient comfort.
C) Assess the patient's feelings and explain the purpose of the examination.
D) Ask the patient if she would like her mother to be present in the room during the examination.

Question 6

During a school physical examination,the nurse reviews the patient's current medical history.With a positive medical history of asthma,eczema,and allergic rhinitis,the nurse expects which physical finding on nasal examination?

A) Polyp
B) Yellow discharge
C) Pale nasal mucosa
D) Puffiness of nasal mucosa

Question 7

A nurse identifies Pediculosis humananus capitis.Considering the possible complications of treatment,the nurse knows to not use which of the following treatment products?

A) Fine-toothed comb
B) Pediculicide
C) Lindane-based shampoo
D) Vinegar hair rinse

Question 8

During an annual gynecological examination,a college student discusses her upcoming college break at a tropical location.After the student receives an oral contraceptive prescription,the nurse identifies the importance of skin cancer prevention education by discussing which evidence-based prevention health topic?

A) Applying water-based sunscreen only before swimming
B) Using tanning bed daily for 7 days before college break trip
C) Applying broad-spectrum sunscreen of SPF 5
D) Taking extra precautions in the sun secondary to the prescription

Question 9

Which is the best examination position for a complete geriatric physical examination on a weak patient with bilateral basilar pneumonia?

A) Prone position
B) Sims' position
C) Supine position
D) Lateral recumbent

Question 10

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student.When privately asked about how the injury occurred,the student described falling on the playground.Upon suspecting abuse,the school nurse's best next action is which of the following?

A) Interviewing the patient in the presence of his/her teacher
B) Ignoring the findings because child abuse is a declining problem
C) Realizing that abuse victims usually report abusive situations
D) Contacting Social Services and reporting suspected abuse

Question 11

A parent calls the school nurse with questions regarding the recent school vision screening.Snellen chart examination revealed 20/60 for both eyes.Considering the visual acuity results,the nurse informs the parent that the child

A) Should have an optometric examination.
B) Is suffering from strabismus.
C) May have presbyopia.
D) Has vision issues most likely due to cataracts.

Question 12

The nurse is urgently called to the gymnasium regarding an injured student.The student is crying in severe pain with a malformed fractured lower leg.The proper sequence for the nurse's initial assessment is

A) Deep palpation, light palpation, inspection.
B) Light palpation, deep palpation, inspection.
C) Inspection, light palpation.
D) Auscultation, deep palpation, light palpation.

Question 13

The patient is a 50-year-old African American male who has come in for his routine annual physical.Which of the following preventive screenings does the nurse recommend?

A) Digital rectal examination of the prostate (DRE) annually
B) Ca125 blood test once a year
C) Complete eye examination every year
D) Colonoscopy every 3 years

Question 14

During a routine pediatric history and physical,the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual.They state that the infant was yellow when born,and that he developed an infection that required "every antibiotic under the sun" to cure him.Considering the neonatal history,the nurse determines that it is especially important to perform a focused _____ examination.

A) Cardiac
B) Respiratory
C) Ophthalmic
D) Hearing acuity

Question 15

Having misplaced his stethoscope,a nurse borrows a colleague's stethoscope.He next enters the patient's room and identifies himself,washes his hands with soap,and states the purpose of his visit.He performs proper identification of the patient before he auscultates her lungs.Which critical health assessment step was not performed?

A) Running warm water over stethoscope for patient comfort
B) Cleaning stethoscope with Betadine
C) Using alcohol-based hand disinfectant
D) Cleaning stethoscope with alcohol

Question 16

During a sexually transmitted illness presentation to high school students,the nurse recommends the HPV vaccine series to prevent

A) Cervical cancer.
B) Genital lesions.
C) Vaginal discharge.
D) Swollen perianal tissues.

Question 17

A febrile preschool-aged child presents to the after-hours clinic.Varicella is diagnosed on the basis of the illness history and the presence of small,circumscribed skin lesions filled with serous fluid.The nurse documents the varicellar lesions as which type of skin lesion?

A) Vesicle
B) Wheal
C) Papule
D) Pustule

Question 18

An elderly patient is being seen for a chronic entropion.The nurse realizes that entropion places the patient at risk for which of the following?

A) Ectropion
B) Infection
C) Exophthalmos
D) Strabismus

Question 19

The nurse is caring for a female victim of rape.To perform the proper evaluation,the nurse should place the patient in which of the following positions?

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

Question 20

Objective physical data describe air moving through small airways over the lung's periphery.The expected inspiratory-to-expiratory phase of this normal vesicular breath sound is which of the following?

A) The inspiratory phase lasts exactly as long as the expiratory phase.
B) The expiration phase is longer than the inspiration phase.
C) The expiration phase is two times longer than the inspiration phase.
D) The inspiratory phase is three times longer than the expiratory phase.

Question 21

During a genitourinary examination of a 30-year-old male patient,the nurse identifies a small amount of a white,thick substance on the patient's uncircumcised glans penis.The nurse's next step is to

A) Notify his provider about a suspected STI.
B) Recognize this as a normal finding.
C) Tell the patient to avoid doing self-examinations until symptoms clear.
D) Avoid embarrassing questions about sexual activity.

Question 22

A nurse is assessing a patient's hearing.Which of the following items does the nurse gather before conducting the assessment?

A) Tuning fork
B) Ophthalmoscope
C) Cotton-tipped applicator
D) Current list of medications
E) Snellen chart

Question 23

The best term for breath sounds created by air moving through large lung airways is

A) Bronchovesicular.
B) Rhonchi.
C) Bronchial.
D) Vesicular.

Question 24

An elderly patient has been on high doses of antibiotics and is experiencing a sudden loss of hearing.The nurse should contact the health care provider and

A) Stop antibiotic use until the physician responds.
B) Tell the patient that older patients often lose low-frequency hearing.
C) Explain that hearing loss usually occurs with thinning of the eardrum.
D) Assure the patient that rapid hearing loss is normal in the elderly.

Question 25

In preparation for a rectal examination of a nonambulatory male patient,the patient is informed of the need to be placed in which position?

A) Sims' position
B) Forward bending with flexed hips
C) Knee-chest
D) Dorsal recumbent

Question 26

A teen female patient reports intermittent abdominal pain for 12 hours.No dysuria is present.When performing an abdominal assessment,the nurse should

A) Recommend that the patient take more laxatives.
B) Ask the patient about the color of her stools.
C) Avoid sexual references such as possible pregnancy.
D) Assess first the spots that are most tender.

Question 27

During a routine physical examination of a 70-year-old patient,a blowing sound is auscultated over the carotid artery.The nurse notifies the medical provider of the unexpected physical finding known as

A) Clubbing.
B) Bruit.
C) Right-sided heart failure.
D) Phlebitis.

Question 28

The school nurse is assessing the tympanic membranes of a 3-year-old child.Which of the following demonstrates proper technique?

A) Using an inverted otoscope grip while pulling the auricle downward
B) Pulling the auricle upward and backward
C) Holding the handle of the otoscope between the thumb and index finger while the child lies on the weight scale
D) Using an inverted otoscope grip while pulling the auricle upward

Question 29

The nurse considers several new female patients to receive additional health education on the need for more frequent Pap smears and gynecological examinations.Which of the following assessment findings reveals the patient at highest risk for cervical cancer and thus having the greatest need for patient education?

A) Nonsmoker, 13 years old, not sexually active
B) Social smoker, 15 years old, celibate
C) 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners
D) 50 years old, stopped smoking 30 years ago, history of hysterectomy

Question 30

During a preschool readiness examination,the nurse prepares to perform visual acuity screenings.Given the children's age,the best equipment to test central vision is which of the following?

A) Snellen test
B) E chart
C) Reading test
D) Penlight

Question 31

A teen patient is tearful and reports locating lumps in her breasts.Other history obtained is that she is currently menstruating.Physical examination reveals soft and movable cysts in both breasts that are painful to palpation.The nurse also notes that the patient's nipples are erect,but the areolae are wrinkled.The next nursing step is which of the following?

A) Reassure patient that her symptoms are normal.
B) Consult a breast surgeon because of the abnormal nipples and areolae.
C) Discuss fibrocystic disease as the likely cause.
D) Tell the patient that the symptoms may get worse when her period ends.

Question 32

The advanced practice nurse is conducting a comprehensive eye examination on an 80-year-old African American woman.Which of the following findings requires the nurse to contact the patient's physician for further examination?

A) A thin white ring along the margin of the iris
B) A black pupil
C) Dilated pupils
D) A black fundus of the eye

Question 33

The patient presents to the clinic with dysuria and hematuria.How does the nurse proceed to assess for kidney inflammation?

A) Lightly palpates each abdominal quadrant
B) Inspects abdomen for abnormal movement or shadows using indirect lighting
C) Uses deep palpation posteriorly
D) Percusses posteriorly the costovertebral angle at the scapular line

Question 34

While assessing the skin of an 82-year-old male patient,a nurse discovers nonpainful ruby red papules on the patient's trunk.What is the nurse's next action?

A) Explain that the patient has basal cell carcinoma and should watch for spread.
B) Document cherry angiomas as a normal geriatric skin finding.
C) Tell the patient that he has a benign squamous cell carcinoma.
D) Document the presence of edema.

Question 35

Asking an adult what the statement "A stitch in time saves nine" means to him is a mental status examination technique used to assess

A) Knowledge.
B) Long-term memory.
C) Abstract thinking.
D) Recent memory.

Question 36

The patient is a 54-year-old male with a medium frame.He weighs 148 pounds and is 5 feet 8 inches tall.The nurse realizes that this patient is

A) Overweight.
B) Underweight.
C) At his desired weight.
D) Obese.

Question 37

A patient in the emergency department is complaining of left lower abdominal pain.The comprehensive abdominal examination would include,in proper order,which of the following?

A) Inspection, palpation, auscultation
B) Percussion, inspection, auscultation
C) Inspection, palpation, percussion
D) Inspection, auscultation, palpation

Question 38

The paramedics transport an adult involved in a motor vehicle accident to the emergency department.On physical examination,the patient's level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli.The nurse correctly identifies the patient's Glasgow Coma Scale score as

A) 5.
B) 7.
C) 9.
D) 11.

Question 39

A nurse suspects an abnormal thyroid shape during the physical examination.The nurse offers the patient a glass of water and observes her drinking to

A) Visualize an enlarged thyroid gland.
B) Evaluate for exostosis.
C) Test the patient's gag reflex.
D) Visualize the uvula and soft palate.

Question 40

The patient has had a stroke that has affected her ability to speak,and she becomes extremely frustrated when she tries to speak.She responds correctly to questions and instructions but cannot form words coherently.This patient is showing signs of _____ aphasia.

A) Expressive
B) Receptive
C) Sensory
D) Combination