Deck 22: Health Assessment

Question 1

The nurse is concerned that an African American client is experiencing cyanosis.Which of the following signs of cyanosis would the nurse look for in this client?

A) The presence of excess interstitial fluid with a decreased elasticity or fullness of the skin
B) A bluish tinge in the skin, tongue, and mucous membranes that does not blanch when pressure is applied
C) A redness and a variety of rashes over the entire body
D) An absence of underlying red tones in the skin most readily seen in the buccal mucosa

Answer 1

A bluish tinge in the skin, tongue, and mucous membranes that does not blanch when pressure is applied

Question 2

A 48-year-old patient comes to the physician's office complaining of diminished near vision,which the nurse confirms with testing.She should document this finding as:

A) Myopia
B) Diplopia
C) Presbyopia
D) Mydriasis

Answer 2

Presbyopia

Question 3

While the nurse assesses a newborn of African American descent,the mother points out a blue-black Mongolian spot on the newborn's back and asks,"What's that? Is something wrong with my baby?" Which response by the nurse is best?

A) "I'll ask the physician to look at the spot."
B) "Those spots are quite common and typically fade with time."
C) "You may want a plastic surgeon to look at that."
D) "That spot is benign so it's nothing you need to worry about."

Answer 3

"Those spots are quite common and typically fade with time."

Question 4

A female patient has excessive facial hair.The nurse should document this finding as:

A) Alopecia
B) Albinism
C) Hirsutism
D) Lanugo

Question 5

Which abnormal laboratory value is associated with an icteric sclera?

A) Bleeding time
B) Bilirubin
C) Hemoglobin
D) Glucose

Question 6

Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse.This finding is associated with:

A) Low albumin levels
B) Zinc deficiency
C) Renal disease
D) Bacterial endocarditis

Question 7

The nurse assesses a 4-year-old child's vision as 20/40.This finding is considered:

A) Myopia
B) Hyperopia
C) Normal
D) Presbyopia

Question 8

Which test should the patient undergo when the Weber test is positive?

A) Romberg test
B) Rinne test
C) Pure tone audiometry
D) Tympanometry

Question 9

An older adult comes to the clinic complaining of pain in the left foot.While assessing the patient,the nurse notes smooth,shiny skin that contains no hair on the client's lower legs.Which condition does this finding suggest?

A) Venous insufficiency
B) Hyperthyroidism
C) Arterial insufficiency
D) Dehydration

Question 10

A mother brings her 6-month-old infant to the clinic for a well-baby checkup.How should the nurse proceed when weighing the patient?

A) Have the mother remain outside the room.
B) Ask the mother to remove the infant's clothing and diaper.
C) Weigh the infant with the diaper only.
D) Place the infant supine on the scale with his knees extended.

Question 11

A 6-week-old infant is brought to the pediatrician's office for a well-baby checkup.The nurse notes a flattening of the skull.Flattening of the skull in the infant might suggest:

A) The baby has been lying in the same position for several hours a day
B) A disorder associated with excessive growth hormone
C) An accumulation of excessive cerebrospinal fluid
D) Temporomandibular joint syndrome

Question 12

The nurse notes ptosis in a patient who just arrived in the emergency department.The nurse quickly triages the patient because she knows that this finding,along with other symptoms,might suggest:

A) Hyperthyroidism
B) Stroke
C) Glaucoma
D) Macular degeneration

Question 13

A client has noticed a decrease in taste sensation.Which of the following cranial nerves are most likely involved?

A) CN V and CN VII
B) CN VII and CN IX
C) CN V and CN VIII
D) CN VI and CN X

Question 14

Which of the following is an abnormal capillary refill finding that the nurse should report?

A) 1 second
B) 2 seconds
C) 3 seconds
D) 4 seconds

Question 15

Which of the following is a correct developmental outcome for an infant? The infant's anterior fontanel (soft spot)typically fuses:

A) At about 8 weeks
B) At about 14 months
C) By 6 months of age
D) Before 1 year of age

Question 16

Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea?

A) Edema
B) Hyperhidrosis
C) Pallor
D) Tenting

Question 17

Which statement best describes the procedure used to assess capillary refill?

A) Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color.
B) Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction.
C) Tap on the skin with short strokes from your fingers.
D) Lift a fold of skin, and allow it to return to its normal position.

Question 18

When testing near vision,the nurse should position printed text how many inches away from the patient?

A) 20
B) 18
C) 16
D) 14

Question 19

The left pupil of a patient fails to accommodate.This finding may reflect an abnormality in which cranial nerve?

A) CN III
B) CN V
C) CN VIII
D) CN X

Question 20

Which portion of the ear is responsible for maintaining equilibrium?

A) External ear
B) Inner ear
C) Middle ear
D) Ossicles

Question 21

The nurse is performing an otoscopic examination on an adult patient.She has the patient tilt his head to the side not being examined and looks into the ear canal to make sure a foreign body is not present.Which step should she perform next?

A) Straighten the ear canal by pulling the helix up and back.
B) Insert the speculum into the ear canal slowly.
C) Test the mobility of the tympanic membrane.
D) Straighten the ear canal by pulling the helix down and back.

Question 22

Which assessment should the nurse perform if she notes a palpable thyroid gland?

A) Illuminate the thyroid gland for the presence of fluid.
B) Auscultate the thyroid gland for bruits.
C) Percuss the thyroid gland for mass size.
D) Measure the thyroid gland to assess change.

Question 23

Based on developmental stage,how should the nurse modify the comprehensive physical examination of an older adult?

A) Work rapidly to finish as quickly as possible.
B) Sequence the examination to limit position changes.
C) Demonstrate equipment before using it.
D) Omit portions of the examination that may be tiring.

Question 24

Bronchovesicular breath sounds are best heard over which area?

A) Midline over the trachea just below the larynx
B) Fourth intercostal space, in the midclavicular line
C) First and second intercostal spaces next to the sternum
D) At the base of the lungs near the diaphragm

Question 25

The nurse is bathing a newborn infant in the nursery and notices scaly white patches over the infant's scalp.What is the most appropriate action by the nurse?

A) Wash the scalp and apply gentle scrubbing.
B) Notify the primary care provider.
C) Obtain a CT (computed tomography) scan of the infant's head.
D) Assess for patches on the infant's lower torso.

Question 26

An 85-year-old patient is brought to the emergency department with lethargy and hypotension.When the nurse assesses the patient's tongue,she notes that it appears dry and furry.This finding suggests:

A) Fungal infection
B) Dehydration
C) Allergy
D) Iron deficiency

Question 27

High-pitched breath sounds produced by airway narrowing are known as:

A) Rales
B) Crackles
C) Rhonchi
D) Wheezing

Question 28

A father brings his 18-month-old child to the pediatric clinic for a well-baby checkup.The father tells the nurse that he is concerned because his child's legs are bowed.Which response by the nurse is appropriate?

A) "Your child will most likely require physical therapy."
B) "You should consider having your child seen by an orthopedic surgeon."
C) "This is a normal finding in children for 1 year after they begin walking."
D) "Your child is walking fine, so you don't need to worry."

Question 29

Which assessment question helps assess immediate memory?

A) "How did you get to the hospital today?"
B) "Can you repeat the numbers 2, 7, 9 for me?"
C) "Do you Knowledge the three items I mentioned earlier?"
D) "What was your birth date including the year?"

Question 30

Abdominal palpation should be avoided in a child who has which disorder?

A) Appendicitis
B) Wilms' tumor
C) Crohn's disease
D) Small bowel obstruction

Question 31

A patient's jugular venous pressure measures 5 cm.This finding indicates:

A) A normal finding
B) Hypovolemia
C) Heart failure
D) Dehydration

Question 32

The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward his knee.The nurse observes active motion against some,but not against full,resistance.How should the nurse document this finding?

A) 5: Normal
B) 4: Slight weakness
C) 3: Weakness
D) 2: Poor ROM

Question 33

The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube for intermittent suction.How should the nurse proceed when performing an abdominal assessment on this patient?

A) Avoid palpating the patient's abdomen.
B) Turn off the suction before auscultating bowel sounds.
C) Listen for bowel sounds for 2 minutes in each quadrant.
D) Percuss the abdomen before auscultating bowel sounds.

Question 34

Assuming that all are accurate,which documentation about a patient's level of consciousness is best?

A) Patient is lethargic and slept when undisturbed.
B) Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped.
C) Patient slept throughout the day, missing his meals and bath.
D) Patient appears to be tired as he slept throughout the day except when bathed.

Question 35

The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude.This documentation indicates that the patient's pulses are:

A) Bounding
B) Normal
C) Full
D) Diminished

Question 36

The nurse asks the patient to spread his fingers and then bring them together again.Which of the following is the nurse testing when asking him to bring his fingers together?

A) Abduction
B) Adduction
C) Flexion
D) Extension

Question 37

While palpating the anterior chest,the nurse notes crackling in the skin around the patient's chest tube insertion site.The nurse recognizes this finding is:

A) Tactile fremitus
B) Egophony
C) Bronchophony
D) Crepitus

Question 38

The nurse notes an S₃ heart sound while performing an assessment on a patient admitted with an acute myocardial infarction.The nurse notifies the physician of the finding,which most likely suggests:

A) Heart failure
B) Coronary artery disease
C) Hypertension
D) Pulmonic stenosis

Question 39

An adult admitted to the hospital after a stroke does not respond to verbal stimuli.What should the nurse do next to try to provoke a response?

A) Apply pressure to the mandible at the jaw.
B) Rub the patient's sternum.
C) Squeeze the trapezius muscle.
D) Gently shake the patient's shoulder.

Question 40

The nurse notes a small pulsation at the fifth intercostal space midclavicular line.This should be documented as a:

A) Thrill
B) Murmur
C) Normal finding
D) Heave

Question 41

The mother of a 1-month-old infant states to the examining nurse,"There is something wrong with my baby's eyes.She seems to be cross-eyed." What is the most appropriate response by the nurse?

A) "I will need to perform a thorough eye examination."
B) "This is not uncommon in infants in their first 2 months of life."
C) "Please try not to overreact. You are new parents and there is much for you to learn."
D) "I will report your concerns to the pediatrician."

Question 42

Which of the following statements describe the proper technique for auscultating heart sounds? Select all that apply.

A) Auscultate in an orderly fashion starting at the aortic area and proceeding to pulmonic, tricuspid, and mitral areas.
B) Listen for S1 first in all landmark areas, then proceed to listening for S2 in all landmark areas.
C) Use the diaphragm of the stethoscope for normal sounds the bell of the stethoscope to detect any extra sounds.
D) Rotate the starting point of landmarks at each patient assessment to detect any changes.

Question 43

The nurse has completed an external genitalia examination on several female clients in the women's health clinic.Which of the following clients would require an internal genital examination? Select all that apply.

A) Client on hormone therapy
B) Client who has had more than three pregnancies
C) A client with an abnormal finding on the external examination
D) A 22-year-old client who is not sexually active

Question 44

An older adult's fingernails appear concave and spoon shaped.The nurse associates this observation with:

A) Normal finding in older adults
B) Chronic lung disease
C) An iron deficiency
D) Chronic heart disease

Question 45

When performing a skin assessment,the nurse notices a mole on the patient's upper back.What are the appropriate actions by the nurse in further investigation of the mole? Select all that apply.

A) Ask the patient about any new moles or changes in moles.
B) Do not alarm the patient by asking questions about the mole.
C) Measure the mole's diameter and elevation.
D) Assess for any exudate on or around the mole.

Question 46

The nurse is planning a breast examination class for a group of women at a community health fair.In planning the class,what is most important for the nurse to consider in preparation for her class?

A) Patients who perform breast self-examinations should be trained in proper technique to avoid false-negative findings.
B) Breast examinations should be performed yearly for all women over the age of 25 years.
C) Research indicates that breast examination and mammography are not needed after the age of 70 years.
D) A breast examination that includes assessment of the breast and axillae is indicated only if the patient is at high risk for breast cancer.

Question 47

Which of the following statements are true of common neurological changes in older adults? Select all that apply.

A) Older adults have a slower reaction and a decreased ability for rapid problem-solving.
B) With advanced age, the number of functioning neurons decreases.
C) Neurological deficits may be attributed to medications or medication interactions.
D) With normal aging, long-term memory and the ability to discriminate decrease.

Question 48

The nurse on a medical unit notes a moderate amount of fluid accumulation in the feet and ankles of a 75-year-old patient.The nurse will further assess this patient for indications of which conditions? Select all that apply.

A) Kidney disease
B) Heart failure
C) Thyroid disease
D) Common age-related changes

Question 49

The nurse is performing a vision examination.In assessing for color blindness,the nurse applies which knowledge? Select all that apply.

A) It may be genetically inherited.
B) It is more common in males.
C) It may be the result of macular degeneration.
D) It may be the result of a lens defect of the eye.

Question 50

The nurse is performing a comprehensive health assessment on several clients in the community clinic.Which clients are most at risk for developing hemorrhoids? Select all that apply.

A) A client with a history of constipation
B) A client with a history of prostate cancer
C) A woman who has had four children
D) Clients older than 65 years

Question 51

The nurse is assessing the level of consciousness of a client who suffered a head injury.She uses the Glasgow Coma Scale and determines that the client's score is 15.Which responses did the nurse assess in this client? Select all that apply.

A) Spontaneous eye opening
B) Tachypnea, bradycardia, and hypotension
C) Unequal pupil size
D) Orientation to person, place, and time
E) Motor response to pain localized

Question 52

The nurse is working in an outpatient clinic in her community.Late in the afternoon,three clients come in with suspected pediculosis.Which of the following assessments will the nurse perform?

A) Integumentary assessment for head lice
B) Oral assessment for bad breath and caries
C) Musculoskeletal assessment for spine alignment
D) Lower extremity assessment for athlete's foot

Question 53

Which of the following statements describe the nurse's general survey? Select all that apply.

A) Consists of an overall impression of the patient
B) Assists in identifying deviations that need further exploration
C) Includes obtaining a full set of vital signs
D) Includes the comprehensive physical assessment

Question 54

The nursing student is performing an otoscopic examination on her patient.In assessing the tympanic membrane,the student assesses for what normal findings in appearance? Select all that apply.

A) Light red
B) Pearly gray
C) Shiny
D) Translucent

Question 55

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday.Which finding(s)require(s)further assessment? Select all that apply.

A) Blood pressure 110/64 mm Hg
B) Pulse rate 118 beats/min
C) Respiratory rate 35 breaths/min
D) Oral temperature 98.6°F (37°C)

Question 56

Which of the following principles apply when performing a focused assessment of the abdomen? Select all that apply.

A) Ask the patient to empty his bladder prior to the assessment.
B) Follow the assessment sequence of inspection, palpation, percussion, and auscultation.
C) Position the patient in supine position with knees slightly flexed.
D) Begin palpating with light pressure to detect surface characteristics and move to deep palpation.

Question 57

Which disorder(s)might limit a patient's visual field? Select all that apply.

A) Diabetes
B) Advanced glaucoma
C) Peripheral vascular disease
D) Cataracts