Deck 16: Health Assessment and Physical Examination

Question 1

The nurse is caring for a patient who has a dangerously low platelet count.Which assessment finding will the nurse expect to note during physical examination of the patient?

A) Bright yellow jaundice in the sclera of the patient's eyes
B) Pinpoint red spots on the skin of the patient's torso
C) Dry,flaky skin with evidence of frequent scratching
D) Thick indurated skin across the patient's back

Answer 1

Pinpoint red spots on the skin of the patient's torso

Question 2

Which term will the nurse use to document the patient's drooping right eyelid?

A) Ectropion
B) Esotropia
C) Photophobia
D) Ptosis

Answer 2

Ptosis

Question 3

The patient comes to the hospital with a variety of symptoms.Which symptom will the nurse assess first?

A) The patient experiences joint stiffness after sitting still for long periods of time.
B) The patient developed an itchy rash after taking the second dose of antibiotics.
C) The patient is nauseated and vomited a small amount earlier this morning.
D) The patient feels short of breath and has audible expiratory wheezes.

Answer 3

The patient feels short of breath and has audible expiratory wheezes.

Question 4

The nurse notes that the patient has bilateral entropion.What will the nurse plan to do as a result of this assessment finding?

A) Instruct the patient to rinse the mouth gently with warm saline solution.
B) Clean the patient's eyelids gently and apply antibiotic ointment.
C) Place a wedge pillow between the patient's legs to prevent crossing at the hip.
D) Elevate the head of the patient's bed and administer supplemental oxygen.

Question 5

The mother of a small infant is surprised when the clinic scale indicates a 1-pound weight gain from the scale used that morning at home.What is the appropriate response of the nurse?

A) "Babies have significantly different weights throughout the day."
B) “Variations occur because of the weight of the baby’s clothing.”
C) “Weight variation of 1 to 2 pounds is common for most scales.”
D) “Weight measurements can vary with different scales.”

Question 6

Which assessment finding will the nurse expect to note during physical examination of the patient with a cast on the lower left leg?

A) The patient's left foot has a musty,fetid smell
B) The patient's left foot has 3+ pitting edema and pallor.
C) The temperature of the left foot is the same as the right foot.
D) The patient's left foot is cool with thin,shiny skin.

Question 7

Which question is best suited for determining the patient's chief complaint?

A) "What brings you to the hospital today?"
B) "How long have you been having chest pain?"
C) "Did your doctor tell you to come to the hospital?"
D) "Have you ever experienced this problem before?"

Question 8

Which technique will the nurse use to facilitate the history and physical examination of a small child?

A) Examine the child's hands and feet before listening to breath sounds.
B) Direct assessment questions to the child to avoid unwanted parental influence.
C) Gently palpate the child's abdomen before auscultating for bowel sounds.
D) Call the parents by their first names to establish a more trusting bond.

Question 9

The nurse is conducting a health history for a patient who does not speak English.What is the best action of the nurse?

A) Communicate with the patient using simple gestures and drawings.
B) Arrange for a medical translator to be present during the health history interview.
C) Ask an English-speaking family member to translate the nurse's questions.
D) Obtain the patient's health history from an English-speaking family member.

Question 10

Which assessment finding is expected for a patient presenting with a middle ear infection?

A) The right tympanic membrane is pink and bulging.
B) The patient becomes dizzy when sitting upright.
C) The pinna is red,swollen,and tender to palpation.
D) The eardrum is a translucent pearly gray color.

Question 11

The patient's pupils are the size of tiny pinpoints.Which factor could lead to this assessment finding?

A) The patient has been taking high doses of steroids.
B) The patient suffered massive head trauma and is brain dead.
C) The patient injected heroin intravenously 1 hour ago.
D) The patient has developed acute narrow angle glaucoma.

Question 12

The nurse is caring for a dehydrated,confused patient whose breath smells like fruity bubble gum.What is the priority action of the nurse based on these assessment findings?

A) Check the patient's pulse oximetry.
B) Check the patient's oral mucosa for thrush.
C) Check the patient's blood sugar.
D) Check the patient's sclerae for jaundice.

Question 13

Why does the nurse utilize a head-to-toe approach when performing physical examinations of patients?

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 14

The patient has red,itchy eyes with thick yellow drainage.What will the nurse plan to do as a result of this assessment finding?

A) Apply antibiotic eyedrops and use alcohol-based hand sanitizer before and after caring for the patient.
B) Assess the patient's visual fields and compare results from each of the patient's eyes.
C) Ask the patient about any history of hyperthyroid disease,hypertension,or Addison's disease.
D) Instruct the patient not to pluck or wax the eyebrows until the eye infection symptoms have resolved completely.

Question 15

The patient is brought in after collapsing outside on a very hot day.Which assessment finding will the nurse expect to note during physical examination of the patient?

A) Pallor of the patient's extremities
B) Cyanosis of the patient's nail beds and lips
C) Dry mucus membranes and poor skin turgor
D) Lower extremity edema and a generalized itchy rash

Question 16

Which assessment finding will the nurse expect to note during physical examination of the patient with a history of uncontrolled hyperthyroid disease?

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

Question 17

Which intervention will facilitate the physical examination of a patient with mobility issues?

A) Be sure that the head of the examination table may be elevated for the patient's comfort.
B) Tune the radio to the nurse's favorite station as a relaxation intervention for the patient.
C) Make sure that the patient has sufficient space and assistance to transfer onto the examination table.
D) Instruct the patient on the safest way to transfer onto the examination table.

Question 18

How can the nurse most accurately assess the skin tone for an older adult African American patient with deeply pigmented skin?

A) Utilize fluorescent lighting.
B) Turn up the heat in the room.
C) Utilize natural sunlight.
D) Turn down the temperature in the room.

Question 19

The nurse is assessing a patient with suspicious bruises.Which action is most appropriate to facilitate an accurate account of the patient's injuries?

A) Ask the patient's family member to wait outside 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) Provide referrals for health counseling once the assessment is complete.

Question 20

While auscultating a patient with pneumonia,a nurse hears low-pitched,rumbling coarse sounds during inspiration and expiration.Which term will the nurse use to document this assessment finding?

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

Question 21

When is the best time for a male patient to perform a testicular self-assessment?

A) Before getting out of bed in the morning
B) After having a bowel movement
C) After getting out of a hot tub
D) Immediately following ejaculation

Question 22

Which assessment finding is expected for a patient who may have a lower extremity deep vein thrombosis (DVT)?

A) Deep burning pain in the extremity that worsens with walking and exercise
B) Weak pedal pulses and an absence of hair on the affected extremity
C) Calf pain when the knee is flexed slightly and the foot is pointed downward
D) Numbness and tingling of the extremity with hyperreactive reflexes

Question 23

Which assessment findings lead the nurse to conclude that the patient has had chronic obstructive pulmonary disease (COPD)for many years?

A) The patient's nails have a clubbed shape.
B) The patient has splinter hemorrhages under the nails.
C) The patient's chest appears rounded and bulging.
D) The patient is short of breath with minimal activity.
E) The patient has soft,spongy gums that bleed easily.

Question 24

The patient has been smoking 2 packs of cigarettes for the last 15 years.How will the nurse chart the patient's tobacco use history in pack-years?

A) 7.5 pack-years
B) 17 pack-years
C) 30 pack-years
D) 35 pack-years

Question 25

Which technique can the nurse use to facilitate assessment of the thyroid gland?

A) Have the patient tip the head back and cough twice.
B) Watch the patient's neck when sipping water from a straw.
C) Have the patient slowly turn the head from side to side.
D) Gently palpate from underneath the jaw to behind the ear.

Question 26

Which assessment findings lead the nurse to suspect that the patient has a history of alcohol abuse?

A) The patient has prominent tiny blood vessels running across the face.
B) The patient's skin is abnormally dry and flaky,especially on the legs.
C) The patient's nails have splinter hemorrhages along the nail bed.
D) The patient's breath smells faintly of fruity chewing gum.

Question 27

Which technique will the nurse use to assess the patient's olfactory nerve?

A) Ask to shrug the shoulders and turn the head against the nurse's hand.
B) Ask the patient to identify the smell of peppermint oil and orange peel.
C) Ask the patient to read the smallest set of letters on a Snellen eye chart.
D) Ask the patient to stick out the tongue and move it side to side from midline.

Question 28

The nurse is caring for a patient who develops slurred speech with right-sided facial drooping.The patient is also unable to make a fist with the right hand.What is the priority action of the nurse?

A) Place a cool washcloth on the patient's forehead and turn down the lights.
B) Obtain an order from the provider for a consultation with a speech therapist.
C) Feed the patient by placing the food on the unaffected side of the mouth.
D) Immediately obtain vital signs and notify the hospital's acute stroke team.

Question 29

The nurse hears a blowing sound when auscultating the patient's carotid artery.What is the appropriate action of the nurse?

A) Notify the health care provider immediately as the patient may be having a stroke.
B) Gently feel over the patient's carotid artery to check for a faint vibration.
C) Massage the patient's carotid artery to determine if the blowing sound subsides.
D) Palpate the patient's carotid pulse while the patient's neck is hyperextended.

Question 30

Which characteristics helped promote the development of the patient's tortuous varicose veins

A) Smoking 2 packs of cigarettes daily for the last 15 years
B) Frequently sitting with the legs crossed
C) Taking naproxen sodium daily for arthritis pain
D) Standing for long periods of time at work
E) Eating a gluten-free,low-sodium diet for the last 10 years

Question 31

The patient becomes acutely short of breath when lying flat in bed.Which term will the nurse use to document this assessment finding?

A) Orthopnea
B) Atelectasis
C) Emphysema
D) Stridor

Question 32

The nurse notes that the patient has hyperactive bowel sounds in all four quadrants of the abdomen.Which factor from the patient's history will account for this assessment finding?

A) The patient has had gastroenteritis for the last 4 days with watery diarrhea.
B) The patient takes iron supplements daily to treat chronic anemia..
C) The patient has a paralytic ileus after undergoing abdominal surgery.
D) The patient takes ibuprofen 3 times daily for arthritis pain.

Question 33

Which question will the nurse ask the patient to assess abstract thinking ability?

A) "Can you tell me the color of the blanket on your bed?"
B) "Can you tell me what you ate for breakfast this morning?"
C) "Can you tell me about what it was like to grow up in your neighborhood?"
D) "What do I mean when I say that something costs an arm and a leg?"

Question 34

The patient has cloudy yellow urine with a faint odor of ammonia.Which laboratory test will the nurse expect to note in the patient's admission orders?

A) Serum albumin and pre-albumin
B) Serum calcium and magnesium levels
C) Fasting blood sugar every morning
D) Urine sample for culture and sensitivity

Question 35

Which factor in the female patient's history places her at higher risk for the development of breast cancer?

A) The patient's first period started at age 10.
B) The patient has three children under the age of 12.
C) The patient used condoms exclusively for contraception.
D) The patient's breasts are tender before each period.

Question 36

The patient presents with fever for the last few days,sore throat,and enlarged lymph nodes under the jaw.What is the appropriate response of the nurse when the patient asks about the cause of the enlarged lymph nodes?

A) "Enlarged lymph nodes are associated with hypertensive heart disease."
B) "You probably have a blockage in the thoracic lymph duct."
C) "You should probably see an oncologist to rule out lymphedema."
D) "They are most likely enlarged as a result of the throat infection."

Question 37

The nurse is caring for a patient who was pulled unconscious from the pool after a near drowning.Which lung sounds will the nurse expect to hear upon auscultation?

A) Moist crackles
B) Expiratory wheezes
C) Friction rub
D) Coarse rhonchi

Question 38

Which test can the nurse use to assess the patient's balance?

A) Have the patient reach out to touch the nurse's finger then the patient's nose.
B) Have the patient track the nurse's finger as it moves through the field of vision.
C) Have the patient stand with feet together,arms out,and eyes closed.
D) Have the patient run the heel of the foot along the shin of the other leg.

Question 39

The patient can follow directions but cannot pronounce words to express needs or thoughts.Which term will the nurse use to document this assessment finding?

A) Expressive aphasia
B) Receptive aphasia
C) Primary dysphagia
D) Vocal dysphagia

Question 40

The nurse hears a distinctive swooshing sound with each heartbeat when auscultating the patient's heart sounds.What is the cause of this assessment finding?

A) The mitral valve is leaking and some blood leaks backward with each heartbeat.
B) The nurse's stethoscope is not placed firmly enough against the patient's skin.
C) The patient's tricuspid valve was replaced with a mechanical prosthetic valve.
D) The patient is having short runs of premature supraventricular contractions.

Question 41

Which positions may be used to perform a rectal examination on the patient?

A) Sim's
B) Supine
C) Lithotomy
D) Lateral recumbent
E) Dorsal recumbent

Question 42

Which assessment findings show that the patient has a history of chronic arterial insufficiency in the legs?

A) The nurse must use a Doppler to find the patient's pedal pulses.
B) The patient has calf pain when the knee is flexed and foot pointed downward.
C) The patient's legs are cool to the touch and show no hair growth.
D) The patient has 3+ pitting pedal edema extending up to the knees.
E) The patient has tortuous varicose veins from the hip to the ankle.