Deck 30: Health Assessment Preview As Pdf

Question 1

The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease.Which finding should the nurse report to the physician immediately?

A)Pulses equal bilaterally
B)Full pulsations
C)Thready pulses
D)Pulses present bilaterally

Answer 1

Thready pulses

Question 2

The nurse is preparing to administer a cardiotonic drug to a client.Which assessment should the nurse perform before administering the medication?

A)Respiratory rate
B)Apical pulse
C)Popliteal pulse
D)Capillary blanch test

Answer 2

Apical pulse

Question 3

The nurse is caring for a client following a cerebrovascular accident (stroke).The client is able to comprehend what is being said to him;however,he is unable to respond by speech or writing.What type of aphasia should the nurse realize this patient is demonstrating?

A)Auditory aphasia
B)Acoustic aphasia
C)Sensory aphasia
D)Expressive aphasia

Answer 3

Expressive aphasia

Question 4

The nurse is preparing for morning rounds.What should the nurse avoid delegating to unlicensed assistive personnel?

A)Vital signs
B)Filling of water pitchers
C)Skull and face assessment
D)Ambulation of surgical clients

Question 5

The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke.When testing for muscle grip strength,the nurse should ask the client to perform which action?

A)Grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out.
B)Hold an arm up and resist while the nurse tries to push it down.
C)Flex each arm and then try to extend it against the nurse's attempt to keep the arm in flexion.
D)Shrug the shoulders against the resistance of the nurse's hands.

Question 6

While performing a health assessment,in which position should the nurse place the client for inspection of the jugular veins?

A)90-degree angle
B)30- to 45-degree angle
C)15-degree angle
D)60-degree angle

Question 7

The nurse is preparing a client for an abdominal examination.What should the nurse done before beginning the examination?

A)Ask the client to urinate.
B)Ask the client to drink 8 ounces of water.
C)Assess vital signs.
D)Assess heart rate.

Question 8

The nurse is utilizing the technique of inspection during a physical examination with a client.When using this technique,the nurse will take which actions?
Standard Text: Select all that apply.

A)Visually observe a body area.
B)Obtain information through the sense of smell.
C)Obtain information through the sense of hearing.
D)Examine the body through the use of touch.
E)Strike the body to elicit a sound from a body part.

Question 9

The nurse is preparing to complete a physical examination on a client.What should the nurse realize as being the purpose for this examination?
Standard Text: Select all that apply.

A)Obtain baseline data.
B)Obtain data to help determine nursing diagnoses.
C)Identify areas for disease prevention.
D)Identify the client's employment status.
E)Obtain data about the client's leisure activities.

Question 10

The nurse is preparing to conduct a mental status assessment.What should the nurse include in this assessment?

A)Cognitive and affective functions
B)Cognitive and effective functions
C)Affective and memory functions
D)Affective and knowledge functions

Question 11

A client has been receiving a new medication to address specific symptoms.The nurse will perform a physical examination to determine
Standard Text: Select all that apply.

A)the progress of the client's health problem.
B)the physiological impact of the prescribed medication.
C)baseline data.
D)data to support nursing diagnoses.
E)areas for health promotion.

Question 12

During the assessment of a client's breasts,the nurse finds both breasts rounded,slightly unequal in size,skin smooth and intact,and nipples without discharge.What should the nurse do next?

A)Notify the charge nurse.
B)Notify the physician.
C)Document the findings in the nurse's notes as normal.
D)Document the findings in the nurse's notes as abnormal.

Question 13

The nurse is preparing the morning assignments.Which assessment could the nurse delegate to unlicensed assistive personnel?

A)Neurological assessment
B)Musculoskeletal assessment
C)Vital signs assessment
D)Female genital assessment

Question 14

The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer.What should the nurse expect the health care provider to perform?

A)Pap test
B)Breast exam
C)Rectal exam
D)Abdominal exam

Question 15

The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye.The nurse should document this as being

A)cyanosis.
B)jaundice.
C)pallor.
D)erythema.

Question 16

The nurse is planning to perform indirect percussion on an area of a client's body during a physical examination.Which actions should the nurse take to use this assessment technique?
Standard Text: Select all that apply.

A)Place the middle finger of the nondominant hand on the client's skin.
B)Use the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand.
C)Perform a striking motion by moving the wrist.
D)Perform short,rapid,firm blows.
E)Use a stethoscope to transmit sounds to the ears.

Question 17

The nurse is performing a lung assessment on a client with suspected pneumonia.Which finding should the nurse report to the physician immediately?

A)Chest symmetrical
B)Breath sounds equal bilaterally
C)Asymmetrical chest expansion
D)Bilateral symmetric vocal fremitus

Question 18

The nurse is preparing to perform a health assessment of the abdomen.In which order should the nurse perform the assessment?

A)Auscultate,percuss,palpate,inspect
B)Inspect,auscultate,palpate,percuss
C)Inspect,auscultate,percuss,palpate
D)Palpate,percuss,auscultate,inspect

Question 19

The nurse is preparing to assess a client's reflexes.What equipment should the nurse gather before entering the room?

A)Sterile gloves
B)Clean gloves
C)Percussion hammer
D)Penlight

Question 20

While performing an assessment of the integument system,the nurse notes the client's eyeballs are protruding and the upper eyelids are elevated.What term should the nurse use to document this finding?

A)Erythema
B)Cyanosis
C)Exophthalmos
D)Normocephalic

Question 21

The nurse is planning a physical examination of a client following a head-to-toe format.In which order should the nurse conduct this assessment?

A)Head,upper extremities,abdomen,lower extremities
B)Neck,head,vital signs,chest and back
C)Lower extremities,abdomen,upper extremities,chest and back
D)Head,neck,lower extremities,abdomen

Question 22

The nurse is concerned that an older client has nutritional deficiencies.What did the nurse find when assessing this client's nails to make this clinical decision?
Standard Text: Select all that apply.

A)White spots
B)Curved nails
C)Deep purple areas
D)Spoon-shaped nails
E)Bands across the nails

Question 23

The nurse is preparing to assess a client with the Glasgow Coma Scale.Which areas is the nurse assessing in this patient?
Standard Text: Select all that apply.

A)Eye response
B)Motor response
C)Verbal response
D)Orientation
E)Musculoskeletal response

Question 24

The nurse is assessing the musculoskeletal status of a 4-year-old child.What findings should the nurse consider as being expected in this client?
Standard Text: Select all that apply.

A)Lordosis
B)Genu valgus
C)Genu varum
D)Pronation of the feet
E)Asymmetric leg abduction

Question 25

The nurse is preparing to perform an eye assessment.What equipment should the nurse have available to complete this assessment?
Standard Text: Select all that apply.

A)Penlight
B)Snellen's chart
C)Sterile gloves
D)Gauze square
E)Millimeter ruler

Question 26

The nurse is assessing the peripheral vascular status of an older client.Which finding should the nurse consider as being normal for this client?

A)Easy to palpate upper extremity arteries
B)Easy to palpate lower extremity arteries
C)Reduction in the number of varicosities
D)Increase in diastolic blood pressure

Question 27

The nurse is preparing to conduct an assessment of the heart.Where should the nurse place the stethoscope to auscultate heart sounds?
Standard Text: Select all that apply.

A)Aortic region
B)Pulmonic region
C)Tricuspid valve region
D)Abdomen
E)Mitral valve region

Question 28

The nurse is assessing the nose and sinuses of a client.Which findings should the nurse identify as being within normal limits?
Standard Text: Select all that apply.

A)Nose straight
B)Nares symmetrical
C)No tenderness over the bridge
D)Air movement restricted in one nare
E)Clear drainage from one nare

Question 29

A client is experiencing abdominal pain.What assessments should the nurse perform to assess this complaint?
Standard Text: Select all that apply.

A)Inspect the abdomen.
B)Auscultate the abdomen.
C)Palpate the abdomen.
D)Assess vital signs.
E)Assess peripheral pulses.