Deck 21: Physical Assessment

Question 1

The initial assessment of a patient who was admitted with a gastrointestinal inflammatory disease revealed that the patient had hyperactive bowel sounds. The follow-up assessment finds that the bowel sounds are still hyperactive but are now audible without a stethoscope. The nurse will correctly chart:

A) "Low-pitched bowel sounds $\times$ D."
B) "Borborygmus noted."
C) "Bowel sounds are high pitched."
D) "Bowel sounds hyperactive $\times$ D."

Answer 1

"Borborygmus noted."

Question 2

While assessing the feet of a 72-year-old male patient with diabetes, the nurse noted that there were no cuts, cracks, or blisters. The patient stated, "I don't have as much feeling in my feet as I used to." The nurse correctly understands that the patient is most likely suffering from

A) Paresthesia.
B) Infection.
C) Lentigines.
D) Necrosis.

Answer 2

Paresthesia.

Question 3

A patient tells the nurse that the cardiologist has told her that she will likely need a mitral valve replacement in a few years. The nurse can best hear her mitral valve

A) Over the apex of the left ventricle.
B) At the second intercostal space to the right of the sternum.
C) At the second intercostal space to the left of the sternum.
D) At the fourth intercostal space just to the left of the sternum.

Answer 3

Over the apex of the left ventricle.

Question 4

A nurse wakes the patient for a focused assessment. The patient, trying to rest, tells the nurse, "I wish you would quit waking me up. Do you really need to keep bothering me?" The nurse appropriately responds:

A) "Most patients would love to get the attention that you are getting."
B) "I understand your frustration, but this has been ordered by your physician."
C) "It is necessary that I do a head-to-toe assessment from which I can determine whether there are any changes in your condition."
D) "It is important to assess your blood pressure and pulse since we just started your new blood pressure medicine."

Question 5

During the physical assessment, the nurse asks an elderly female patient if she experiences constipation. The nurse knows that

A) Elderly patients almost always abuse laxatives, which creates problems with constipation.
B) Aging patients always have difficulty having a bowel movement while hospitalized.
C) In elderly patients, the rectal sphincter has lost elasticity, which decreases the sensation of urgency.
D) It is common for intestinal peristalsis to slow down as a person ages, causing problems with constipation.

Question 6

When performing a physical assessment of a patient, a nurse uses the five techniques of obtaining objective data. The technique that provides data by using the hands is

A) Palpation.
B) Auscultation.
C) Observation.
D) Olfaction.

Question 7

The patient's blood pressure at 8:00 a.m. was 124/80 mm Hg, and now at 12:00 p.m., it is 152/94 mm Hg. The charge nurse appropriately instructs the newly hired nurse that

A) The patient's blood pressure should be rechecked in 15 minutes.
B) Any abnormal findings should be rechecked within 8 hours.
C) Because the blood pressure has become elevated, it should be rechecked in 1 to 2 hours.
D) There is no reason to recheck the blood pressure because this pattern of elevation is typical for this patient.

Question 8

The nurse charts that the patient is eupneic. This finding indicates that respirations

A) Require the use of costal, sternal, and subclavicular muscles.
B) Are very shallow and at a rate between 8 and 12 per minute.
C) Are between 20 and 24 per minute and that the patient is using his thoracic muscles.
D) Are considered to be normal in depth and rate with use of the abdominal muscles.

Question 9

At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are

A) Subjective.
B) Measurable.
C) Reported by the patient.
D) Hidden.

Question 10

A nurse, preparing to auscultate breath sounds, correctly positions the patient in the most favorable position, which is

A) Supine position.
B) Low Fowler position.
C) Semi-Fowler position.
D) High Fowler position.

Question 11

A stable male patient, who was just admitted for left-lower-lobe pneumonia, tells the nurse that his cough is nonproductive. When assessing the patient's breath sounds, the nurse suspects consolidation when, over the left lower lobe, she detects

A) Rales.
B) Absent breath sounds.
C) Stridor.
D) Rhonchi.

Question 12

A male patient has been admitted with congestive heart failure. Although the patient is sitting in a semi-Fowler position, the nurse cannot auscultate distinct heart tones. The nurse will correctly first

A) Document that the heart tones are muffled.
B) Count the apical rate as best as possible and then document it.
C) Have the patient lean forward and toward his left side.
D) Report the findings to the charge nurse.

Question 13

A female patient who was admitted after suffering a stroke becomes frustrated because she is unable to respond verbally to the nurse's questions. The nurse, understanding the complications following a stroke, charts that the patient is

A) Dysphasic.
B) Dysphagic.
C) Aphasic.
D) Dyspneic.

Question 14

The nurse correctly assesses a patient's abdomen by following the sequence of

A) Inspection, palpation, and auscultation.
B) Palpation, inspection, and auscultation.
C) Palpation, auscultation, and inspection.
D) Inspection, auscultation, and palpation.

Question 15

The nurse gives the patient the following instructions: "Focus on my pencil and follow it as I move it away from you and then back toward you." The nurse is assessing the

A) Anisocoria of the patient's pupils.
B) Patient's accommodation response.
C) Patient's consensual reflex.
D) Direct pupil response of the patient.

Question 16

A patient who is one day postoperative is complaining of nausea and refusing to eat. Upon auscultation of the abdomen, the nurse finds that the patient's bowel sounds are hypoactive. This is most likely due to

A) Peritonitis.
B) A bowel obstruction.
C) Anesthesia.
D) Paralytic ileus.

Question 17

The nurse correctly uses percussion when assessing the patient for

A) Hyperinflated lungs.
B) An enlarged heart.
C) A heart arrhythmia.
D) Rebound tenderness.

Question 18

A 75-year-old patient is breathing at a rate of 30 and denies dyspnea. The breath sounds are clear to auscultation in all five lobes. The nurse will further assess the patient's respiratory and circulatory systems by checking capillary refill. A normal finding would be

A) Nail beds pink, capillary refill 6 seconds.
B) Nail beds cyanotic, capillary refill 4 seconds.
C) Nail beds pink, capillary refill 5 seconds.
D) Nail beds blanched, capillary refill 3 seconds.

Question 19

After completing the initial head-to-toe shift assessment, the nurse determines that no changes are needed in the patient's plan of care. This decision is a result of the nurse's

A) Ensuring that each patient receives a comprehensive health assessment.
B) Evaluating the effectiveness of nursing interventions.
C) Reviewing the organizational plan for the shift.
D) Learning that the patient may be discharged from the hospital during this shift.

Question 20

The nurse takes additional time getting to know a patient admitted for surgery because

A) The patient may not fully cooperate with the nurse otherwise.
B) It is important that the nurse be prepared to answer any questions that the family may have about the patient.
C) The nurse believes that a patient responds better if she and the patient are on a first-name basis.
D) The nurse believes that establishing rapport with a patient leads to a trusting nurse-patient relationship.

Question 21

A patient's feet appear to be edematous, so the nurse first

A) Charts, "Patient's feet appear to be swollen."
B) Percusses the tissue that appears edematous.
C) Applies pressure over a bony prominence of the foot for 2 seconds.
D) Elevates the patient's feet on a pillow to decrease swelling.

Question 22

A male patient, who was admitted for evaluation of the cardiovascular system, has strong and equal peripheral pulses. The nurse correctly documents:

A) "Peripheral pulses 2+ and equal bilaterally."
B) "Pedal and radial pulses 1+ and equal."
C) "All pulses 3+ and equal bilaterally."
D) "Peripheral pulses present and equal."

Question 23

A terminally ill patient's respiratory pattern has changed and is now cyclic in nature, with increasing and then decreasing depths that are spaced by brief periods of apnea. The nurse charts that the patient is having

A) Cheyne-Stokes respirations.
B) Biot respirations.
C) Apnea.
D) Eupnea.

Question 24

A nurse trying to establish trust and rapport with a newly admitted patient would want to avoid

A) Touching the patient.
B) Greeting the patient using his first name.
C) Using a relaxed posture.
D) Putting the patient in a private room.

Question 25

A patient is readmitted to the hospital 3 days after having been discharged. She presents with the same respiratory symptoms she presented with on her first admission. She is assigned to the same nurse. The first thing that nurse should do is

A) A comprehensive health assessment, because as much information as possible is needed about why the patient has returned to the hospital.
B) A focused assessment of her respiratory system, because that is the system with the recurring problem.
C) An initial head-to-toe shift assessment to establish a baseline for future assessments.
D) Any form of assessment, because the nurse already has plenty of recent assessments from the patient's previous hospital stay to use as baselines.

Question 26

When reassessing a patient's respiratory system, the nurse finds that the patient's condition has deteriorated, and although the respirations are regular, they are abnormally deep and rapid. The nurse documents that the patient has

A) Bradypnea
B) Cheyne-Stokes respirations
C) Kussmaul's respirations
D) Biot respirations

Question 27

In a postoperative assessment of a patient who has had knee replacement surgery, the nurse notes that the patient is experiencing moderate knee pain and somewhat slurred speech. The nurse appropriately

A) Checks the patient's chart to determine whether her slurred speech can be attributed to her postoperative medications and, if not, summons her doctor to determine whether she is having postoperative complications.
B) Asks the doctor to adjust the patient's pain medications to relieve the pain and prevent any further slurring of speech.
C) Asks the patient to let the nurse know if the pain or the slurred speech gets worse, then reassesses the patient's symptoms in 4 hours.
D) Calls the patient's doctor immediately because she may be suffering a stroke because of a blood clot that traveled from her legs postoperatively.

Question 28

A nurse supervising a certified nursing assistant (CNA) would correctly intervene upon hearing the CNA say:

A) "Hi again, Mr. Jones. Are you feeling better today? Oh, really? Tell me what's wrong and I'll see what I can do."
B) "Hello, Mr. Jones, my name is Andrea. The doctor says we need to move you to another unit today, so please let me know where you're keeping your personal belongings so we can send those along as well."
C) "Hello, Mr. Jones. Please roll up your sleeve."
D) "Hi, Mr. Jones. Ah, I see the Girl Scouts have come through today because you've got some cookies there, haven't you? Well, make sure to leave those alone till your kids come by to visit, okay? [Laughs] We don't want the doctor getting mad about you going off your diet."

Question 29

Before weighing an elderly patient, the nurse will correctly first

A) Determine whether the patient can stand alone.
B) Ensure that the patient is in a bed with built-in scales.
C) Call transportation to get a bed weight on the patient.
D) Make sure that the scale is calibrated correctly.

Question 30

A nurse asks a patient if a primary care physician has ever told her that she has scoliosis. The patient asks what scoliosis is, and the nurse correctly replies:

A) "It is a slight convex curve in the spine."
B) "The vertebrae are midline and straight, rather than curving."
C) "It is a curvature of the spine to the left or right."
D) "It is an increased concave curve of the lumbar spine."

Question 31

An unlicensed assistive personnel (UAP) asks a nurse how to tell the difference between the first and second heart sounds. The nurse replies:

A) "The first heart sound, or systolic sound, is shorter and higher pitched than the second heart sound, or diastolic sound."
B) "The first heart sound, or diastolic sound, is shorter and higher pitched than the second heart sound, or systolic sound."
C) The first heart sound, or diastolic sound, is shorter, softer, and lower pitched than the second heart sound, or systolic sound.
D) "The first heart sound, or systolic sound, is longer, louder, and lower pitched than the second hart sound, or diastolic sound."

Question 32

When assessing the integrity of a patient's skin, the nurse is

A) Checking the elasticity of the skin.
B) Looking for cuts or breaks in the skin.
C) Assessing the color of the skin.
D) Determining whether the skin is moist or dry.

Question 33

A charge nurse would appropriately intervene if she heard a nurse under her supervision say:

A) "Ms. Anderson, it sounds like in addition to your abdominal pain, you have an irregular heartbeat. Have you ever had this before? It's important to check your pulse if you have any abnormal feelings in your chest, and if your pulse feels irregular, you should call your doctor right away."
B) "Mr. Sanchez, my name is MaryAnn. Can you repeat my name back to me? No, that's not right-try again. No, that's not how you pronounce it-it's "MARY ANN." Can you say that? No? I think you may be having a stroke."
C) "Mr. Allen, it seems you're having rebound tenderness-meaning increased pain after I apply pressure to your abdomen and then release the pressure. That's a possible sign of appendicitis. Have you had your appendix removed?"
D) "Mrs. McBain, have you experienced numbness in your feet before? Really, how often? The reason I ask is that it can be a sign of diabetes or other serious illnesses like multiple sclerosis. Have you ever been tested for diabetes or MS before?"

Question 34

A nurse performing an initial assessment might appropriately educate a patient

A) With poor dental hygiene that it can lead to a greater risk for heart disease.
B) Who is not oriented to place or time about the possibility that he might have early-onset Alzheimer disease.
C) With congestive heart failure that he might want to look into being put on the transplant candidate list.
D) With a degenerative neurological disease about the benefits of making a living will.

Question 35

A primary care physician has ordered daily weight monitoring. The nurse correctly understands that to most accurately monitor the patient's weight,

A) It must be measured and recorded in kilograms.
B) The patient must be weighed at 7:30 every morning.
C) The patient must be weighed using the bed scales.
D) The patient must be ambulatory and able to stand on the scales.

Question 36

In response to a student nurse's question, the nurse correctly states:

A) "The first heart sound reflects the sound produced by relaxation of the atria."
B) "The first heart sound reflects the closing of the mitral and tricuspid valves."
C) "The first heart sound reflects the closing of the pulmonary and aortic valves."
D) "The first heart sound reflects the beginning of the atrial contraction."

Question 37

A student nurse would properly contact and advise the supervisory staff nurse if

A) A patient demands to be moved to a different room but will not say why.
B) A physically larger patient for whom the student nurse is providing ambulation therapy has trouble getting back into bed and the student is unable to get him into bed herself.
C) A patient seems to be trying to communicate something urgent but cannot do so because of a language barrier.
D) A patient's condition seems worse than at the staff nurse's last assessment.

Question 38

When doing an initial assessment, a nurse can use palpation to assess for

A) Hyperinflated lungs.
B) Distension of the bladder.
C) Liver size.
D) Level of respiratory effort.

Question 39

A patient has been admitted for observation following an automobile accident. The nurse suspects that the patient's condition may be deteriorating because

A) The patient was previously lethargic and is now alert.
B) The blood pressure and pulse have not changed.
C) The patient still cannot remember the events before the accident.
D) The patient was oriented to person, place, time, and situation 1 hour ago and is now oriented to person and place only.

Question 40

A nurse is unable to palpate a patient's left pedal pulse. The nurse will correctly first

A) Notify the primary care physician that the patient's pedal pulse is not palpable.
B) Reassess the patient's left pedal pulse every 2 to 4 hours.
C) Chart, "Left pedal pulse nonpalpable, foot warm and dry."
D) Obtain a Doppler to further detect whether the pulse is present.

Question 41

When weighing a patient who can stand unassisted, the nurse must make sure to

A) Let the patient get out of bed and walk to the scale unassisted, to respect the patient's boundaries and help maintain the patient's sense of control.
B) Weigh the patient at different times of day to get an average weight over time.
C) Place a hand a few inches behind the patient's back when he steps on the scale, in case the patient loses his balance.
D) Allow the patient to hold on to something while being weighed, if he wishes.

Question 42

A patient who was admitted with long-standing chronic obstructive pulmonary disease (COPD) is at risk for respiratory failure. Every 4 hours, the nurse will perform a focused respiratory assessment, which includes which of the following?

A) Neck vein distention
B) Color of nailbeds
C) Presence of sternal retractions
D) Temperature of extremities
E) SpO₂

Question 43

A nurse performing an assessment would correctly note that an absent pulse in one or more of the extremities indicates

A) A blockage.
B) Shock.
C) Decreased plasma volume.
D) Problems with the heart's electrical conduction system.

Question 44

A nurse doing an assessment would correctly summon a physician immediately if he detected the breath sounds known as

A) Rales.
B) Rhonchi.
C) Wheezes.
D) Stridor.

Question 45

A male nurse performing an assessment should take extra care to ask permission before touching a patient who is

A) A Latina woman.
B) An African American man.
C) A Native American man.
D) Any of the above.

Question 46

When positioning a patient to listen to breath sounds, the nurse is correctly aware that which of the following lobes can only be heard by anterior or lateral auscultation?

A) Left upper lobe
B) Left lower lobe
C) Right upper lobe
D) Right middle lobe
E) Right lower lobe

Question 47

A nurse performing an assessment would correctly identify that a patient has a greater chance of contracting health-care facility-acquired pneumonia if he has

A) Difficulty swallowing.
B) An existing respiratory disease.
C) Poor oral hygiene.
D) Any of the above.

Question 48

A nurse assessing a patient's oral health must assess which of the following as an immediate safety hazard?

A) The color of the mucous membranes
B) The ability to swallow
C) The presence of ulcerations or lesions in the mouth
D) The presence of bleeding in the mouth

Question 49

A charge nurse is discussing with recently licensed nurses the importance of accurately assessing and documenting patients' heart sounds. The nurse correctly tells them which of the following?

A) To compare the intervals between the heartbeats
B) To compare the radial pulse with the apical pulse
C) To chart "distinct" if both heart tones are clearly heard
D) To listen to the apical pulse for a full 30 seconds
E) To document the rate for the apical pulse

Question 50

A nurse is performing a focused assessment of the patient's cardiovascular system every 4 hours. The nurse correctly assesses which of the following?

A) Skin color, moisture, and temperature
B) Blood pressure
C) Use of accessory muscles
D) Strength and equality of peripheral pulses
E) Capillary refill of extremities

Question 51

If a nurse needs to rouse a patient to perform a neurological assessment, the nurse may correctly

A) Skip the neurological assessment if the patient appears to be comatose, since she can't hear the nurse or follow instructions.
B) Exert mild pain on the patient (e.g., pressing on a nailbed).
C) Turn up the volume on the radio or television.
D) Gently slap the patient.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 52

A nurse charts that the patient has halitosis. Halitosis can be a symptom of which of the following?

A) Stomach problems
B) Sinus infection
C) Leukemia
D) Poor hygiene
E) Pernicious anemia