Deck 21: Physical Assessment

Question 1

Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse.With what should the nurse realize this finding is associated?

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

Answer 1

Bacterial endocarditis

Question 2

Which portion of the ear is responsible for maintaining equilibrium?

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

Answer 2

Inner ear

Question 3

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.

Answer 3

Briefly press the tip of the nail with firm,steady pressure,then release and observe for changes in color.

Question 4

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease.Which finding might the nurse expect when assessing the patient's nails?

A) Soft,boggy nails
B) Brittle nails
C) Thickened nails
D) Thick nails with yellowing

Question 5

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 6

Which abnormal laboratory value is associated with icteric sclerae?

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

Question 7

Where should the nurse assess skin color changes in the dark-skinned patient?

A) Elbow
B) Any exposed area
C) Oral mucosa
D) Behind the knee

Question 8

When should the nurse instruct a new mother to expect the anterior fontanel of her infant to fuse?

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

Question 9

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."

Question 10

The nurse notes ptosis in a patient who just arrived in the emergency department.What should the nurse realize this finding might indicate?

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

Question 11

A female patient has excessive facial hair.How should the nurse document this finding?

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

Question 12

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 13

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 wearing only the diaper.
D) Place the infant supine on the scale with his knees extended.

Question 14

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 15

A patient's ankles appear swollen.When the nurse assesses the edema,the skin depresses 6 mm,and the depression lasts 2 minutes.How should the nurse document this finding?

A) Trace edema
B) +1 edema
C) +2 edema
D) +3 edema

Question 16

What should the nurse use to assess skin temperature?

A) Dorsum of the hand
B) Pad of the fingertip
C) Palm of the hand
D) Dorsum of the wrist

Question 17

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

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

Question 18

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 19

While assessing an older adult patient,the nurse notes clubbing of the fingers.What does this finding indicate to the nurse?

A) Fungal infection
B) Malnutrition
C) Iron deficiency
D) Long-term hypoxia

Question 20

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

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

Question 21

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 recall the three items I mentioned earlier?"
D) "What was your birth date including the year?"

Question 22

The nurse asks the patient to spread the fingers and then bring them together again.What is the nurse testing when asking the patient to bring the fingers together?

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

Question 23

The parent of an 18-month-old child is concerned because the 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 24

The nurse notes a small pulsation at the fifth intercostal space midclavicular line.How should the nurse document this finding?

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

Question 25

The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude.What should this finding indicate about the client's pulses?

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

Question 26

While palpating the anterior chest,the nurse notes crackling in the skin around the patient's chest tube insertion site.What should the nurse realize this finding indicates?

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

Question 27

Which assessment should the nurse perform if a palpable thyroid gland is present?

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 28

The nurse is performing an otoscopic examination on an adult patient.After having the patient tilt the head to the side not being examined and looking into the ear canal to make sure a foreign body is not present,what should the nurse do next?

A) Straighten the ear canal by pulling the pinna 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 pinna down and back.

Question 29

The nurse notes an S₃ heart sound while performing an assessment on a patient admitted with an acute myocardial infarction.What should this finding indicate to the nurse?

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

Question 30

A patient's jugular venous pressure measures 5 cm.What should this finding indicate to the nurse?

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

Question 31

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 32

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.What does this finding indicate to the nurse?

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

Question 33

The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube to 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

The nurse assesses a 4-year-old child's vision as 20/40.What should the nurse realize this finding indicates?

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

Question 35

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 36

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 37

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 exam to limit position changes.
C) Demonstrate equipment before using it.
D) Omit portions of the exam that may be tiring.

Question 38

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 39

How should the nurse document high-pitched breath sounds produced by narrowed airways?

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

Question 40

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 41

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
E) Macular degeneration

Question 42

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 43

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/minute
C) Respiratory rate 35 breaths/minute
D) Oral temperature 98.6°F (37°C)
E) Pulse oximetry reading 94% on room air

Question 44

The nurse prepares to complete a focused physical assessment on a client with a chronic health problem.What should the nurse explain to the client as being the purpose of this assessment? Select all that apply.

A) Adds data to the database
B) Examines all body systems
C) Focuses on one body system
D) Focuses on a particular body part
E) Includes a health history interview

Question 45

A client asks why the nurse needs so much time to complete a physical assessment.What should the nurse explain as the purposes for this type of assessment? Select all that apply.

A) Obtain baseline data
B) Identify nursing diagnoses
C) Screen for health problems
D) Evaluate teaching provided
E) Monitor previously identified problems