Deck 33: Health Assessment and Physical Examination

Question 1

When auscultating the client's lungs,a nurse notes normal vesicular sounds as:
1) Medium-pitched blowing sounds with inspirations that equal expirations
2) Loud,high-pitched,hollow sounds with expiration longer than inspiration
3) Soft,breezy,low-pitched sounds with longer inspiration
4) Sounds created by air moving through small airways

Answer 1

3
Normal vesicular sounds are soft,breezy,and low-pitched.The inspiratory phase is 3 times longer than the expiratory phase.Medium-pitched blowing sounds with inspiration equaling expiration are bronchovesicular breath sounds.Loud,high-pitched,hollow sounds with longer expiration are bronchial breath sounds.Vesicular sounds are created by air moving through smaller airways.Abnormal breath sounds result from air passing through narrowed airways.

Question 2

A female client is seen in the outpatient clinic for numerous cuts,bruises,and apparent burns.In a discussion with the client,the nurse finds that the injuries are inconsistent with the stated cause.The client also states that she is having trouble sleeping,and she appears anxious.Based on these findings,the nurse suspects that the client may be experiencing:
1) Substance abuse
2) Domestic violence
3) Vascular disease
4) Mental illness

Answer 2

2
Injuries and trauma that are inconsistent with the reported cause;multiple injuries including bruises,cuts,and burns;and behavioral findings of difficulty sleeping and appearing anxious are all indicators of possible domestic violence.The findings are not consistent with substance abuse.Indicators of substance abuse may include frequent missed appointments or emergency department visits,having a history of changing doctors,history of activities that place the client at risk for HIV infections,complaints of insomnia or chest pain,and a family history of addiction.People who abuse substances may have cuts,burns (especially of the fingers),needle marks,homemade tattoos,or increased vascularity of the face.These findings are not indicative of vascular disease.Symptoms of vascular disease may include edema,color changes of the lower extremities,and weakened pedal pulses.These findings are not indicative of mental illness.The client is coherent.

Question 3

The position that maximizes the nurse's ability to assess the client's body for symmetry is:
1) Sitting
2) Supine
3) Prone
4) Dorsal recumbent

Answer 3

1
Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts.The supine position maximizes the nurse's ability to assess pulse sites.The prone position is used only to assess extension of the hip joint.
The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles.

Question 4

The client has an enlarged thyroid gland and is currently admitted to a medical nursing unit.Which of the following is accurate regarding the procedure for a thyroid assessment for this client?
1) Deep palpation should be used anterior and posterior.
2) Swallowing sips of water causes the isthmus of the thyroid gland to rise.
3) The posterior approach is used when the fingers are placed over the trachea.
4) The diaphragm of the stethoscope is best used for the auscultation of bruits.

Question 5

The best position for the nurse to position the client in order to auscultate the apical site,if a low-pitched murmur is suspected during prior assessment,is:
1) Sitting up
2) Standing
3) Lying on the left side
4) Dorsal recumbent

Question 6

A client in the clinic has been having severe headaches and some visual disturbances.The nurse performs an eye examination.Which of the following is true concerning the procedure for this assessment?
1) The red reflex should be assessed with the ophthalmoscope.
2) To evaluate the lower eyelids,the nurse uses a syringe with sterile water.
3) Accommodation is tested by asking the client to comply with the nurse's requests.
4) The lacrimal apparatus is assessed with a dull object to stimulate normal reflex conditions.

Question 7

The expected appearance of the oral mucosa in a light-skinned adult is:
1) Pinkish-red,smooth,and moist
2) Light pink,rough,and dry
3) Cyanotic,with rough nodules
4) Deep red,with rough edges

Question 8

The nurse suspects that the client may have vascular disease.During the examination,the nurse is alert to the client's complaints of:
1) Headache,dizziness,and tingling of body parts
2) Diplopia,floaters,and headaches
3) Leg cramps,numbness of extremities,and edema
4) Pain and cramping in the lower extremities relieved by walking

Question 9

In preparing to conduct a physical examination on a client,the nurse plans to:
1) Perform painful procedures at the end of the exam
2) Take long,detailed notes of all the findings during the exam
3) Keep the TV or radio on to distract the client throughout the exam
4) Assess the dominant side of the client's body only in the examination

Question 10

During an assessment of the client's integument,the nurse notes a flat,nonpalpable change in skin color that is smaller than 1 cm.This finding is documented by the nurse as a:
1) Macule
2) Papule
3) Vesicle
4) Nodule

Question 11

A student nurse is working with a client who has asthma.The primary nurse tells the student that wheezes can be heard on auscultation.The student expects to hear:
1) Coarse crackles and bubbling
2) High-pitched musical sounds
3) Dry,grating noises
4) Loud,low-pitched rumbling

Question 12

Measurement of the client's ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?
1) Optic
2) Facial
3) Trigeminal
4) Oculomotor

Question 13

The nurse asks a client to explain the meaning of the phrase,"Every cloud has a silver lining." This part of the examination is designed to measure:
1) Knowledge
2) Judgment
3) Association
4) Abstract thinking

Question 14

The nurse notes an exaggeration of the posterior curvature of the thoracic spine,during the assessment of a 90-year-old client,as:
1) Lordosis
2) Osteoporosis
3) Scoliosis
4) Kyphosis

Question 15

When assessing the pallor of a client with dark skin,the nurse will specifically look at the:
1) Buccal mucosa of the mouth
2) Dorsal surface of the hands
3) Ear lobe
4) Sclera

Question 16

A 21-year-old woman asks when she should perform a breast self-examination during the month.The nurse should inform the client:
1) "Any time you think of it."
2) "At the same time each month."
3) "On the first day of your menstrual period."
4) "Two to three days after your menstrual period."

Question 17

Part of the neurological exam is evaluating the response of the cranial nerves.To test cranial nerve VIII,the nurse should:
1) Ask the client to read printed material
2) Assess the directions of gaze
3) Assess the client's ability to hear the spoken word
4) Ask the client to say "ah"

Question 18

The nurse could best auscultate the point of maximum impulse (PMI)in an 8-year-old child at the:
1) Fourth intercostal space,left of the midclavicular line
2) Fifth intercostal space,left of the midclavicular line
3) Second intercostal space,right of the midclavicular line
4) Third intercostal space,right of the midclavicular line

Question 19

As part of the examination,the nurse will be assessing the client's balance.The test that should be administered is the:
1) Weber test
2) Allen test
3) Romberg test
4) Rinne test

Question 20

Assessment of the client's skin reveals a fluid-filled circumscribed elevation of 0.4 cm.The nurse identifies this as a:
1) Nodule
2) Macule
3) Vesicle
4) Wheal

Question 21

The sounds heard over the trachea during the auscultation of the thorax,are expected to be:
1) Soft,low-pitched,and breezy
2) Loud,high-pitched,and hollow
3) Moist,crackling,and bubbling
4) High-pitched and musical

Question 22

An older adult client is visiting the physician's office for a check-up.The client asks the nurse how often the influenza and pneumonia vaccines should be obtained.The nurse responds to the client that these vaccinations should be done:
1) Every 6 months
2) Annually
3) Every 5 years
4) Every 7 years

Question 23

Which of the following statements best reflects an understanding of the most effective means of showing nursing accountability for client care?
1) "I always try to tailor client education to my client's care needs."
2) "A client's care plan is never stagnate;it always needs updating."
3) "Selecting the most appropriate interventions is the key to quality care."
4) "By re-assessing the client regularly,I can tell if the interventions are working."

Question 24

Which of the following statements made by a nurse reflects the best understanding of the health value of conducting a blood pressure (BP)screening at a senior citizens center's health fair?
1) "This is a high risk group,so assessing BP allows us to identify clients at risk and send them for treatment."
2) "Older adults enjoy health fairs,so it's a good place to screen substantial numbers of clients for hypertension."
3) "Hypertension doesn't present symptoms early on,so screening elder adults is a wonderful preventive measure."
4) "Blood pressure problems are common among this group,so it's a good way to monitor the effectiveness of their medications."

Question 25

The nurse is evaluating the client for conduction deafness in the right ear.In using Weber's test,the nurse appropriately places the tuning fork and confirms this type of deafness when:
1) Sound is not heard in either ear
2) Sound is heard best by the client in the left ear
3) Sound is heard best by the client in the right ear
4) Sound is reduced and heard longer through air conduction

Question 26

At a medical clinic,a client with vascular insufficiency is seen frequently.The nurse will give the client additional instruction about her condition if the client:
1) Walks regularly
2) Wears knee-length stockings
3) Elevates the feet when sitting
4) Alternates periods of sitting and standing

Question 27

Which of the following statements made by the RN preparing to conduct a client's initial health history shows the best understanding of the therapeutic objective of the interview?
1) "It's all about finding out what the problems are and discovering the best way to fix them."
2) "Clients are more comfortable when you take the time to get to know them and their problems."
3) "I use it as an opportunity to show the client that his care is very important to the hospital's staff."
4) "It is the most appropriate way to initiate the therapeutic nature of the nurse-client relationship."

Question 28

The presence of arterial insufficiency is suspected during an inspection of the lower extremities when the nurse observes:
1) Increased hair growth
2) Cooler skin temperatures
3) Marked edema
4) Brown pigmentation

Question 29

A pregnant client is seen by the nurse in the antenatal clinic.On inspection,the nurse expects that this client's breasts will have:
1) Softer tissue
2) Flatter nipples
3) Darkened areola
4) Diminished superficial veins

Question 30

A client with cardiopulmonary disease receives a physical examination performed by a nurse.Knowing the client history,the nurse is attentive when checking the nails for the presence of:
1) Clubbing
2) Paronychia
3) Beau's lines
4) Splinter hemorrhages

Question 31

While bathing an elderly client who has limited abilities for self-care,the nurse notices several patches of dry skin on the client's heels,elbows,and coccyx.The nurse cleans and dries all the areas well and applies a moisturizing lotion.The most appropriate immediate follow-up by the nurse to ensure appropriate nursing care for this client's skin is to:
1) Revise the client's care plan to show the need for the application of moisturizing lotion
2) Assume personal responsibility to apply the moisturizing lotion daily to the client's skin
3) Encourage the client to tell whomever bathes her to apply the moisturizing lotion to her areas of dry skin
4) Inform the staff that the client's skin is showing signs of breakdown and moisturizing lotion needs to be applied daily

Question 32

A client reports pain in his left ankle since "twisting it" yesterday.Which of the following assessment findings best supports the client's claims of ankle pain?
1) The client grimaces when walking to the examination room.
2) The client's left ankle is swollen with noted bruising.
3) The client reports a pain rating of 7 on a scale of 1 to 10.
4) The client's heart rate increases after walking to the examination room.

Question 33

The nurse encourages the client to "relax and take a deep,slow breath" in order to prepare for a palpating assessment of the abdomen.The primary reason for this is to:
1) Encourage the client to be emotionally comfortable and relaxed
2) Distract the client from the actual possible discomfort the pressure may cause
3) Facilitate the effectiveness of the palpating technique to detect abdominal masses
4) Allow the client an opportunity to cope with any bad feelings regarding the examination

Question 34

The nurse tests the function of the client's cranial nerves during the neurological component of the physical examination.In testing cranial nerve III,the nurse verifies the client's ability to:
1) Smile and frown
2) Read printed material
3) Identify sweet and sour tastes
4) React to light with changes in pupil size

Question 35

During the physical examination,the client tells the nurse that he has been told he has myopia.The nurse expects to find that the client:
1) Is nearsighted
2) Has decreased peripheral vision
3) Has diminished night vision
4) Experiences more glare,flashes,and floaters

Question 36

The school-aged child is taken to the school nurse after experiencing a nosebleed during a softball game.The appropriate intervention is for the nurse to:
1) Have the child lean backward
2) Apply pressure to the anterior nose
3) Apply a warm cloth to the area
4) Have the child close his mouth and blow his nose

Question 37

During the physical examination,the nurse should assess the client's glands by using the:
1) Dorsum of the hand
2) Pads of the fingers
3) Palmar surface of the hand
4) Fingertip grasp of the tissue

Question 38

The nurse instructs the male client that the protocol for testicular self-examination is to:
1) Perform the examination annually after age 35
2) Use both hands to roll the testicles and feel the consistency
3) Perform the examination before bathing or showering
4) Contact the physician if a cordlike structure is felt on the top and back of the testicle

Question 39

The nurse uses olfaction in the client's assessment.If a sweet,fruity smell is noticed in the oral cavity,the nurse suspects:
1) Diabetic acidosis
2) Gum disease
3) Stomatitis
4) Malabsorption syndrome

Question 40

The nurse is about to palpate the client's abdomen to determine the margins of the liver.The primary reason for using the bimanual palpation method is to:
1) Minimize client discomfort
2) Minimize lower hand desensitivity
3) Assist in manipulation of the organ
4) Facilitate quick assessment of the abdomen

Question 41

The most appropriate method to use to assess for a carotid artery for the presence of a bruit is to:
1) Palpate each artery lightly;first the right side and then the left
2) Have the client turn the head toward the side being auscultated
3) Place the bell of the stethoscope over artery near outer edge of the clavicle
4) Have the client hold the breath while auscultating with the stethoscope bell

Question 42

The shift report states that a client has "crackles in both lungs." Which statement by the nurse preparing to assess the client best reflects a thorough understanding of the recorded assessment finding?
1) "I wonder if they are fine,medium or coarse."
2) "I'll listen again and reassess after I ask him to cough."
3) "That musical sound is hard to miss as they breathe out."
4) "I wish it was recorded where in the lungs they were heard."

Question 43

The shift report states that a client has "crackles in both lungs." Which statement by the nurse,preparing to assess the client,best reflects a thorough understanding of the recorded assessment finding?
1) "I wonder if they are fine,medium,or coarse."
2) "I'll listen again and reassess after I ask him to cough."
3) "That musical sound is hard to miss as they breathe out."
4) "I wish it was recorded where in the lungs they were heard."

Question 44

The primary reason for encouraging a client to urinate before beginning a physical examination is:
1) It avoids stimulation of the bladder during palpation or percussion of the abdomen
2) It minimizes the possibility of urinary incontinence caused by embarrassment or awkward positioning
3) A full bladder can hinder the examination of the client's abdominal,genitalia,and rectal areas
4) Voiding before the examination will encourage the client to relax,thus facilitating the assessment

Question 45

The most appropriate method to use to assess a carotid artery for the presence of a bruit is to:
1) Palpate each artery lightly;first the right side and then the left
2) Have the client turn the head towards the side being auscultated
3) Place the bell of the stethoscope over the artery near the outer edge of the clavicle
4) Have the client hold the breath while auscultating with the stethoscope bell

Question 46

Which of the following statements made by a nursing student regarding assessment technique requires immediate follow-up by the clinical instructor?
1) "I always rub my hands together before touching the client."
2) "I found that both of the client's carotid arteries beat simultaneously."
3) "It will take a lot of practice for me to be master the art of percussion."
4) "I always warm the stethoscope's diaphragm before listening for bowel sounds."

Question 47

The nurse recognizes that which of the following clients should be thoroughly assessed for their ability to be safely placed in the supine position?
1) An 18-year-old who suffered a fractured elbow playing football
2) A 20-year-old hospitalized with abdominal pain to rule out an appendicitis
3) A 74-year-old client who requires 3 L of continuous oxygen via nasal cannula
4) A 37-year-old reporting complaints of vaginal bleeding between menstrual periods

Question 48

A male nursing student is assigned to change the abdominal dressing of a 74-year-old female.The clinical nursing instructor asks that a female nurse assist him with the procedure.The primary reason for this decision is:
1) It diverts the client's attention during the assessment and procedure
2) It provides a third party to ensure proper conduct of all involved
3) It facilitates a comfortable,efficient environment for the client
4) It assists with the wound assessment and changing of the abdominal dressing