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Health Assessment Real Exam
Health Assessment Exam Update
2025 Questions and Correct Answers
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Prior to beginning a physical examination of a client, the nurse would carry out which activities? - ANSWER-Wash hands, provide privacy for the client, explain the procedure to the client, and position the client comfortably. The nurse performing a physical assessment is unable to palpate a pulse. What is the best first action for the nurse to take? - ANSWER-The nurse should use a Doppler to listen for the pulse that is not palpable. The nurse is preparing to conduct a physical assessment of a client's chest and will be utilizing all the following steps. Place the techniques in the correct order for use: Percussion, Auscultation, Inspection, Palpation - ANSWER-Inspection, Palpation, Percussion, Auscultation The nurse has used percussion to assess the client's abdomen. The nurse documents which normal characteristic assessed over the liver in the RUQ? - ANSWER- Dullness During physical assessment, the nurse would palpate the skin for which characteristics? Select all that apply.
- Temperature
- Texture
- Pigmentation
- Moisture
- Elasticity - ANSWER-Temperature, texture, moisture, elasticity In an effort to provide a comfortable environment for a client during a physical assessment, the nurse would take which action? - ANSWER-Drape the client prior to beginning the examination
The nurse notes during a routine screening examination that the client has a thready pulse. In what other way could this finding be documented? - ANSWER- Pulse is difficult to palpate and obliterates easily The nurse would plan to do which of the following as a high priority during a routine health assessment? - ANSWER-Teach the client about ways to maintain health and wellness The nurse plans to do which of the following using the skill of inspection during health assessment on an adult? - ANSWER-Use eyes, ears, and sense of smell to make observations The client tells the nurse during the health history, "I feel jumpy all over since using my new respiratory inhaler." Which question would be most appropriate for the nurse to ask next? - ANSWER-Can you tell me what you mean by jumpy? What data regarding the family history of an adult client is most important for the nurse to obtain during an initial interview? - ANSWER-Major diseases of close family When obtaining information about a child's health history, the nurse would include which data? - ANSWER-Past medical history, present medical complaint, review of systems A client is admitted for evaluation of upper GI symptoms. The nurse would document which statement as objective data in the client's medical record? Client states, "I have a headache" Client states," I had chickenpox as a child" Client has distended abdomen and active bowel sounds Client states," I feel nauseated after eating" - ANSWER-Client has distended abdomen and active bowel sounds The clinic nurse is conducting a health history. Place in proper sequence the following questions the nurse would ask using the standard format for collecting health history information. Does anyone in your family have diabetes? For what reason did you come to the clinic today? What is your date of birth? Can you tell me about your support system? Have you ever been hospitalized? - ANSWER-What is your date of birth? For what reason did you come to the clinic today?
Submandibular - ANSWER-medial border of the mandible Submental - ANSWER-behind the tip of the mandible Deep cervical - ANSWER-within and around the sternomastoid Posterior cervical - ANSWER-in the posterior triangle Superficial cervical - ANSWER-superficial to the sternomastoid Supraclavicular - ANSWER-between clavicles and sternomastoid Which of the following is true of cluster headaches? May be precipitated by alcohol Usual occurrence is two per month, each lasting 1-3 days Characterized as throbbing Tend to be supraorbital, retro-orbital or frontotemporal - ANSWER-may be precipitated by alcohol If the thyroid is enlarged, which of the following next steps is appropriate? Check for tracheal deviation Listen for a bruit over the carotid arteries Listen for a murmur over the aortic area Listen for a bruit over the thyroid lobes - ANSWER-listen for bruit over thyroid lobes When assessing carotid pulses, what action should the nurse avoid? - ANSWER- bilateral compression of the arteries While assessing an older client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should? - ANSWER-refer the patient to the physician for further evaluation The examiner records "positive consensual light reflex." This is: - ANSWER-The simultaneous constriction of the other pupil when one eye is exposed to bright light An adult client tells the nurse that she has had a sudden change in her vision. For which of the following should the nurse assess the patient? Diabetes Hypertension
Head trauma The normal effect of the aging process - ANSWER-Head trauma Visual acuity is assessed with: - ANSWER-the Snellen eye chart Which of the following is not used to assess extraoccular muscle strength? Cover test Corneal light reflex test Positions test Rosenbaum test - ANSWER-Rosenbaum test An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before. The nurse should instruct the client that prolonged wearing of contact lenses can lead to: - ANSWER-corneal damage Conductive hearing - ANSWER-transmission of sound through external/middle ear Sensorineural hearing - ANSWER-transmission of sound waves in the inner ear Presbycusis - ANSWER-Gradual hearing loss of aging Otorrhea - ANSWER-Drainage of the ears Otalgia - ANSWER-Ear pain Tinnitus - ANSWER-Ringing in the ears Vertigo - ANSWER-Feeling that the room is spinning Swimmer's ear - ANSWER-Infection in the ear canal Using the otoscope, the tympanic membrane is visualized. The color of a normal membrane is: - ANSWER-Pearly grey Sensorineural hearing loss may be related to: - ANSWER-Gradual nerve degeneration In examining the ear of an adult, the canal is straightened by pulling the auricle: - ANSWER-Up and back
- It is often associated with nerve damage - ANSWER-It can be difficult to treat effectively Which technique is the most effective method for the nurse to use to validate an alert client's level of pain? - ANSWER-ask the client to use a pain scale An elderly female client is admitted to the ED after falling on ice and sustaining a fractured hip. The client's daughter pulls the nurse aside and says, "Watch my mother carefully - she has an unbelievable tolerance for pain." If this information is accurate, the nurse will anticipate which client need? Select all that apply
- The client will be able to endure a great deal of pain
- The client will experience discomfort with the slightest movement
- The client will probably not experience significant pain
- The client will ask for pain medication more often than prescribed
- The client will not ask for pain medication and may need to be assessed more frequently for comfort - ANSWER-1. The client will be able to endure a great deal of pain 5.The client will not ask for pain medication and may need to be assessed more frequently for comfort To assess the intensity of a client's pain during a health assessment, the nurse could ask the client to do which of the following? - ANSWER-Rate the pain on a scale of 1- The nurse is obtaining a 24 hour diet recall from a client who is losing approximately 1-1.5 pounds per week. What are the most appropriate questions for the nurse to ask this client about the diet consumed? Select all that apply.
- When was the first time you ate yesterday? 2. How much water did you drink yesterday?
- What nutritional supplements did you take yesterday? 4, What did you have for breakfast? 5. What was the first thing you ate yesterday? - ANSWER-1. When was the first time you ate yesterday?
- What nutritional supplements did you take yesterday?
- What did you have breakfast?
- What was the first thing you ate yesterday? The client has been slowly losing weight for the past several months. The client states, "I have always been of normal weight up til now." The nurse determines that it is essential to gather information about which of the following? - ANSWER-
Poor dentition, swallowing and chewing difficulties, and functional and physical decline The nurse is performing a nutritional and physical assessment on an adult client. The nurse documents that the client has yellow subcutaneous fat deposits around the eyes. The nurse should expect which lab test to be ordered? - ANSWER- Cholesterol The nurse is teaching the client about MyPyramid. The nurse can evaluate that the client understands the teaching when the client states that MyPyramid does which of the following? - ANSWER-Reflects an individualized approach to nutrition When asking a client newly admitted to the hospital about diet history, which question by the nurse would be the most important?
- What time of day do you eat each meal? 2. Do you eat alone or with family members? 3. How often do you eat meals in restaurants? 4. Do you have any dietary restrictions? - ANSWER-4. Do you have any dietary restrictions? While the nurse is performing an admission assessment on a client, the client states "I am very unsteady on my feet." What assessment would the nurse perform to evaluate the client's statement? - ANSWER-Perform assessments to evaluate cerebellar function The nurse is examining an elderly client who is unable to stand with his eyes closed, feet together, arms at his sides. The man leans from side to side during this part of the exam. The nurse would conclude that this is a positive finding for which assessment? - ANSWER-Romberg test The nurse is testing the client's ability to recognize familiar objects. When the nurse places a coin in the client's hand he correctly identifies the object. How would the nurse document the finding? - ANSWER-Steriognosis The clinical educator on a neurological unit is teaching a new nurse how to elicit deep tendon reflexes. The educator would evaluate the orientee as having appropriate knowledge of a positive triceps reflex if she describes this as which of the following? - ANSWER-Extension of the forearm To evaluate the client for anosmia, the nurse would perform what assessment? - ANSWER-Have the client close his eyes and identify a familiar smell
ANSWER-Instruct the client to sleep in a Semi-Fowler's position because of the paroxysmal nocturnal dyspnea The nurse has auscultated the client's lungs and hears bubbling sounds bilaterally in the lower lung fields. The nurse would document which finding in the client's medical record? - ANSWER-Bilateral crackles at the bases The nurse is performing a respiratory assessment on a client who is presenting with an underlying obstructive pulmonary disease. What is the most important question for the nurser to ask the client during the interview to provide information about contributing factors? - ANSWER-Have you ever smoked tobacco products? The client is admitted to the hospital reporting inability to sleep because of shortness of breath. The nurse should take which preferred action? - ANSWER- Have the client sleep on two or three pillows The nurse is performing a respiratory assessment on a client and finds unequal chest expansion. The nurse would conclude that this may be caused by what factors? - ANSWER-Collapse or obstruction of part of the lung The client has a history of chronic obstructive pulmonary disease (COPD). The nurse should expect to document which clinical manifestations found on the physical examination? Select all that apply. Increased tactile fremitus Asymmetrical excursion Decreased bilateral excursion Fine crackles A transverse to anteroposterior diameter of 1:1 - ANSWER-Decreased bilateral excursion A transverse to anteroposterior diameter of 1: In what order would the nurse complete the following components of a respiratory assessment on an assigned client? Percuss the anterior thorax Palpate the anterior thorax Position the client Explain the procedure to the client Auscultate the anterior thorax - ANSWER-Explain the procedure to the client Position the client Palpate the anterior thorax Percuss the anterior thorax
Auscultate the anterior thorax The nurse is obtaining a health assessment on a client who reports leg pain and inability to perform ADLs. The nurse would ask which questions to obtain information about the client's ability to carry out ADL's? Select all that apply. Can you tell me how the pain is affecting your life? Do you know what is causing the problem? Does anyone in your family have any musculoskeletal problems? Can you describe how your activity level has changed? Can you tell me about your hobbies? - ANSWER-Can you tell me how the pain is affecting your life? Can you describe how your activity level has changed? To determine alleviating factors for symptoms of a musculoskeletal injury, it is essential that the nurse ask the client which question? - ANSWER-Have you used over the counter medications? When performing an assessment of the client presenting with a musculoskeletal problem, which action should the nurse take first? - ANSWER-Inspect the area of pain or inflammation What action would the nurse take to examine the temporomandibular joint? - ANSWER-Have the client open and close the mouth while palpating the joint in front of the tragus When testing the ROM of a client's shoulder, the nurse hears a grating sound. The nurse should document which of the following assessment findings? - ANSWER- crepitus The client reports shoulder pain without palpation or movement. The nurse should evaluate the client for which health problem? - ANSWER-A cardiac problem The nurse has assessed the client's shoulder strength and finds the client has full resistance and ROM. The nurse should document this finding with which of the following ratings? - ANSWER-Normal (5) The nurse palpates a round, fluid filled cyst on the dorsum of the wrist. The nurse interprets this finding as consistent with what? - ANSWER-a ganglion
Have you been treated for cardiovascular disease? Do you know your cholesterol and triglyceride levels? - ANSWER-Are you able to perform your activities of daily living? Have you had any weight changes? Do you have any musculoskeletal aches? Have you been treated for cardiovascular disease? In preparing to perform a cardiovascular assessment the nurse should initially place the client in which position? - ANSWER-sitting upright When palpating the carotid arteries it is essential that the nurse do which of the following? - ANSWER-Avoid palpating the arteries simultaneously What approach would the nurse use to elicit the cooperation of a school-age child during a cardiovascular examination? - ANSWER-permit the child to listen to their parent's chest with the stethoscope The client has a history of aortic stenosis and an S3murmur. What action would the nurse take to auscultate this murmur? - ANSWER-use the bell of the stethoscope When auscultating the apical pulse the nurse should assess for which characteristics? Select all that apply. Rate Intensity Temperature Regularity Rhythm - ANSWER-Rate Intensity Regularity Rhythm The nurse caring for a client experiencing chest discomfort should obtain which assessment data from the client? Presence of a fever Description of the pain and its location Recent weight gain Whether the client smokes - ANSWER-Description of the pain and its location During inspection of the carotid arteries the nurse assesses a bounding pulse. The nurse should evaluate the client for which additional finding? - ANSWER-fever
The nurse is performing a cardiovascular assessment. To evaluate the client for pulmonary edema the nurse would assess the client for which manifestation? - ANSWER-Shortness of breath When assessing the abdomen, the nurse performs the following examination techniques. In which sequence should the nurse complete the assessment? Place the answers in the correct order. Auscultation Palpation Inspection Percussion - ANSWER-Inspection Auscultation Palpation Percussion When obtaining information about appetite from a client who reports not feeling hungry in the last few weeks, the nurse should ask the client which questions? Select all that apply. Has your weight changed? Can you complete a dietary recall? Have you had any changes in your elimination patterns? When did you notice your appetite change? Are you experiencing any additional symptoms associated with the weight change?
- ANSWER-Has your weight changed? Can you complete a dietary recall? When did you notice your appetite change? Are you experiencing any additional symptoms associated with the weight change? To assess whether a client is having symptoms of abdominal problems, the nurse would ask him or her about which of the following? Select all that apply. Nausea Indigestion Vomiting Fever Dietary intake - ANSWER-Nausea Indigestion Vomiting
CHF
Renal Failure
