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NUR2092 Health Assessment / Health
Assessment Final Exam: Review Questions
An elderly patient is admitted to the hospital. While performing a skin assessment, the nurse discovers bruises in various stages of healing all over the patient's body. Why is it important for the nurse to promptly document and report these findings? a.The patient may have been abused. b.The patient is elderly. c.The patient may have peripheral vascular disease. d.The patient may have a cognitive deficit. - ANSWER a. The patient may have been abused When the nurse observes the patient for general characteristics including age, gender, and level of alertness, what aspect of assessment are you performing? a.Inspecting b.Interviewing c.Palpating d.Ausculating - ANSWER a. Inspecting
The four areas to consider during the general survey include: a. Dress, medical history, nonverbal behavior, and mobility. b.Ethnicity, gender, age, and socioeconomic status. c.Physical appearance, gender, ethnicity, and medical history. d.Physical appearance, body structure, mobility, and behavior. - ANSWER d. Physical appearance, body structure, mobility, and behavior. When reading the patient's medical record, the nurse sees the following notation: Patient states, "I have had a cold for about a week, and I am having difficulty breathing." This is an example of: a.A past health history. b.A review of systems. c.A functioning assessment. d.A chief compliant. - ANSWER d.A chief compliant. Normal cervical lymph nodes are: a.Smaller than 1 cm b.Warm and red c.Fixed d.Firm - ANSWER a.Smaller than 1 cm The first step to cultural competency by a nurse is to:
a.The palms of the hands. b.The back of the hands c.The fingertips. d.The ventral surfaces of the hands. - ANSWER b.The back of the hands The nurse is conducting a patient interview and responds to the patient in a way that encourages the patient to more completely describe his or her problems. What is this called? a.Guided questioning b.Focusing c.Clarification d.Restatement - ANSWER a.Guided questioning A risk factor for melanoma is: a.Brown eyes b.Darkly pigmented skin c.Use of sunscreen products d.Skin that freckles or burns before tanning - ANSWER d.Skin that freckles or burns before tanning
What is the nurse assessing when asking the patient, "What things seem to make it better?" a.Relieving/exacerbating factors b.Functional goal c.Pain goal d.Duration - ANSWER a.Relieving/exacerbating factors The nurse examines the nail beds of a patient. Which findings indicates a normal angle? a.160 degrees b.100 degrees c.60 degrees d.180 degrees - ANSWER a.160 degrees The nurse notes the appearance of freckles while assessing a patient's skin. What is the appropriate term to use when documenting this finding? a.Macules b.Vesicles c.Bulla d.Patches - ANSWER a.Macules To assess for early jaundiced, the nurse should assess:
The nurse is conducting an interview in the room of a newly admitted patient. Because the nurse is expecting a phone call, the nurse stands near the door. Which would have been a more appropriate approach? a.Use this approach given the circumstances. b.Arrange for a time free of interruptions after the initial physical examination is complete. c.Have someone else answer the phone so their full attention was focused on the patient. d.Arrange to have someone notify them when the call came, thus allowing the nurse to sit on the side of the bed. - ANSWER c.Have someone else answer the phone so their full attention was focused on the patient. While interviewing a patient, the nurse asks, "What happens when you have low blood glucose?" This type of response to the patient is used for what purpose? a.To promote objectivity. b.To summarize the conversion. c.To clarify. d.To restate what the patient has said. - ANSWER c.To clarify. The nurse performs a head and neck assessment on an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? a.Refer the patient to their primary care provider. b.Position the patient supine and reattempt palpation.
c.Perform a focused endocrine exam. d.Document this as an expected assessment finding. - ANSWER d.Document this as an expected assessment finding. The nurse is admitting a 27 year old patient to the hospital's medical unit. While performing the admission assessment, the patient tells the nurse that she is being abused by her spouse. Which of the following is the nurse's best action? a. Make a referral to the social worker. b. Make a referral to the hospital chaplin. c. Report the abuse to the hospital CEO. d. Call 911 immediately. - ANSWER a. Make a referral to the social worker. While completing a neurological assessment, a nurse is assessing a patient for abnormalities of gait. The nurse is concerned that the patient is at increased risk for a fall. Which instruction should the nurse give the patient first? a."Walk heel to toe." b."Hop on one foot." c."Walk across the room and back." d."Walk on your toes then on your heels." - ANSWER c."Walk across the room and back."
The nurse is examining the movements of a patient's eyes through each of the 6 cardinal gazes. Which crainal nerves are being assessed by the nurse? a.Abducens nerve b.Facial nerve c. Hypoglossal nerve d.Oculomotor nerve e.Trochlear nerve - ANSWER a.Abducens nerve d.Oculomotor nerve e.Trochlear nerve Your patient has a productive cough and is expectorating yellow mucous at times. Which breath sound would the nurse expect to auscultate due to the presence of mucous in this patient's respiratory tract? a.Absent b.Crackles c.Stridor d.Rhonchi - ANSWER d.Rhonchi When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the patient to do? a.Clench the teeth b.Smell coffee beans c.Smile
d.Cover one eye - ANSWER c.Smile A patient's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding? a.Right knee+4; Left knee + b.Right knee +1; Left knee 0 c.Right knee +2; Left knee + d.Right knee +3; Left knee +2 - ANSWER c.Right knee +2; Left knee + The nurse is completing a neurological assessment on a patient. To test for stereognosis the nurse would: a.Have the person close his or her eyes and then raise the patient's arm and ask them to describe its location. b.Touch the patient with a cold object. c.Place a coin in the patient's hand and ask him or her to identify it. d.Touch the patient with a tuning fork. - ANSWER c.Place a coin in the patient's hand and ask him or her to identify it. A patient has a barrel-shaped chest. A barrel - shaped chest is characterized by: a.Anteroposterior to transverse (lateral) diameter of 2:1 and the elevation of the ribs.
Which of the following is considered an 'adventitious' type of breath sounds? a.Bronchial b.Bronchovesicular c.Vesicular d.Wheeze - ANSWER d.Wheeze While conducting a mental status history, the nurse notes that the patient is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the mental health assessment is this information most important? a.Thoughts and perception b.Mood c.Appearance and behavior d.Speech and language - ANSWER d.Speech and language Which of the following assessments best confirms the approach to check for symmetric chest expansion? a.Placing hands on the posterior chest wall with thumbs at the level of T10 and then sliding the hands up to pinch a small fold of skin between the thumbs. b.Inspection of the shape and configuration of the chest wall. c.Placing the palmer surface of the fingers of one hand against the chest and having the person repeat the words "ninety- nine". d.Tapping with your fingers on multiple areas of the chest anteriorly and posteriorly. - ANSWER a.Placing hands on the posterior
chest wall with thumbs at the level of T10 and then sliding the hands up to pinch a small fold of skin between the thumbs. A nurse is caring for a patient with an injury to Broca's area. Which finding would the nurse expect to assess in this patient? a.Difficulty speaking b.Receptive aphasia c.Visual disturbances d.Emotional lability - ANSWER a.Difficulty speaking Fine crackles are best detected by: a.Palpation b.Auscultation c.Observation d.Percussion - ANSWER b.Auscultation Which muscles are tested for muscle strength when the nurse assesses the function of cranial nerve XI (spinal accessory nerve)? Select all that apply. a.Biceps b.Quadriceps c.Sternomastoid d.Trapezius - ANSWER c.Sternomastoid
A patient is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the patient is demonstrating motor function of which cranial nerve? a.Facial b.Glossopharyngeal c.Trigeminal d.Vagus - ANSWER c.Trigeminal When examining for tactile fremitus, it is important for the nurse to: a.Ask the patient to breath quickly. b.Ask the patient to cough. c.Use the bell of the stethoscope. d.Palpate and compare areas bilaterally. - ANSWER d.Palpate and compare areas bilaterally. The Glasgow Coma Scale (GCS) is divided into three areas. These include: a.Orientation, rapid alternating movements, and the Romberg test. b.Pupillary response, a reflex test, and assessing pain. c.Response to fine touch, stereognosis, and sense of position. d.Eye opening, motor response to stimuli, and verbal response. - ANSWER d.Eye opening, motor response to stimuli, and verbal response.
A patient with a history of depression and manic episodes acknowledges suicidal thinking over the past week and verbalized a plan. What are you most concerned about initially in caring for this patient? a.Mental health b.Mental status c.Neurologic function d.Safety - ANSWER d.Safety
