NURSING ADVANCED HEALTH ASSESSMENT EXAM Q & A 2024, Exams of Nursing

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NURSING 7410

Advanced Health

Assessment

Q & A w/ Rationales

1. Which assessment technique is used to evaluate the quality and intensity of breath sounds? a. Inspection b. Percussion c. Auscultation d. Palpation Answer: c. Auscultation Rationale: Auscultation involves using a stethoscope to listen to various body sounds, including breath sounds. This technique helps assess the quality, intensity, and characteristics of breath sounds to identify any abnormalities.
2. A nurse is assessing a patient and notes a palpable vibration over the chest wall. Which assessment technique should be utilized to further evaluate this finding? a. Inspection b. Percussion c. Auscultation d. Palpation Answer: d. Palpation Rationale: Palpation involves using touch to assess the body surface and underlying structures. The presence of a palpable vibration over the chest wall signifies tactile fremitus, which can be assessed by palpation.
3. During an abdominal assessment, the nurse performs deep palpation to assess:

d. Cranial nerve XII Answer: d. Cranial nerve XII Rationale: Assessing tongue movement helps evaluate the function of cranial nerve XII - the hypoglossal nerve. This nerve controls the muscles responsible for tongue movement and speech articulation.

6. The nurse is assessing a patient's cardiovascular system and measures the blood pressure in both arms. A difference of >10 mmHg between the arms should raise suspicion of: a. Peripheral artery disease b. Aortic aneurysm c. Coarctation of the aorta d. Deep vein thrombosis Answer: c. Coarctation of the aorta Rationale: A difference of >10 mmHg between the arms in blood pressure measurements may indicate coarctation of the aorta, which is a narrowing of the aorta. This condition can cause unequal blood flow to the upper extremities.
7. A nurse is assessing a patient's pain level using a pain rating scale. Which scale is commonly used to assess pain intensity in non-verbal patients? a. FLACC scale b. Numeric Rating Scale (NRS) c. Visual Analog Scale (VAS) d. Wong-Baker FACES Pain Rating Scale

Answer: a. FLACC scale Rationale: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is commonly used to assess pain intensity in non-verbal patients, such as infants or individuals with cognitive impairment.

8. A nurse is assessing a patient's skin turgor to evaluate hydration status. A delayed return to normal skin contour is indicative of: a. Dehydration b. Excessive moisture c. Allergic reaction d. Normal skin elasticity Answer: a. Dehydration Rationale: Normal skin turgor indicates adequate hydration. A delayed return to normal skin contour suggests dehydration, as the skin loses its elasticity due to reduced fluid volume.
9. During an assessment of a patient's musculoskeletal system, the nurse observes a visible curvature of the spine when the patient bends forward. This finding is consistent with: a. Lordosis b. Kyphosis c. Scoliosis d. Hyperextension Answer: c. Scoliosis

Rationale: The ankle-brachial index (ABI) is a non- invasive test used to evaluate arterial circulation and assess for peripheral artery disease (PAD). It compares the blood pressure in the ankles to that in the arms.

12. During an abdominal assessment, the nurse uses light palpation to assess for areas of tenderness, muscle guarding, and surface characteristics. Which depth should the nurse use during light palpation? a. 0-1 cm b. 1-2 cm c. 2-3 cm d. 3-4 cm Answer: a. 0-1 cm Rationale: Light palpation involves using gentle pressure with the fingertips to assess superficial structures and evaluate areas of tenderness, muscle guarding, and surface characteristics. The depth of light palpation is approximately 0-1 cm.
13. A nurse is performing a focused respiratory assessment and notes a high-pitched, musical sound heard during inspiration. This finding is indicative of: a. Rhonchi b. Wheezes c. Crackles d. Friction rub Answer: b. Wheezes

Rationale: Wheezes are high-pitched, musical sounds heard during inspiration or expiration. They result from narrowed airways due to bronchospasm, inflammation, or excessive mucus production.

14. The nurse is assessing a patient's cranial nerves and asks the patient to shrug their shoulders against resistance. This assesses the function of which cranial nerve? a. Cranial nerve IX b. Cranial nerve X c. Cranial nerve XI d. Cranial nerve XII Answer: c. Cranial nerve XI Rationale: Assessing shoulder shrug against resistance evaluates the function of cranial nerve XI - the accessory nerve. This nerve controls the trapezius and sternocleidomastoid muscles, necessary for shoulder movement and head rotation. 1 5. During a cardiac assessment, the nurse identifies a harsh, grating sound heard on auscultation of the precordium. This finding is consistent with: a. S3 heart sound b. S4 heart sound c. Pericardial friction rub d. Murmur Answer: c. Pericardial friction rub Rationale: A pericardial friction rub is the result of

Rationale: Given the characteristics of the mass, scheduling a mammogram is essential to further evaluate the nature of the mass and rule out malignancy. A 65-year-old male patient presents with unilateral facial drooping, slurred speech, and weakness in the right arm. The nurse suspects a cerebrovascular accident (CVA). What assessment tool should the nurse utilize to quickly assess the severity of the patient's symptoms? a) National Institutes of Health Stroke Scale (NIHSS) b) Glasgow Coma Scale (GCS) c) Mini-Mental State Examination (MMSE) d) Montreal Cognitive Assessment (MoCA) Answer: a) National Institutes of Health Stroke Scale (NIHSS) Rationale: The NIHSS is specifically designed to assess the severity of stroke symptoms and is a crucial tool in the rapid evaluation of stroke patients. A 30-year-old female patient complains of recurrent abdominal pain, bloating, and altered bowel habits. The nurse suspects irritable bowel syndrome (IBS). Which diagnostic test is most appropriate for confirming the diagnosis? a) Colonoscopy b) Abdominal ultrasound c) Stool culture d) Rome IV criteria assessment Answer: d) Rome IV criteria assessment Rationale: Diagnosis of IBS is primarily based on

symptom assessment and adherence to the Rome IV criteria, which involves specific guidelines for the diagnosis of functional gastrointestinal disorders. A 55-year-old male patient with a history of hypertension presents with sudden, severe, tearing chest and back pain. The nurse should suspect which life-threatening condition? a) Acute myocardial infarction b) Aortic dissection c) Pulmonary embolism d) Esophageal rupture Answer: b) Aortic dissection Rationale: The sudden onset of tearing chest and back pain in a patient with hypertension raises concern for aortic dissection, a potentially fatal condition that requires immediate medical intervention. A 70-year-old female patient presents with involuntary trembling of the hands at rest. The nurse should recognize this as a cardinal sign of which neurological disorder? a) Parkinson's disease b) Amyotrophic lateral sclerosis (ALS) c) Multiple sclerosis (MS) d) Huntington's disease Answer: a) Parkinson's disease Rationale: Involuntary trembling at rest, known as resting tremor, is a hallmark symptom of Parkinson's disease, a progressive neurological disorder. A 60-year-old male patient reports a sudden, severe

Which laboratory test is most specific for confirming the diagnosis? a) Erythrocyte sedimentation rate (ESR) b) C-reactive protein (CRP) c) Antinuclear antibody (ANA) test d) Anti-neutrophil cytoplasmic antibody (ANCA) test Answer: d) Anti-neutrophil cytoplasmic antibody (ANCA) test Rationale: The presence of ANCA is highly specific for certain types of vasculitis, particularly granulomatosis with polyangiitis and microscopic polyangiitis. A 35-year-old female patient presents with fatigue, weight gain, cold intolerance, and dry skin. The nurse suspects hypothyroidism. Which laboratory test is the most sensitive indicator of thyroid function? a) Thyroid-stimulating hormone (TSH) b) Free thyroxine (T4) c) Total triiodothyronine (T3) d) Thyroid peroxidase antibodies (TPOAb) Answer: a) Thyroid-stimulating hormone (TSH) Rationale: TSH is the most sensitive indicator of thyroid function, as it reflects the body's overall thyroid hormone status and is often the initial test for assessing thyroid function. A 55-year-old male patient with a history of chronic alcohol abuse presents with ascites, jaundice, and spider angiomas. The nurse suspects cirrhosis. Which diagnostic test is most specific for confirming the presence of

cirrhosis? a) Liver ultrasound b) Liver biopsy c) Serum alpha-fetoprotein (AFP) level d) Prothrombin time (PT) Answer: b) Liver biopsy Rationale: Liver biopsy is the most specific test for confirming the presence of cirrhosis, as it allows for direct visualization of liver tissue architecture and assessment of fibrosis. A 70-year-old female patient presents with sudden-onset right-sided weakness and slurred speech. The nurse suspects an acute ischemic stroke. Which imaging modality is most appropriate for rapidly assessing the presence of a cerebral infarction? a) Non-contrast CT scan b) MRI of the brain c) Transcranial Doppler ultrasound d) Cerebral angiography Answer: a) Non-contrast CT scan Rationale: A non-contrast CT scan is the imaging modality of choice for rapidly assessing the presence of a cerebral infarction, as it can quickly rule out hemorrhagic stroke and identify early signs of ischemic stroke. A 45-year-old male patient presents with persistent, non- radiating epigastric pain that worsens after meals and is relieved by antacids. The nurse suspects peptic ulcer disease. Which diagnostic test is most appropriate for

of aortic dissection? a) CT angiography b) MRI angiography c) Transthoracic echocardiography d) Aortic angiography Answer: a) CT angiography Rationale: CT angiography is the gold standard for confirming the diagnosis of aortic dissection, as it provides detailed visualization of the aorta and can accurately delineate the extent of the dissection. C:

1. A 45-year-old male patient presents with chest pain, dyspnea, diaphoresis, and nausea. He has a history of hypertension, diabetes, and smoking. You suspect he is having an acute myocardial infarction (AMI). What is the most appropriate initial diagnostic test to confirm your suspicion? a) Electrocardiogram (ECG) b) Cardiac enzymes c) Chest X-ray d) Echocardiogram Answer: a) Electrocardiogram (ECG) Rationale: An ECG is the most sensitive and specific test to diagnose an AMI, as it can detect changes in the electrical activity of the heart due to ischemia or necrosis of the myocardial tissue. Cardiac enzymes, such as troponin and creatine kinase, are also useful to confirm an AMI, but they

may take several hours to rise after the onset of symptoms. A chest X-ray can rule out other causes of chest pain, such as pneumonia or pneumothorax, but it cannot diagnose an AMI. An echocardiogram can assess the function and structure of the heart, but it is not as readily available or accurate as an ECG.

2. A 60-year-old female patient complains of fatigue, weight gain, dry skin, hair loss, and constipation. She has a history of hypothyroidism and takes levothyroxine daily. You suspect she has inadequate thyroid hormone replacement. What is the most appropriate laboratory test to evaluate her thyroid function? a) Thyroid-stimulating hormone (TSH) b) Free thyroxine (FT4) c) Total thyroxine (TT4) d) Triiodothyronine (T3) Answer: a) Thyroid-stimulating hormone (TSH) Rationale: TSH is the most sensitive and reliable indicator of thyroid function, as it reflects the feedback mechanism between the hypothalamus, pituitary gland, and thyroid gland. A high TSH level indicates hypothyroidism, as it means that the pituitary gland is stimulating the thyroid gland to produce more thyroid hormones. FT4, TT4, and T3 are also measures of thyroid hormones, but they can be affected by various factors, such as medications, illness, and binding proteins. Therefore, they are not as accurate or consistent as TSH.
3. A 35-year-old female patient presents with fever, chills,

test to confirm your diagnosis and determine the extent of the disease? a) Barium swallow b) Esophagogastroduodenoscopy (EGD) c) Esophageal manometry d) Computed tomography (CT) scan Answer: b) Esophagogastroduodenoscopy (EGD) Rationale: An EGD is the most definitive test for diagnosing esophageal cancer, as it allows direct visualization of the esophagus and biopsy of any suspicious lesions. It can also assess the degree of obstruction or invasion of the tumor into surrounding tissues. A barium swallow can show structural abnormalities of the esophagus, such as narrowing or ulceration, but it cannot confirm the presence or type of cancer. Esophageal manometry can measure the pressure and motility of the esophagus, but it is mainly used to diagnose esophageal motility disorders, such as achalasia or spasm. A CT scan can provide cross-sectional images of the chest and abdomen and detect any metastasis to the lymph nodes or other organs, but it cannot diagnose esophageal cancer by itself.

5. A 25-year-old female patient presents with amenorrhea, hirsutism, acne, obesity, and infertility. She has a history of irregular menstrual cycles and polycystic ovary syndrome (PCOS). You suspect she has hyperandrogenism, which is an excess of male hormones. What is the most appropriate laboratory test to evaluate her androgen levels? a) Luteinizing hormone (LH) and follicle-stimulating

hormone (FSH) b) Testosterone and dehydroepiandrosterone sulfate (DHEAS) c) Prolactin and thyroid-stimulating hormone (TSH) d) Estradiol and progesterone Answer: b) Testosterone and dehydroepiandrosterone sulfate (DHEAS) Rationale: Testosterone and DHEAS are the main androgens in women, and they are elevated in hyperandrogenism. Testosterone is produced by the ovaries and the adrenal glands, while DHEAS is mainly produced by the adrenal glands. Measuring both hormones can help determine the source of hyperandrogenism and guide the treatment. LH and FSH are pituitary hormones that regulate ovulation and ovarian function, and they are often imbalanced in PCOS, but they are not direct measures of androgen levels. Prolactin and TSH are also pituitary hormones that can affect menstrual cycles and fertility, but they are not related to hyperandrogenism. Estradiol and progesterone are female hormones that reflect the ovarian function and cycle phases, but they are not affected by hyperandrogenism.

6. A 40-year-old male patient presents with hematuria, flank pain, fever, and weight loss. He has a history of smoking and hypertension. You suspect he has renal cell carcinoma, which is a type of kidney cancer. What is the most appropriate diagnostic test to confirm your diagnosis and determine the stage of the disease? a) Urinalysis