Question 1

When performing an assessment of the cardiovascular system,the nurse evaluates the skin and nails of the patient.Inadequate tissue perfusion is known as ______________.

Accepted Answer

A)  ischemia 
B)  anemia 
C)  cyanosis 
D)  necrosis 
A)  ischemia 
B)  anemia 
C)  cyanosis 
D)  necrosis A

Question 2

While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart failure,the nurse is unable to palpate the point of maximal impulse (PMI)with the patient lying supine.What might her next step be?

Accepted Answer

A)  Have the patient turn onto his left side. 
B)  Have the patient lean forward. 
C)  Have the patient move to a sitting position. 
D)  Palpate the PMI to the right of the midclavicular line. 
A)  Have the patient turn onto his left side. 
B)  Have the patient lean forward. 
C)  Have the patient move to a sitting position. 
D)  Palpate the PMI to the right of the midclavicular line. A

Question 3

Which of the following may an unregulated care provider (UCP)be responsible for determining?

Accepted Answer

A)  Vital signs 
B)  Cranial nerve function 
C)  Neck vein distension 
D)  Auscultation of bowel sounds 
A)  Vital signs 
B)  Cranial nerve function 
C)  Neck vein distension 
D)  Auscultation of bowel sounds A

Question 4

What should the nurse do when preparing to complete an assessment for a 16-year-old patient?

Accepted Answer

A)  Focus on illness behaviours. 
B)  Plan for a diminished energy level. 
C)  Treat the patient as an individual. 
D)  Have the parents present throughout. 
A)  Focus on illness behaviours. 
B)  Plan for a diminished energy level. 
C)  Treat the patient as an individual. 
D)  Have the parents present throughout.

Question 5

Which is the best position in which to place the patient to hear low-pitched cardiovascular sounds?

Accepted Answer

A)  Supine 
B)  Sitting up 
C)  Dorsal recumbent 
D)  Left lateral recumbent 
A)  Supine 
B)  Sitting up 
C)  Dorsal recumbent 
D)  Left lateral recumbent

Question 6

Where is the pulmonic area for auscultation found?

Accepted Answer

A)  Second intercostal space on the right side 
B)  Second intercostal space on the left side 
C)  Third intercostal space (Erb's point) 
D)  Fourth intercostal space along the sternum 
A)  Second intercostal space on the right side 
B)  Second intercostal space on the left side 
C)  Third intercostal space (Erb's point) 
D)  Fourth intercostal space along the sternum

Question 7

Which technique is most appropriate for a nurse to implement during the assessment of the abdomen?

Accepted Answer

A)  Assessing painful areas first 
B)  Auscultating for 5 minutes over each quadrant 
C)  Positioning the patient in a supine position with the arms behind or over the head 
D)  Palpating painful masses or organ enlargement deeply and firmly 
A)  Assessing painful areas first 
B)  Auscultating for 5 minutes over each quadrant 
C)  Positioning the patient in a supine position with the arms behind or over the head 
D)  Palpating painful masses or organ enlargement deeply and firmly

Question 8

The nurse is preparing to examine a comatose patient on a ventilator.Before beginning the procedures,she (Select all that apply.)

Accepted Answer

A)  speaks to the patient to minimize anxiety. 
B)  drapes the body parts not being examined. 
C)  encourages the patient to ask questions. 
D)  uses medical terms to let the patient know that she is professional. 
A)  speaks to the patient to minimize anxiety. 
B)  drapes the body parts not being examined. 
C)  encourages the patient to ask questions. 
D)  uses medical terms to let the patient know that she is professional.

Question 9

In providing a physical assessment of an 88-year-old patient,the nurse should

Accepted Answer

A)  do it as quickly as possible to prevent fatigue. 
B)  assume that the patient will have disabilities. 
C)  prepare to perform a mental status examination. 
D)  always do the exam in the small exam room to prevent chills. 
A)  do it as quickly as possible to prevent fatigue. 
B)  assume that the patient will have disabilities. 
C)  prepare to perform a mental status examination. 
D)  always do the exam in the small exam room to prevent chills.

Question 10

During assessment of a patient with anemia,a nurse is alert for the presence of

Accepted Answer

A)  pallor. 
B)  jaundice. 
C)  cyanosis. 
D)  erythema. 
A)  pallor. 
B)  jaundice. 
C)  cyanosis. 
D)  erythema.

Question 11

A late sign of decreased oxygen levels may cause a change in skin colour known as _________.

Accepted Answer

A)  erythema 
B)  anemia 
C)  cyanosis 
D)  jaundice 
A)  erythema 
B)  anemia 
C)  cyanosis 
D)  jaundice

Question 12

Which of the following is an expected outcome for a patient after cardiac assessment?

Accepted Answer

A)  Apical pulse rate equals 58 beats per minute 
B)  Carotid bruits present 
C)  Point of maximal impulse (PMI)palpable at left fifth intercostal space at midclavicular line 
D)  Jugular veins distended with patient in sitting position 
A)  Apical pulse rate equals 58 beats per minute 
B)  Carotid bruits present 
C)  Point of maximal impulse (PMI)palpable at left fifth intercostal space at midclavicular line 
D)  Jugular veins distended with patient in sitting position

Question 13

Increased visibility of oxyhemoglobin caused by dilation or increased blood flow is known as ________________.

Accepted Answer

A)  erythema 
B)  anemia 
C)  cyanosis 
D)  jaundice 
A)  erythema 
B)  anemia 
C)  cyanosis 
D)  jaundice

Question 14

The patient is admitted with fever and acute lower abdominal pain.He has taken Tylenol but says he still feels feverish.Before taking the patient's temperature,the nurse may

Accepted Answer

A)  touch the patient's skin with the dorsum of her hand. 
B)  touch the patient's skin with the pads of her fingers. 
C)  palpate the skin using the bimanual method. 
D)  tap the patient's skin using the fingertips. 
A)  touch the patient's skin with the dorsum of her hand. 
B)  touch the patient's skin with the pads of her fingers. 
C)  palpate the skin using the bimanual method. 
D)  tap the patient's skin using the fingertips.

Question 15

A nurse is documenting a patient's breath sounds.Rhonchi are heard as

Accepted Answer

A)  loud,low-pitched,coarse sounds. 
B)  high-pitched,musical squeaks. 
C)  dry,grating sounds on inspiration. 
D)  high-pitched,fine sounds at the end of inspiration. 
A)  loud,low-pitched,coarse sounds. 
B)  high-pitched,musical squeaks. 
C)  dry,grating sounds on inspiration. 
D)  high-pitched,fine sounds at the end of inspiration.

Question 16

How should the nurse document an exaggeration of the posterior curvature of the thoracic spine found during the assessment of a 90-year-old patient?

Accepted Answer

A)  Lordosis 
B)  Osteoporosis 
C)  Scoliosis 
D)  Kyphosis 
A)  Lordosis 
B)  Osteoporosis 
C)  Scoliosis 
D)  Kyphosis

Question 17

The nurse is preparing to examine a patient who has chronic lung disease.She realizes that the patient most likely will need to be in which position for the examination?

Accepted Answer

A)  Sitting upright 
B)  Supine 
C)  Side-lying 
D)  Prone 
A)  Sitting upright 
B)  Supine 
C)  Side-lying 
D)  Prone

Question 18

The nurse is caring for a patient who is recovering from an acute myocardial infarction.While providing cardiac education,the nurse realizes that the patient needs more education when he

Accepted Answer

A)  describes changes in his behaviour that may improve cardiovascular function. 
B)  describes the schedule,dosage,and purpose of his medication. 
C)  states that he will take his medication when he has chest pain or when his heart rate is greater than 100. 
D)  describes the benefits of taking his medication regularly. 
A)  describes changes in his behaviour that may improve cardiovascular function. 
B)  describes the schedule,dosage,and purpose of his medication. 
C)  states that he will take his medication when he has chest pain or when his heart rate is greater than 100. 
D)  describes the benefits of taking his medication regularly.

Question 19

Which of the following is a major cause of lung cancer,cerebrovascular disease,heart disease,and chronic lung disease?

Accepted Answer

A)  Diabetes 
B)  UV exposure 
C)  Radiation 
D)  Smoking 
A)  Diabetes 
B)  UV exposure 
C)  Radiation 
D)  Smoking

Question 20

The purpose of the physical assessment is to (Select all that apply.)

Accepted Answer

A)  compare the patient's status with previous findings. 
B)  help the nurse gather additional data. 
C)  help select the best nursing measures. 
D)  teach patients about better health promotion. 
E)  None of the above 
A)  compare the patient's status with previous findings. 
B)  help the nurse gather additional data. 
C)  help select the best nursing measures. 
D)  teach patients about better health promotion. 
E)  None of the above

Exam 8: Health Assessment

When performing an assessment of the cardiovascular system,the nurse evaluates the skin and nails of the patient.Inadequate tissue perfusion is known as ______________.

While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart failure,the nurse is unable to palpate the point of maximal impulse (PMI)with the patient lying supine.What might her next step be?

Which of the following may an unregulated care provider (UCP)be responsible for determining?

What should the nurse do when preparing to complete an assessment for a 16-year-old patient?

Which is the best position in which to place the patient to hear low-pitched cardiovascular sounds?

Where is the pulmonic area for auscultation found?

Which technique is most appropriate for a nurse to implement during the assessment of the abdomen?

The nurse is preparing to examine a comatose patient on a ventilator.Before beginning the procedures,she (Select all that apply.)

In providing a physical assessment of an 88-year-old patient,the nurse should

During assessment of a patient with anemia,a nurse is alert for the presence of

A late sign of decreased oxygen levels may cause a change in skin colour known as _________.

Which of the following is an expected outcome for a patient after cardiac assessment?

Increased visibility of oxyhemoglobin caused by dilation or increased blood flow is known as ________________.

The patient is admitted with fever and acute lower abdominal pain.He has taken Tylenol but says he still feels feverish.Before taking the patient's temperature,the nurse may

A nurse is documenting a patient's breath sounds.Rhonchi are heard as

How should the nurse document an exaggeration of the posterior curvature of the thoracic spine found during the assessment of a 90-year-old patient?

The nurse is preparing to examine a patient who has chronic lung disease.She realizes that the patient most likely will need to be in which position for the examination?

The nurse is caring for a patient who is recovering from an acute myocardial infarction.While providing cardiac education,the nurse realizes that the patient needs more education when he

Which of the following is a major cause of lung cancer,cerebrovascular disease,heart disease,and chronic lung disease?

The purpose of the physical assessment is to (Select all that apply.)

Evidence-Informed Nursing Practice

Transitions in Care

Communication and Collaboration

Documentation and Informatics

Medical Asepsis

Sterile Technique

Vital Signs

Specimen Collection

Diagnostic Procedures

Safe Patient Handling, transfer, and Positioning

Exercise Mobility

Support Surfaces and Special Beds

Patient Safety

Emergency Preparedness and Disaster Management

Pain Assessment and Management

Palliative Care

Personal Hygiene and Bed Making

Care of the Eye and Ear

Safe Medication Preparation

Nonparenteral Medications

Parenteral Medications

Oxygen Therapy

Performing Chest Physiotherapy

Airway Management

Cardiac Care

Closed Chest Drainage Systems

Emergency Measure for Life Support

Vascular Access and Infusion Therapy

Blood Therapy

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Urinary Elimination and Catheterization

Bowel Elimination and Gastric Intubation

Ostomy Care

Preoperative and Postoperative Care

Intraoperative Care

Prevention and Care of Skin Breakdown

Wound Care Management and Dressings

Therapeutic Use of Heat and Cold

Safety in the Community

Self-Care Teaching in the Community

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