Question 1

Bronchovesicular breath sounds are best heard over which area?

Accepted Answer

A)  Midline over the trachea just below the larynx 
B)  Fourth intercostal space, in the midclavicular line 
C)  First and second intercostal spaces next to the sternum 
D)  At the base of the lungs near the diaphragm 
A)  Midline over the trachea just below the larynx 
B)  Fourth intercostal space, in the midclavicular line 
C)  First and second intercostal spaces next to the sternum 
D)  At the base of the lungs near the diaphragm

Question 2

Which of the following is an abnormal capillary refill finding that the nurse should report?

Accepted Answer

A)  1 second 
B)  2 seconds 
C)  3 seconds 
D)  4 seconds 
A)  1 second 
B)  2 seconds 
C)  3 seconds 
D)  4 seconds

Question 3

The nurse is planning a breast examination class for a group of women at a community health fair.In planning the class,what is most important for the nurse to consider in preparation for her class?

Accepted Answer

A)  Patients who perform breast self-examinations should be trained in proper technique to avoid false-negative findings. 
B)  Breast examinations should be performed yearly for all women over the age of 25 years. 
C)  Research indicates that breast examination and mammography are not needed after the age of 70 years. 
D)  A breast examination that includes assessment of the breast and axillae is indicated only if the patient is at high risk for breast cancer. 
A)  Patients who perform breast self-examinations should be trained in proper technique to avoid false-negative findings. 
B)  Breast examinations should be performed yearly for all women over the age of 25 years. 
C)  Research indicates that breast examination and mammography are not needed after the age of 70 years. 
D)  A breast examination that includes assessment of the breast and axillae is indicated only if the patient is at high risk for breast cancer.

Question 4

Which statement best describes the procedure used to assess capillary refill?

Accepted Answer

A)  Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color. 
B)  Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction. 
C)  Tap on the skin with short strokes from your fingers. 
D)  Lift a fold of skin, and allow it to return to its normal position. 
A)  Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color. 
B)  Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction. 
C)  Tap on the skin with short strokes from your fingers. 
D)  Lift a fold of skin, and allow it to return to its normal position.

Question 5

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday.Which finding(s)require(s)further assessment? Select all that apply.

Accepted Answer

A)  Blood pressure 110/64 mm Hg 
B)  Pulse rate 118 beats/min 
C)  Respiratory rate 35 breaths/min 
D)  Oral temperature 98.6°F (37°
C)  
A)  Blood pressure 110/64 mm Hg 
B)  Pulse rate 118 beats/min 
C)  Respiratory rate 35 breaths/min 
D)  Oral temperature 98.6°F (37°
C)

Question 6

Which of the following principles apply when performing a focused assessment of the abdomen? Select all that apply.

Accepted Answer

A)  Ask the patient to empty his bladder prior to the assessment. 
B)  Follow the assessment sequence of inspection, palpation, percussion, and auscultation. 
C)  Position the patient in supine position with knees slightly flexed. 
D)  Begin palpating with light pressure to detect surface characteristics and move to deep palpation. 
A)  Ask the patient to empty his bladder prior to the assessment. 
B)  Follow the assessment sequence of inspection, palpation, percussion, and auscultation. 
C)  Position the patient in supine position with knees slightly flexed. 
D)  Begin palpating with light pressure to detect surface characteristics and move to deep palpation.

Question 7

The nurse is performing an otoscopic examination on an adult patient.She has the patient tilt his head to the side not being examined and looks into the ear canal to make sure a foreign body is not present.Which step should she perform next?

Accepted Answer

A)  Straighten the ear canal by pulling the helix up and back. 
B)  Insert the speculum into the ear canal slowly. 
C)  Test the mobility of the tympanic membrane. 
D)  Straighten the ear canal by pulling the helix down and back. 
A)  Straighten the ear canal by pulling the helix up and back. 
B)  Insert the speculum into the ear canal slowly. 
C)  Test the mobility of the tympanic membrane. 
D)  Straighten the ear canal by pulling the helix down and back.

Question 8

A female patient has excessive facial hair.The nurse should document this finding as:

Accepted Answer

A)  Alopecia 
B)  Albinism 
C)  Hirsutism 
D)  Lanugo 
A)  Alopecia 
B)  Albinism 
C)  Hirsutism 
D)  Lanugo

Question 9

While palpating the anterior chest,the nurse notes crackling in the skin around the patient's chest tube insertion site.The nurse recognizes this finding is:

Accepted Answer

A)  Tactile fremitus 
B)  Egophony 
C)  Bronchophony 
D)  Crepitus 
A)  Tactile fremitus 
B)  Egophony 
C)  Bronchophony 
D)  Crepitus

Question 10

Which of the following is a correct developmental outcome for an infant? The infant's anterior fontanel (soft spot)typically fuses:

Accepted Answer

A)  At about 8 weeks 
B)  At about 14 months 
C)  By 6 months of age 
D)  Before 1 year of age 
A)  At about 8 weeks 
B)  At about 14 months 
C)  By 6 months of age 
D)  Before 1 year of age

Question 11

Which of the following statements describe the proper technique for auscultating heart sounds? Select all that apply.

Accepted Answer

A)  Auscultate in an orderly fashion starting at the aortic area and proceeding to pulmonic, tricuspid, and mitral areas. 
B)  Listen for S1 first in all landmark areas, then proceed to listening for S2 in all landmark areas. 
C)  Use the diaphragm of the stethoscope for normal sounds the bell of the stethoscope to detect any extra sounds. 
D)  Rotate the starting point of landmarks at each patient assessment to detect any changes. 
A)  Auscultate in an orderly fashion starting at the aortic area and proceeding to pulmonic, tricuspid, and mitral areas. 
B)  Listen for S1 first in all landmark areas, then proceed to listening for S2 in all landmark areas. 
C)  Use the diaphragm of the stethoscope for normal sounds the bell of the stethoscope to detect any extra sounds. 
D)  Rotate the starting point of landmarks at each patient assessment to detect any changes.

Question 12

The nurse has completed an external genitalia examination on several female clients in the women's health clinic.Which of the following clients would require an internal genital examination? Select all that apply.

Accepted Answer

A)  Client on hormone therapy 
B)  Client who has had more than three pregnancies 
C)  A client with an abnormal finding on the external examination 
D)  A 22-year-old client who is not sexually active 
A)  Client on hormone therapy 
B)  Client who has had more than three pregnancies 
C)  A client with an abnormal finding on the external examination 
D)  A 22-year-old client who is not sexually active

Question 13

Which assessment question helps assess immediate memory?

Accepted Answer

A)  "How did you get to the hospital today?" 
B)  "Can you repeat the numbers 2, 7, 9 for me?" 
C)  "Do you Knowledge the three items I mentioned earlier?" 
D)  "What was your birth date including the year?" 
A)  "How did you get to the hospital today?" 
B)  "Can you repeat the numbers 2, 7, 9 for me?" 
C)  "Do you Knowledge the three items I mentioned earlier?" 
D)  "What was your birth date including the year?"

Question 14

Which assessment should the nurse perform if she notes a palpable thyroid gland?

Accepted Answer

A)  Illuminate the thyroid gland for the presence of fluid. 
B)  Auscultate the thyroid gland for bruits. 
C)  Percuss the thyroid gland for mass size. 
D)  Measure the thyroid gland to assess change. 
A)  Illuminate the thyroid gland for the presence of fluid. 
B)  Auscultate the thyroid gland for bruits. 
C)  Percuss the thyroid gland for mass size. 
D)  Measure the thyroid gland to assess change.

Question 15

When performing a skin assessment,the nurse notices a mole on the patient's upper back.What are the appropriate actions by the nurse in further investigation of the mole? Select all that apply.

Accepted Answer

A)  Ask the patient about any new moles or changes in moles. 
B)  Do not alarm the patient by asking questions about the mole. 
C)  Measure the mole's diameter and elevation. 
D)  Assess for any exudate on or around the mole. 
A)  Ask the patient about any new moles or changes in moles. 
B)  Do not alarm the patient by asking questions about the mole. 
C)  Measure the mole's diameter and elevation. 
D)  Assess for any exudate on or around the mole.

Question 16

The nurse asks the patient to spread his fingers and then bring them together again.Which of the following is the nurse testing when asking him to bring his fingers together?

Accepted Answer

A)  Abduction 
B)  Adduction 
C)  Flexion 
D)  Extension 
A)  Abduction 
B)  Adduction 
C)  Flexion 
D)  Extension

Question 17

Which abnormal laboratory value is associated with an icteric sclera?

Accepted Answer

A)  Bleeding time 
B)  Bilirubin 
C)  Hemoglobin 
D)  Glucose 
A)  Bleeding time 
B)  Bilirubin 
C)  Hemoglobin 
D)  Glucose

Exam 22: Health Assessment

Bronchovesicular breath sounds are best heard over which area?

Which of the following is an abnormal capillary refill finding that the nurse should report?

The nurse is planning a breast examination class for a group of women at a community health fair.In planning the class,what is most important for the nurse to consider in preparation for her class?

Which statement best describes the procedure used to assess capillary refill?

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday.Which finding(s)require(s)further assessment? Select all that apply.

Which of the following principles apply when performing a focused assessment of the abdomen? Select all that apply.

The nurse is performing an otoscopic examination on an adult patient.She has the patient tilt his head to the side not being examined and looks into the ear canal to make sure a foreign body is not present.Which step should she perform next?

A female patient has excessive facial hair.The nurse should document this finding as:

While palpating the anterior chest,the nurse notes crackling in the skin around the patient's chest tube insertion site.The nurse recognizes this finding is:

Which of the following is a correct developmental outcome for an infant? The infant's anterior fontanel (soft spot)typically fuses:

Which of the following statements describe the proper technique for auscultating heart sounds? Select all that apply.

The nurse has completed an external genitalia examination on several female clients in the women's health clinic.Which of the following clients would require an internal genital examination? Select all that apply.

Which assessment question helps assess immediate memory?

Which assessment should the nurse perform if she notes a palpable thyroid gland?

When performing a skin assessment,the nurse notices a mole on the patient's upper back.What are the appropriate actions by the nurse in further investigation of the mole? Select all that apply.

The nurse asks the patient to spread his fingers and then bring them together again.Which of the following is the nurse testing when asking him to bring his fingers together?

Which abnormal laboratory value is associated with an icteric sclera?

Evolution of Nursing Thought Action

Critical Thinking: Nursing Process

Nursing Process: Assessment

Nursing Process: Diagnosis

Nursing Process: Planning Outcomes

Nursing Process: Planning Interventions

Nursing Process: Implementation Evaluation

Evidence-Based Practice: Theory Research

Life Span: Infancy Through Middle Adulthood

Life Span: Older Adults

Experiencing Health Illness

Stress Adaptation

Psychosocial Health Illness

The Family

Culture Ethnicity

Spirituality

Loss,Grief, Dying

Documenting Reporting

Teaching Learning

Measuring Vital Signs

Communication Therapeutic Relationships

Promoting Asepsis Preventing Infection

Promoting Safety

Facilitating Hygiene

Administering Medications

Nutrition

Urinary Elimination

Bowel Elimination

Sensation,Perception, Cognition

Pain

Physical Activity Mobility

Sexual Health

Sleep and Rest

Skin Integrity-Wound Healing

Oxygenation

Circulation

Fluids,Electrolytes, Acidbase Balance

Perioperative Care

Leading Managing

Nursing Informatics

Promoting Health

Community-Home Health Nursing

Ethics Values

Legal Accountability

Holistic Healing

Filters