Question 1

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

Accepted Answer

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

Question 2

The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube for intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient?

Accepted Answer

A) Avoid palpating the patient's abdomen. 
B) Turn off the suction before auscultating bowel sounds. 
C) Listen for bowel sounds for 2 minutes in each quadrant. 
D) Percuss the abdomen before auscultating bowel sounds.

Question 3

Bronchovesicular breath sounds are best heard over which area?

Accepted Answer

A) Midline over the trachea just below the larynx 
B) Fifth 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 4

An older adult's fingernails appear concave and spoon shaped. The nurse associates this observation with which condition?

Accepted Answer

A) A normal finding in older adults 
B) Chronic lung disease 
C) Iron deficiency 
D) Chronic heart disease

Question 5

The nurse finds a small pulsation at the patient's fifth intercostal space midclavicular line. This should be documented as a:

Accepted Answer

A) Thrill 
B) Murmur 
C) Normal finding 
D) Heave

Question 6

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

Accepted Answer

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

Question 7

The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triages the patient because the nurse knows that this finding, along with other symptoms, might suggest the patient is experiencing which condition?

Accepted Answer

A) Hyperthyroidism 
B) Stroke 
C) Glaucoma 
D) Macular degeneration

Question 8

A father brings his 18-month-old child to the pediatric clinic for a well-baby checkup. The father tells the nurse that he is concerned because the child's legs are bowed. Which response by the nurse is appropriate?

Accepted Answer

A) "Your child will most likely require physical therapy." 
B) "You should consider having your child seen by an orthopedic surgeon." 
C) "This is a normal finding in children for 1 year after they begin walking." 
D) "Your child is walking fine, so you don't need to worry."

Question 9

The nurse on a medical unit notes fluid accumulation in the feet and ankles of a 75-year-old patient. What are the rationales for the nurse performing a physical examination? Select all that apply.

Accepted Answer

A) Obtain baseline data. 
B) Determine health problems. 
C) Address needs of the patient. 
D) Receive reimbursement for care. 
E) Provide discretion and privacy.

Question 10

The nurse is performing a vision examination. In assessing for color blindness, the nurse applies which knowledge? Select all that apply.

Accepted Answer

A) It may be genetically inherited. 
B) It is more common in males. 
C) It may be the result of macular degeneration. 
D) It may be the result of a lens defect of the eye. 
E) It can be tested by using the letters on the Snellen chart.

Question 11

Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult?

Accepted Answer

A) Work rapidly to finish as quickly as possible. 
B) Sequence the examination to limit position changes. 
C) Demonstrate equipment before using it. 
D) Omit portions of the examination that may be tiring.

Question 12

An 85-year-old patient is brought to the emergency department with lethargy and hypotension. As the nurse assesses the patient's tongue, it appears dry and furry. Which condition would the nurse suspect the patient is experiencing?

Accepted Answer

A) Fungal infection 
B) Dehydration 
C) Allergy 
D) Iron deficiency

Question 13

Which information describes the nurse's general survey? Select all that apply.

Accepted Answer

A) Consists of an overall impression of the patient 
B) Assists in identifying deviations that need further exploration 
C) Includes obtaining a full set of vital signs 
D) Includes the comprehensive physical assessment 
E) Focuses solely on the physical

Question 14

The nurse is bathing a newborn infant in the nursery and notices scaly white patches over the infant's scalp. What is the most appropriate action by the nurse?

Accepted Answer

A) Wash the scalp, and apply gentle scrubbing. 
B) Notify the primary care provider. 
C) Obtain a computed tomography (CT) scan of the infant's head. 
D) Assess for patches on the infant's lower torso.

Question 15

When testing near vision, the nurse should position printed text how many inches away from the patient?

Accepted Answer

A) 20 (50.8 cm) 
B) 18 (45.7 cm) 
C) 16 (40.4 cm) 
D) 14 (35.5 cm)

Question 16

Which 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, and then proceed to listening for S2 in all landmark areas. 
C) Use the diaphragm of the stethoscope for normal sounds and 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. 
E) Perform cardiac auscultation from the patient's left side, whenever possible.

Question 17

Abdominal palpation should be avoided in a child who has which disorder?

Accepted Answer

A) Appendicitis 
B) Wilms' tumor 
C) Crohn's disease 
D) Small bowel obstruction

Question 18

When performing a skin assessment, the nurse notices a mole on the patient's upper back. Which actions would the nurse take to further investigate 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. 
E) Avoid palpating the mole.

Question 19

Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea?

Accepted Answer

A) Edema 
B) Hyperhidrosis 
C) Pallor 
D) Tenting

Question 20

While palpating the anterior chest, the nurse notes crackling in the skin around the patient's chest tube insertion site. Which term would the nurse use to document this finding?

Accepted Answer

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

Exam 22: Health Assessment