Question 1

The 4-year-old child's vision is not 20/20. What does this result indicate?

Accepted Answer

A) Strabismus 
B) Anisocoria 
C) Normal finding 
D) Presbyopia

Question 2

While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborn's back and asks, "What's that? Is something wrong with my baby?" Which response by the nurse is best?

Accepted Answer

A) "I'll ask the physician to look at the spot." 
B) "Those spots are quite common and typically fade with time." 
C) "You may want a plastic surgeon to look at that." 
D) "That spot is benign so it's nothing you need to worry about."

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 the class?

Accepted Answer

A) Women 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) Clinical breast exams are recommended for average-risk women at any age. 
D) A breast examination that includes assessment of the breast and axillae is indicated only if the woman is at high risk for breast cancer.

Question 4

A female patient has excessive facial hair. The nurse should document this finding using which term?

Accepted Answer

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

Question 5

The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patient's pulses are:

Accepted Answer

A) Bounding 
B) Normal 
C) Full 
D) Diminished

Question 6

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which findings require 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)  
E) Blood pressure 118/78 mm Hg

Question 7

A patient's jugular venous pressure measures 5 cm. What should this finding indicate to the nurse?

Accepted Answer

A) A normal finding 
B) Hypovolemia 
C) Heart failure 
D) Dehydration

Question 8

The nurse is performing an otoscopic examination on the patient. In assessing the tympanic membrane, the nurse assesses for which normal findings in appearance? Select all that apply.

Accepted Answer

A) Light red 
B) Pearly gray 
C) Shiny 
D) Translucent 
E) Retracted

Question 9

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 using middle fingers. 
D) Lift a fold of skin, and allow it to return to its normal position.

Question 10

The nurse is performing an otoscopic examination on an adult patient. The nurse has the patient tilt head to the side not being examined. Which step should the nurse perform next?

Accepted Answer

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

Question 11

Which abnormal capillary refill finding would the nurse report?

Accepted Answer

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

Question 12

A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the infant?

Accepted Answer

A) Have the mother remain outside the room. 
B) Ask the mother to remove the infant's clothing and diaper. 
C) Weigh the infant with the diaper only. 
D) Place the infant supine on the scale with knees extended.

Question 13

Which statements regarding common neurological changes in older adults are true? Select all that apply.

Accepted Answer

A) Older adults have slower reactions and decreased ability for rapid problem solving. 
B) With advanced age, the number of functioning neurons decreases. 
C) Neurological deficits may be attributed to medications or medication interactions. 
D) With normal aging, memory and the ability to discriminate decrease. 
E) Intelligence decreases during the normal aging process.

Question 14

Which length of time accurately describes when the infant's anterior fontanel (soft spot) typically fuses?

Accepted Answer

A) At about 8 weeks 
B) At about 18 months 
C) By 6 months of age 
D) Before 1 year of age

Question 15

Which abnormal laboratory value is associated with an icteric sclera?

Accepted Answer

A) Occult blood 
B) Bilirubin 
C) Hemoglobin 
D) Glucose

Exam 22: Health Assessment