Question 1

A nurse is a preceptor for a nurse who just graduated from nursing school.When caring for a patient,the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment.Which of the following statements made by the new graduate nurse requires the preceptor to intervene?

Accepted Answer

A)   "I will use the information from my assessment to figure out if your antihypertensive medication is working effectively."
B)   "Nursing assessment data are used only to provide information about the effectiveness of your medical care."
C)   "Nurses use data from their patient's physical assessment to determine a patient's educational needs."
D)   "Information gained from physical assessment helps nurses better understand their patients' emotional needs." B

Question 2

A febrile preschool-aged child presents to the after-hours clinic.Varicella is diagnosed on the basis of the illness history and the presence of small,circumscribed skin lesions filled with serous fluid.The nurse documents the varicellar lesions as which type of skin lesion?

Accepted Answer

A)   Vesicle
B)   Wheal
C)   Papule
D)   Pustule A

Question 3

In preparation for a rectal examination of a nonambulatory male patient,the patient is informed of the need to be placed in which position?

Accepted Answer

A)   Sims' position
B)   Forward bending with flexed hips
C)   Knee-chest
D)   Dorsal recumbent A

Question 4

On admission,a patient weighs 250 pounds.The weight is recorded as 256 pounds on the second inpatient day.The nurse should evaluate the patient for

Accepted Answer

A)   Fluid retention.
B)   Fluid loss.
C)   Decreased nutritional reserves.
D)   Anorexia.

Question 5

A nurse suspects an abnormal thyroid shape during the physical examination.The nurse offers the patient a glass of water and observes her drinking to

Accepted Answer

A)   Visualize an enlarged thyroid gland.
B)   Evaluate for exostosis.
C)   Test the patient's gag reflex.
D)   Visualize the uvula and soft palate.

Question 6

During a preschool readiness examination,the nurse prepares to perform visual acuity screenings.Given the children's age,the best equipment to test central vision is which of the following?

Accepted Answer

A)   Snellen test
B)   E chart
C)   Reading test
D)   Penlight

Question 7

During a genitourinary examination of a 30-year-old male patient,the nurse identifies a small amount of a white,thick substance on the patient's uncircumcised glans penis.The nurse's next step is to

Accepted Answer

A)   Notify his provider about a suspected STI.
B)   Recognize this as a normal finding.
C)   Tell the patient to avoid doing self-examinations until symptoms clear.
D)   Avoid embarrassing questions about sexual activity.

Question 8

An elderly patient has been on high doses of antibiotics and is experiencing a sudden loss of hearing.The nurse should contact the health care provider and

Accepted Answer

A)   Stop antibiotic use until the physician responds.
B)   Tell the patient that older patients often lose low-frequency hearing.
C)   Explain that hearing loss usually occurs with thinning of the eardrum.
D)   Assure the patient that rapid hearing loss is normal in the elderly.

Question 9

A teen female patient reports intermittent abdominal pain for 12 hours.No dysuria is present.When performing an abdominal assessment,the nurse should

Accepted Answer

A)   Recommend that the patient take more laxatives.
B)   Ask the patient about the color of her stools.
C)   Avoid sexual references such as possible pregnancy.
D)   Assess first the spots that are most tender.

Question 10

The patient is a 50-year-old African American male who has come in for his routine annual physical.Which of the following preventive screenings does the nurse recommend?

Accepted Answer

A)   Digital rectal examination of the prostate (DR
E)   annually
B)   Ca125 blood test once a year
C)   Complete eye examination every year
D)   Colonoscopy every 3 years

Question 11

Objective physical data describe air moving through small airways over the lung's periphery.The expected inspiratory-to-expiratory phase of this normal vesicular breath sound is which of the following?

Accepted Answer

A)   The inspiratory phase lasts exactly as long as the expiratory phase.
B)   The expiration phase is longer than the inspiration phase.
C)   The expiration phase is two times longer than the inspiration phase.
D)   The inspiratory phase is three times longer than the expiratory phase.

Question 12

Having misplaced his stethoscope,a nurse borrows a colleague's stethoscope.He next enters the patient's room and identifies himself,washes his hands with soap,and states the purpose of his visit.He performs proper identification of the patient before he auscultates her lungs.Which critical health assessment step was not performed?

Accepted Answer

A)   Running warm water over stethoscope for patient comfort
B)   Cleaning stethoscope with Betadine
C)   Using alcohol-based hand disinfectant
D)   Cleaning stethoscope with alcohol

Question 13

During an annual gynecological examination,a college student discusses her upcoming college break at a tropical location.After the student receives an oral contraceptive prescription,the nurse identifies the importance of skin cancer prevention education by discussing which evidence-based prevention health topic?

Accepted Answer

A)   Applying water-based sunscreen only before swimming
B)   Using tanning bed daily for 7 days before college break trip
C)   Applying broad-spectrum sunscreen of SPF 5
D)   Taking extra precautions in the sun secondary to the prescription

Question 14

The nurse is urgently called to the gymnasium regarding an injured student.The student is crying in severe pain with a malformed fractured lower leg.The proper sequence for the nurse's initial assessment is

Accepted Answer

A)   Deep palpation, light palpation, inspection.
B)   Light palpation, deep palpation, inspection.
C)   Inspection, light palpation.
D)   Auscultation, deep palpation, light palpation.

Question 15

During a routine pediatric history and physical,the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual.They state that the infant was yellow when born,and that he developed an infection that required "every antibiotic under the sun" to cure him.Considering the neonatal history,the nurse determines that it is especially important to perform a focused _____ examination.

Accepted Answer

A)   Cardiac
B)   Respiratory
C)   Ophthalmic
D)   Hearing acuity

Question 16

The paramedics transport an adult involved in a motor vehicle accident to the emergency department.On physical examination,the patient's level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli.The nurse correctly identifies the patient's Glasgow Coma Scale score as

Accepted Answer

A)   5.
B)   7.
C)   9.
D)   11.

Question 17

During a routine physical examination of a 70-year-old patient,a blowing sound is auscultated over the carotid artery.The nurse notifies the medical provider of the unexpected physical finding known as

Accepted Answer

A)   Clubbing.
B)   Bruit.
C)   Right-sided heart failure.
D)   Phlebitis.

Question 18

A nurse identifies Pediculosis humananus capitis.Considering the possible complications of treatment,the nurse knows to not use which of the following treatment products?

Accepted Answer

A)   Fine-toothed comb
B)   Pediculicide
C)   Lindane-based shampoo
D)   Vinegar hair rinse

Question 19

During a school physical examination,the nurse reviews the patient's current medical history.With a positive medical history of asthma,eczema,and allergic rhinitis,the nurse expects which physical finding on nasal examination?

Accepted Answer

A)   Polyp
B)   Yellow discharge
C)   Pale nasal mucosa
D)   Puffiness of nasal mucosa

Question 20

The best term for breath sounds created by air moving through large lung airways is

Accepted Answer

A)   Bronchovesicular.
B)   Rhonchi.
C)   Bronchial.
D)   Vesicular.

Exam 30: Health Assessment and Physical Examination