HEALTH ASSESSMENT

1. The pancreas of an adult is located

A. Below the diaphragm and below right costal margin
B. High and deep under the diaphragm - can't be palpated
C. Deep in the upper abdomen and is not normally palpable
D. Posterior to the left midaxillary line and posterior to the stomach

2. The nurse is preparing to assess the abdomen of a hospitalized client 2 days after
abdominal surgery. The nurse should first
A. Palpate the incision site
B. Auscultate for bowel sounds

C. Percuss for tympany

D. Inspect the abdominal area

3. If assessing a client for kidney tenderness, where would you begin?

A. Right upper quadrant
B. Left upper quadrant
C. External oblique angle
D. Costovertebral angle

4. Decreased abdominal respiration, the client should be further assessed for

A. Liver disease
B. Umbilical hernia
C. Intestinal obstruction
D. Peritoneal irritation
5. To percuss the liver of an adult, where should the nurse begin the assessment?
A. Right upper quadrant
B. Right lower quadrant
C. Left upper quadrant
D. Left lower quadrant

6. If a client’s umbilicus is enlarged and to the left - what is this indicitive of?
A. Umbilical hernia
B. Ascites
C. Intraabdominal bleeding
D. Pancreatitis

7. To palpate the spleen, where should you begin the assessment?

A. Right upper quadrant
B. Right lower quadrant
C. Left upper quadrant
D. Left lower quadrant

8. The primary function of the gallbladder is to

A. Store and excrete bile
B. Aid in the digestion of protein
C. Produce alkaline hormones
D. Produce hormones

9. To palpate tenderness of an adult's appendix, where should you begin?

A. Left lower quadrant
B. Left upper quadrant
C. Right lower quadrant
 D. Right upper quadrant

10. Which term refers to the pain that has a slower onset, is diffuse, radiates, and is
marked by somatic pain from organs in any body activity?
A. Acute pain
B. Deep pain
C. Chronic pain
D. Superficial pain

11. Newly hired nurse Katy is excited to perform her very first physical assessment with
a 19-year-old client. Which assessment examination requires Katy to wear gloves?
A. Ophthalmic
B. Breast
C. Oral
D. Integumentary

12. Jolo was scheduled for a physical assessment. When percussing the client’s chest,
the nurse would expect to find which assessment data as a normal sign over his lungs?
A. Tympany
B. Dullness
C. Hyperresonance
D. Resonance
Normally, when percussing a client's chest, percussion over the lungs reveals resonance, a
hollow or loud, low-pitched sound of long duration. Tympany is typically heard on percussion
over such areas as a gastric air bubble or the intestine. Dullness is typically heard on
percussion of solid organs, such as the liver or areas of consolidation. Hyperresonance would
be evidenced by percussion over areas of overinflation such as an emphysematous lung.
13. When assessing the lower extremities for arterial function, which intervention should
the nurse perform?
A. Palpating the pedal pulses
B. Performing Allen’s test
C. Assessing the medial malleoli for pitting edema
D. Assessing the Homans’ sign
Palpating the client's pedal pulses assists in determining if arterial blood supply to the lower
extremities is sufficient. Assessing the medial malleoli for pitting edema is appropriate for
assessing venous function of the lower extremity. Allen's test is used to evaluate arterial blood
flow before inserting an arterial line in an upper extremity or obtaining arterial blood gases.
Homans' sign is used to evaluate the possibility of deep vein thrombosis.

14. Which term would the nurse use to document pain at one site that is perceived in
other site?
A. Intractable pain
B. Referred pain
C. Aftermath of pain
D. Phantom pain
Referred pain is pain occurring at one site that is perceived in another site. Referred pain
follows dermatome and nerve root patterns. Phantom pain refers to pain in a part of the body
that is no longer there, such as in amputation. Intractable pain refers to moderate to severe pain
that cannot be relieved by any known treatment. Aftermath of pain, a phase of the pain
experience and the most neglected phase, addresses the client's response to the pain
experience.

15. Physical assessment is being performed to Geoff by Nurse Tine. During the
abdominal examination, Tine should perform the four physical examination techniques
in which sequence?
A. Auscultation immediately after inspection and then percussion and palpation -
Given
B. Percussion, followed by inspection, auscultation, and palpation
C. Palpation of tender areas first and then inspection, percussion, and
auscultation
D. Inspection and then palpation, percussion, and auscultation
 With an abdominal assessment, auscultation always is performed before percussion and
palpation because any abdominal manipulation, such as from palpation or percussion, can alter
bowel sounds. Percussion should never precede inspection or auscultation, and any tender or
painful areas should be palpated last.

16. Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac
function. Which is the best area for auscultating the apical pulse?
A. Aortic arch
B. Pulmonic area - Given
C. Tricuspid area
D. Mitral area

17. Examination of a patient in a supine position reveal distended jugular veins from the
base of the neck to the angle of the jaw. This finding indicates:
A. decreased venous return.
B. increased central venous pressure.
C. increased pulmonary artery capillary pressure
D. left-sided heart failure

18. It is a transparent membrane that focuses the light that enters the eyes to the retina.
A. Lens
B. Sclera
C. Cornea
D. Pupils

19. The chamber of the heart that receives oxygenated blood from the lungs is the:
A. Left atrium
B. Right atrium
C. Left ventricle
D. Right ventricle
20. Ryan underwent an open reduction and internal fixation of the left hip. One day after
the operation, the client is complaining of pain. Which data would cause the nurse to
refrain from administering the pain medication and to notify the health care provider
instead?
A. Left leg in functional anatomic position - Given
B. Left hip dressing dry and intact
C. Left foot cold to touch; no palpable pedal pulse
D. Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute

21. Mrs. Nerd who had abdominal surgery 3 days earlier, complains of sharp, throbbing
abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Which
intervention should the nurse implement first?
A. Assessing the client to rule out possible complications secondary to surgery
B. Checking the client’s chart to determine when pain medication was last
administered
C. Explaining to the client that the pain should not be this severe 3 days
postoperatively
D. Obtaining an order for a stronger pain medication because the client’s pain
has increased

22. During an otoscopic examination, which action should be avoided to prevent the
client from discomfort and injury?
A. Tipping the client’s head away from the examiner and pulling the ear up and
back
B. Inserting the otoscope inferiorly into the distal portion of the external canal
C. Inserting the otoscope superiorly into the proximal two-thirds of the external
canal
D. Bracing the examiner’s hand against the client’s head
23. When assessing the lower extremities for arterial function, which intervention should
the nurse perform?
A. Assessing the medial malleoli for pitting edema
B. Performing Allen’s test
C. Assessing the Homans’ sign
D. Palpating the pedal pulses

24. What equipment would be necessary to complete an evaluation of cranial nerves 9

and 10 during a physical assessment?
A. A cotton ball
B. A penlight
C. An ophthalmoscope – for eye re eeee bubu
D. A tongue depressor and flashlight

25. When a client wishes to improve the appearance of their eyes by removing excess
skin from the face and neck, the nurse should provide teaching regarding which of the
following procedures?
A. Dermabrasion – scraping
B. Rhinoplasty - reshape
C. Blepharoplasty - removes excess skin from the eyelids
D. Rhytidectomy - ere

26. While caring for a client, the nurse notes a pulsating mass in the client’s
periumbilical area. Which of the following assessments is appropriate for the nurse to
perform?
A. Measure the length of the mass
B. Auscultate the mass
C. Percuss the mass
D. Palpate the mass
 Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an
abdominal aneurysm and will form the basis of information given to the provider. The mass should not
be palpated because of the risk of rupture

27. After determining a nursing diagnosis of acute pain, the nurse develops the
following appropriate client-centered goal:
A. Encourage client to implement guided imagery when pain begins.
B. Determine effect of pain intensity on client function.
C. Administer analgesic 30 minutes before physical therapy treatment.
D. Pain intensity reported as a 3 or less during hospital stay.

28. When developing a nursing care plan for a client with a fractured right tibia, the
nurse includes in the plan of care independent nursing interventions, including:
A. Apply a cold pack to the tibia.
B. Elevate the leg 5 inches above the heart.
C. Perform range of motion to right leg every 4 hours.
D. Administer aspirin 325 mg every 4 hours as needed.

29. Which of the following nursing interventions are written correctly? Select all that
apply.
A. Apply continuous passive motion machine during day.
B. Perform neurovascular checks.
C. Elevate head of bed 30 degrees before meals.
D. Change dressing once a shift.
30. A client’s wound is not healing and appears to be worsening with the current
treatment. The nurse first considers:
A. Notifying the physician.
B. Calling the wound care nurse
C. Changing the wound care treatment.
D. Consulting with another nurse.
31. When calling the nurse consultant about a difficult client-centered problem, the
primary nurse is sure to report the following:
A. Length of time the current treatment has been in place.
B. The spouse’s reaction to the client’s dressing change.
C. Client’s concern about the current treatment.
D. Physician’s reluctance to change the current treatment plan.

32. It controls emotions, appetite, water balance, pituitary secretions and control /
affects body temperature.
A. Pons
B. Diencephalon
C. Thalamus
D. Hypothalamus

33. Which of the following cranial nerves is for tongue movement?

A. CN IV
B. CN VIII
C. CN X
D. CN XII

34. How many pairs of Spinal Nerves?

A. 12
B. 16
C. 26
D. 31

35. Which of the following is define as the largest brain region?

A. Pons
B. Midbrain
 C. Cerebellum
D. Cerebrum

36. Which of the following influences personality, judgment, abstract reasoning, social
behavior, language expression, and movement?
A. Parietal lobe
B. Temporal lobe
C. Frontal lobe
D. None of the above

37. In Endocrine System it is also known as the Master Gland?

A. Pituitary gland
B. Thyroid gland
C. Adrenal gland
D. Pineal gland

38. The neural relay cycle for quick response to a harmful sensory stimulus;
A. CNS
B. PNS
C. Reflex arc
D. Immediate response

39. Paired of muscles that allow movement and provide support to the head and neck?
A. Cricoid and parotid
B. Hyoid and Cricoid
C. Vertebra prominens
D. Trapezius and Sternomastoid
40. Healthy eyes are essentials for vision. The tarsal plates of the upper eyelid which of
the following?
A. Tear ducts
B. Meibomian glands
C. Ocular muscles
D. Sebaceous gland

41. In assessing the thoracic area of an adult client, the nurse plans to auscultate for
voice sounds. To assess bronchosphony, the nurse should ask the client to;
A. Repeat the letter “E”
B. Repeat the phrase “ninety-nine”
C. Repeat the letter “A”
D. Whisper the phrase “one-two-three”

42. Heart Murmurs occurs when the leaflets of the aortic valve fails to close completely;
A. Mitral regurgitations
B. Mitral Stenosis
C. Aortic regurgitations
D. Pulmonic stenosis

43. The CAGE Questionnaire is used in which of the following?

A. Substance Abuse Screening
B. Alcoholism Screening Tool
C. Tobacco Use Screening Tool
D. All of the above
44. In assessing the eye of an adult, the nurse observes an inward turning of the client`s
eye. The nurse should document the client`s eye;
A. Strabismus
B. Phoria
C. Esotropia
D. Exotropia

45. In assessing the breast of a female client, the nurse should explain to the client that
most breast tumors occur in the;
A. Lower inner quadrant
B. Upper outer quadrant
C. Upper inner quadrant
D. Lower outer quadrant

46. Ms. Vivian visits the clinic because she experience bright hematemesis yesterday.
Nurse Karen should refer Ms. Vivian to a physician for this symptom is an indicative of;
A. Pancreatic cancer
B. Decrease gastric motility
C. Abdominal tumors
D. Stomach Ulcer

47. Upon inspecting the skin color of Mr. Tee`s leg, the nurse observes the Mr. Tee`s
legs are slightly cyanotic while sitting on the edge of the examination table. The nurse
should refer the client to a physician for possible;
A. Congestive heart failure
B. Raynaud`s Disease
C. Venous insufficiency
D. Arterial insufficiency
48. Physical Examination of an adult client, the nurse is preparing to auscultate the
client`s abdomen. The nurse should;
A. Use the diaphragm of the stethoscope
B. Listen in each quadrant for 15 minutes
C. Palpate the abdomen before auscultation
D. Start auscultation in the left upper quadrant

49. In assessing for rebound tenderness on the abdomen, the nurse should;
A. Ask the client to assume a side-lying position
B. Palpate deeply while quickly releasing pressure
C. Palpate lightly while slowly releasing pressure
D. Perform abdominal assessment first

50. The cell`s control center

A. Cilia
B. Nucleus
C. Plasma membrane
D. Flagella

51. It controls hearing, language comprehension and storage and recall of memories?
A. Frontal Lobe
B. Temporal Lobe
C. Parietal Lobe
D. All of the above

52. The blood vessels in the cardiovascular system are subdivided into three circuits
know as the;
A. Pulmonary, systemic and arterial circuits
B. Coronary, pulmonary and systemic circuits
 C. Lymphatic, pulmonary and systemic circuits
D. Pulmonary, venous and arterial circuits

53. The primary function of a mature blood cell is;

A. Defense against toxins and pathogen
B. Transport of respiratory gases
C. Delivery of enzymes to target tissues
D. All of the above

54. The breakdown of Red Blood Cell`s by hemolysis will be excreted in the;
A. Skin
B. Intestine
C. Kidney
D. Tears

55. It is the beginning structure of the lower Respiratory System?

A. Pharynx
B. Larynx
C. Trachea
D. Internal nares

56. The active process that occurs when materials enter the digestive tract via the
mouth is;
A. Absorption
B. Ingestion
C. Excretion
D. Secretion
57. Food particle or liquids manage to touch the surfaces of the ventricular or vocal
folds, the:
A. Individual will choke to death
B. Glottis will remain open
C. Coughing reflex will be triggered
D. Epiglottis will not function

58. Air enters the respiratory passageways when the pressure inside the lungs is lower
than the;
A. Abdominal pressure
B. Arterial pressure
C. Atmospheric pressure
D. Blood pressure

59. The nurse assesses a prolonged late deceleration of the fetal heart rate while the
client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing
intervention would be to:
A. Turn the client to the left
B. Change the fluid to Ringer’s Lactate
C. Turn off the infusion
D. Increase mainline IV rate

60. Which nursing approach would be most appropriate to use while administering an
oral medication to a 4-month-old?
A. Place medication in 45cc of formula
B. Place medication in a full bottle of formula
C. Place medication in an empty nipple
D. Place in supine position. Administer medication using a plastic syringe
61. Which nursing intervention would be a priority during the care of a 2-month-old after
surgery?
A. Minimize stimuli for the infant
B. Encourage stroking of the infant
C. Restrain all extremities
D. Demonstrate to the mother how she can assist with her infant’s care.

62. While performing a physical examination on a newborn, which assessment should

been reported to the physician?
A. Chest circumference of 32 cm
B. Acrocyanosis and edema of the scalp
C. Head circumference of 40 cm
D. Heart rate of 160 and respirations of 40

63. Which action by the mother of a preschooler would indicate a disturbed family
interaction?
A. Explains that the injection will burn like a bee sting.
B. Tells her child that the injection can be given while he’s in her lap
C. Tells her child that if he does not sit down and shut up she will leave him
there.
D. Reassures child that it is acceptable to cry.

64. During the history, which information from a 21 year old client would indicate a risk
for development of testicular cancer?
A. Genital Herpes
B. Undescended testicle
C. Hydrocele
D. Measles
65. The family of a 6-year-old with a fractured femur asks the nurse if the child’s height
will be affected by the injury. Which statement is true concerning long bone fractures in
children?
A. Growth problems will occur if the fracture involves the periosteum
B. Children usually heal very quickly, so growth problems are rare
C. Epiphyseal fractures often interrupt a child’s normal growth pattern
D. Adequate blood supply to the bone prevents growth delay after fractures

66. Which technique would be best in caring for a client following receiving a diagnosis
of a state IV tumor in the brain?
A. Offering the client pamphlets on support groups for brain cancer
B. Asking the client if there is anything he or his family needs
C. Providing accurate information about the disease and treatment options
D. Reminding the client that advances in technology are occurring everyday

67. An 8.8 lb, 6.1 oz infant is delivered to a diabetic mother. Which nursing intervention
would be implemented when the neonate becomes jittery and lethargic?
A. Feed the infant glucose water (10%)
B. Administer insulin
C. Administer oxygen
D. Place infant in a warmer

68. What question would be most important to ask a male client who is in for a digital
rectal examination?
A. “Do you notice polyuria in the AM?”
B. “Do you notice any burning with urination or any odor to the urine?”
C. “Have you noticed a change in the force of the urinary system?”
D. “Have you noticed a change in tolerance of certain foods in your diet?”
69. While caring for a client, the nurse notes a pulsating mass in the client’s
periumbilical area. Which of the following assessments is appropriate for the nurse to
perform?
A. Percuss the mass
B. Palpate the mass
C. Measure the length of the mass
D. Auscultate the mass

70. When observing 4-year-old children playing in the hospital playroom, what activity
would the nurse expect to see the children participating in?
A. Playing alone with hand held computer games
B. Playing cooperatively with other preschoolers
C. Competitive board games with older children
D. Playing with their own toys along side with other children

71. The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the
main source of fluids for an infant until about 12 months of age?
A. Dilute nonfat dry milk
B. Warmed fruit juice
C. Formula or breastmilk
D. Fluoridated tap water

72. The nurse should do the following to maintain a patient`s skin integrity except;
A. Clean the deep folds of the skin
B. Rub the patient`s back in circular motion with alcohol
C. Assess the patient`s bony prominences every 2 hours
D. Encourage patient to move in bed
73. A client who is unconscious needs frequent mouth care. While performing mouth
care, in what position should the client be placed?
A. Trendelenburg
B. Supine
C. Side lying
D. Fowler`s

74. Human Skeletal System is composed of how many bones?

A. 206
B. 216
C. 260
D. 266

75. The nurse observes an orange-peel appearance or peau d-orange of the areolae of
the client`s breast. The nurse should explain to the client that this is most likely due to;
A. Fibrocystic breast disease
B. Blocked lymphatic drainage
C. Fibroadenomas
D. Tumors

76. While assessing the peripheral vascular system of an adult client, the nurse detects
cold clammy skin and loss of hair on the client`s legs. The nurse suspects that the client
may be experiencing.
A. Arterial insufficiency
B. Thrombophlebitis
C. Venous stasis
D. Varicose veins
77. What is the standard method for evaluation of the newborn and serves as a baseline
for future evaluations?
A. Ballard Scoring
B. Glossgow Scale
C. APGAR scoring
D. None of the above

78. Which of the following relay all sensory stimuli as they ascend to the cerebal cortex,
except olfactory. Its function includes primitive awareness of PAIN, screening of
incoming stimuli and focusing attention?
A. Diencephalon
B. Thalamus
C. Pons
D. Hypothalamus

79. In assessing a client`s head and neck the nurse examine the carotid arteries, each
arteries is individually assess to prevent a;
A. Rapid rise in the client`s pulse pressure
B. Reduction of the blood supply to the brain
C. Decrease pulse pressure
D. Premature ventricular heart sound

80. An adult client visits the clinic and tells the nurse that she had headaches recently
that area intense and stabbing and often occurs in the late evening. The nurse should
document the presence of.
A. Migraine
B. Tension
C. Cluster
D. Tumor related
81. A client`s complain of dull, aching, tight and diffuse headaches that have lasted for
several days. The nurse recognize that this a sign of;
A. Tension
B. Cluster
C. Tumor related
D. Migraine

82. The nurse is preparing to assess the lymph nodes of the adult client. The nurse
should instruct the client to;
A. Stand upright in front of the nurse
B. Sit in an upright position
C. Lie in supine position
D. Lie on a side lying position

83. In nursing assessment, the client’s skin, hair, and nails are among the most easily
observed characteristics. They also provide clues to the client’s general health
condition. The following questions are presented to help you review your observation
and other assessment skills. To assess an adult client’s skin turgor, the nurse should
A. Use the finger pads to palpate the skin at the sternum
B. Use two fingers to pinch the skin under the clavicle
C. Press down on the skin of the feet
D. Use the dorsal surfaces of the hands on the client’s arms

84. A vitamin B12 deficiency results in the type of anemia known as:
A. sickle-cell
B. aplastic
C. pernicious
D. hemorrhagic
85. An African American female client named JoHon visits the clinic. She tells the nurse
that that she her ears pierced several weeks ago, and an elevated, irregular, reddened
mass has now developed at the earlobe. The nurse should document a;
A. Bulla
B. Keloid
C. Cyst
D. Lichenification

86. The tarsal plates of the upper eyelid contain which of the following?
A. Ocular muscles
B. Tear duct
C. Meibomian glands
D. Sebaceous gland

87. During quiet breathing, the diaphragm and external intercostals muscles contract.
What effect does this have on the thoracic cavity?
A. increases the volume and increases the pressure of the thoracic cavity
B. increases the pressure and decreases the volume of the thoracic cavity
C. increases the volume and decreases the pressure of the thoracic cavity
D. decreases the volume and decreases the pressure of the thoracic cavity

88. Waist circumference guidelines may not be accurate for adult who are shorter than
5 feet in height. This restriction is also concern for which other anthropometric
measurements?
A. Ideal weight
B. Mid-arm circumference
C. Body mass index
D. Triceps skin fold measurement
89. The most powerful and important muscle used when chewing food is the:
A. pterygoid
B. zygomaticus
C. buccinators
D. masseter

90. The purpose of the fluid in the pleural cavity is to:

A. provide lubrication for diaphragmatic constriction
B. allow for the exchange of electrolytes during respiratory movements
C. provide a medium for the exchange of O2 and CO2
D. reduce friction between the parietal and visceral pleura

91. The nurse is assessing an elderly postsurgical in the home. To begin the physical
examination, the nurse should first assess the client’s
A. Height and weight
B. Ability to swallow
C. Vital signs
D. Gait

92. Which of the following facial nerves does not supply the tongue?
A. glossopharyngeal nerves (IX)
B. trigeminal nerves (V)
C. hypoglossal nerves (XII)
D. vagus nerves (X)

93. The major components of the cardiovascular system are the:

A. lymph, plasma, hemoglobin
B. blood, heart, blood vessels
C. red blood cells, white blood cells, platelets
 D. veins, arteries, capillaries

94. An important function of subcutaneous layer is to;

A. Adjust gland secretion rate
B. Stabilize the position of the skin in relation to underlying tissues
C. Provide sensation of pain and temperature
D. Monitor sensory receptors

95. Nail production occurs at an epithelial fold not visible from the surface called the:
A. lunula
B. cuticle
C. eponychium
D. nail root

96. Hair turns gray or white because of:

A. decreased blood supply to the dermis
B. a decline in glandular activity
C. decreased melanocyte activity
D. a decrease in the number of Langerhans cells

97. Why are infants often given intramuscular injections in their vastus lateralis muscle?
A. Because the muscle is large, it is easier to make an injection there than in the
gluteus maximus or deltoid muscle.
B. The muscle is very large, and it is less likely that an injection there will
puncture a blood vessel or nerve
C. Because infants cannot walk, it is not likely that an injection in that muscle
would give them significant pain.
D. All of the above.
98. The names of the muscles of the tongue are readily identified because their
descriptive names end in:
A. pollicus
B. hallucis
C. glossus
D. Genio

99. Skin exposure to small amounts of ultraviolet radiation serves to:

A. induce melanocyte production
B. induce growth of cancerous tissue in the skin
C. Convert a steroid related to cholesterol into vitamin D
D. produce a tan that is beneficial to the skin

100. When auscultating the lungs of a patient with thick, tenacious mucus in the
bronchi, the nurse will hear:
A. Crepitation
B. Crackles
C. Rhonchi
D. Stridor