Health Assessment Exam 1- PPT and quiz questions

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Which of the following is an open ended question?

a. What brought you in today? Answer:A. It is the only choice that would invite a paragraph for an
b. Where does it hurt? answer rather than a short statement.
c. Have you been checking your blood pressure?
d. When was the last time you were seen by a doctor?
Which of the following is the most basic function and therefore
should be tested first in an assessment of mental status?
Answer: B. According to your textbook, consciousness is the most
a.Behavior fundamental of these particular characteristics; therefore, it would
b. Consciousness be tested first.
c. Judgment
d. Language
Which of the following is not a significant contributor to the as-
sessment of mental status?

a.Known illness or health problem Answer: C. The other choices are all elements of the interview that
b. Current medications known to affect mood or cognition contribute to interpretation of the findings of the examination.
c. Racial background
d. Personal history; current stress, social habits, sleep habits, drug
and alcohol use
Correct order of physical examination skills: Inspection, Palpation, Percussion, Auscultation
NCLEX question
The nurse is preparing to percuss the abdomen of a patient. The
purpose of the percussion is to assess the underlying tissue: ANSWER: C
Percussion yields a sound that depicts the location, size, and
A) turgor. density of the underlying organ. Turgor and texture are assessed
B)texture. with palpation.
C)density.
D)consistency.
NCLEX question
The nurse is reviewing percussion techniques with a newly grad-
ANSWER: A
uated nurse. Which technique, if used by the new nurse, indicates
For percussion, the nurse should percuss two times over each
that more review is needed? The nurse:
location. The striking finger should be lifted off quickly because a
resting finger damps off vibrations. The tip of the striking finger
A)percusses once over each area.
should make contact, not the pad of the finger. The wrist must be
B)lifts the striking finger off quickly after each stroke.
relaxed, and it is used to make the strikes, not the arm
C)strikes with the finger tip, not the finger pad.
D)uses the wrist to make the strikes, not the arm.
NCLEX question
The nurse is teaching a class on basic assessment skills. Which
of these statements is true regarding the stethoscope and its use?
ANSWER: B
A)The slope of the earpieces should point posteriorly (toward the
The stethoscope does not magnify sound but does block out
occiput).
extraneous room sounds. The slope of the earpieces should point
B)The stethoscope does not magnify sound but does block out
forward toward the examiner's nose. Longer tubing will distort
extraneous room noise.
sound. The fit and quality of the stethoscope are important.
C)The fit and quality of the stethoscope are not as important as
its ability to magnify sound.
D)The ideal tubing length should be 22 inches to dampen distor-
tion of sound.
NCLEX question
The nurse is unable to palpate the right radial pulse on a patient.
ANSWER: C
The best action would be to:
Doppler devices are used to augment pulse or blood pressure
measurements. Goniometers measure joint range of motion. A
A)auscultate over the area with a fetoscope.
fetoscope is used to auscultate fetal heart tones. Stethoscopes
B)use a goniometer to measure the pulsations.
are used to auscultate breath, bowel, and heart sounds.
C)use a Doppler device to check for pulsations over the area.
D)check for the presence of pulsations with a stethoscope.

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NCLEX question
When performing a physical examination, safety must be consid-
ered to protect the examiner and the patient against the spread of
infection. Which of these statements describes the most appro-
ANSWER: B
priate action the nurse should take when performing a physical
The nurse should wash his or her hands before and after every
examination?
physical patient encounter; after contact with blood, body flu-
ids, secretions, and excretions; after contact with any equipment
A)There is no need to wash one's hands after removing gloves,
contaminated with body fluids; and after removing gloves. Hands
as long as the gloves are still intact.
should be washed after gloves have been removed, even if the
B)Wash hands before and after every physical patient encounter.
gloves appear to be intact. Gloves should be worn when there is
C)Wash hands between the examination of each body system
potential contact with any body fluids.
to prevent the spread of bacteria from one part of the body to
another.
D)Wear gloves throughout the entire examination to demonstrate
to the patient concern regarding the spread of infectious diseases.
NCLEX question
ANSWER: C
Which of these statements is true regarding the use of standard
Standard precautions are designed to reduce the risk of transmis-
precautions in the health care setting?
sion of microorganisms from both recognized and unrecognized
sources. They are intended for use for all patients, regardless of
A) Standard precautions apply to all body fluids, including sweat.
their risk or presumed infection status. They apply to blood and
B)Use alcohol-based hand rub if hands are visibly dirty.
all other body fluids, secretions and excretions except sweat—re-
C)Standard precautions are intended for use with all patients
gardless of whether they contain visible blood, nonintact skin, or
regardless of their risk or presumed infection status.
mucous membranes. Hands should be washed with soap and
D)Standard precautions are to be used only when there is nonin-
water if visibly soiled with blood or body fluids; alcohol-based hand
tact skin, excretions containing visible blood, or expected contact
rubs can be used if hands are not visibly soiled
with mucous membranes.
NCLEX question
The nurse is preparing to assess a hospitalized patient who is ex-
periencing significant shortness of breath. How should the nurse
proceed with the assessment?
ANSWER: D
It may be necessary in this situation to alter the position of the
A)Have the patient lie down to obtain an accurate cardiac, respi-
patient during the examination and to collect a mini data base
ratory, and abdominal assessment.
by examining the body areas appropriate to the problem. You
B)Obtain a thorough history and physical assessment information
may return later to complete the assessment after the distress is
from the patient's family member.
resolved.
C)Perform a complete history and physical assessment immedi-
ately to obtain baseline information.
D)Examine body areas appropriate to the problem and then com-
plete the assessment after the problem has resolved.
The nurse is performing a general survey. Which action is a
component of the general survey?
ANSWER: A
A)Observing the patient's body stature and nutritional status
The general survey is a study of the whole person that includes
B)Interpreting the subjective information the patient has reported
observation of physical appearance, body structure, mobility, and
C)Measuring the patient's temperature, pulse, respirations, and
behavior.
blood pressure
D)Observing specific body systems while performing the physical
assessment
Which patient would be most likely to present with a pulse rate that
is lower than normal?
Answer: B. Athletes who train for endurance are likely to have a
a. A 70-year-old telephone salesman presenting with dehydration.
low resting heart rate because of a high cardiac output.
b. A 20-year-old runner who had surgery 4 days ago for a fractured
leg.
c. A 67-year-old who presented with an exacerbation of his COPD
NCLEX question
A patient's weekly blood pressure readings for 2 months have
ranged between 124/84 and 136/88 mm Hg, with an average ANSWER: B
reading of 126/86 mm Hg. The nurse knows that this blood pres- According to the JNC-VII guidelines, prehypertension blood pres-
sure falls within which blood pressure category?

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A)Normal blood pressure
B)Prehypertension sure readings are systolic 120 to 139 mm Hg or diastolic 50 to 89
C)Stage I hypertension mm Hg.
D)Stage 2 hypertension
NCLEX question
The nurse should measure rectal temperatures in which of these ANSWER: C
patients? Rectal temperatures should be taken when the other routes are
not practical, such as for comatose or confused persons, for per-
A)School-age child sons in shock, or for those who cannot close the mouth because
B)Elderly adult of breathing or oxygen tubes, wired mandible, or other facial
C)Comatose adult dysfunctions.
D)Patient receiving oxygen by nasal cannula
NCLEX question
A student is late for his appointment and has rushed across
campus to the health clinic. Before assessing his vital signs, the
nurse should:
ANSWER: A
A)allow him 5 minutes to relax and rest before checking his vital
A comfortable, relaxed person yields a valid blood pressure. Many
signs.
people are anxious at the beginning of an examination; the nurse
B)check the blood pressure in both arms, expecting a difference
should allow at least a 5-minute rest before measuring his blood
in the readings because of his recent exercise.
pressure.
C)monitor his vital signs immediately on his arrival at the clinic,
then 5 minutes later, and notice any differences.
D)check his blood pressure in the supine position because this
will give a more accurate reading and will allow him to relax at the
same time.
The nurse will perform a palpated pressure before auscultating
blood pressure. The reason for this is to: ANSWER: B
Inflation of the cuff 20 to 30 mm Hg beyond the point at which
A)hear the Korotkoff sounds more clearly. a palpated pulse disappears will avoid missing an auscultatory
B)detect the presence of an auscultatory gap. gap, which is a period when the Korotkoff sounds disappear during
C)avoid missing a falsely elevated blood pressure. auscultation.
D)identify phase IV of the Korotkoff sounds more readily.
NCLEX question
ANSWER: D
The nurse is performing a general survey. Which finding is con-
When performing the general survey, the patient's arm span (fin-
sidered normal?
gertip to fingertip) should equal the patient's height. An arm span
greater than the person's height may indicate Marfan syndrome.
A)When standing, the patient's base is narrow.
The base should be wide when standing, and an appearance older
B)The patient appears older than his stated age.
than the stated age may indicate a history of a chronic illness or
C)Arm span (fingertip to fingertip) is greater than the height.
chronic alcoholism.
D)Arm span (fingertip to fingertip) equals height.
After a class on culture and ethnicity, the new graduate nurse
reflects a correct understanding of the concept of ethnicity with
which statement?

a. "Ethnicity is dynamic and ever-changing."

Answer: C
b. "Ethnicity is the belief in a higher power."
c. "Ethnicity pertains to a social group within the social system
that claims shared values and traditions."
d. "Ethnicity is learned from birth through the processes of lan-
guage acquisition and socialization."

A man has been admitted to the observation unit for observation

after being treated for a large cut on his forehead.
As the nurse works through the interview, one of the standard
questions has to do with alcohol, tobacco, and drug use.
When the nurse asks him about tobacco use, he states, "I quit Answer: D
smoking after my wife died 7 years ago." However, the nurse
notices an open package of cigarettes in his shirt pocket. Using
confrontation, the nurse could say:

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a. "Mr. K, I know that you are lying
b. "Mr. K, come on, tell me how much you smoke."
c. "Mr. K, I didn't realize that your wife had died. It must be difficult
for you at this time. Please tell me more about that."
d. "Mr. K, you have said that you don't smoke, but I see that you
have an open package of cigarettes in your pocket."
A pregnant woman states, "I just know labor will be so painful that
I won't be able to stand it. I know it sounds awful,
but I really dread going into labor. The nurse responds by stating,
"Oh, don't worry about labor so much. I have been through it,
and although it is painful there are many good medications to
decrease the pain." Which statement is true regarding this re-
sponse?
It was a:
Answer: B
a. therapeutic response. By sharing something personal, the
nurse gives hope to this woman.
b. nontherapeutic response. By providing false reassurance, the
nurse actually cut off further discussion of the woman's fears.
c. therapeutic response. By providing information about the med-
ications available, the nurse is giving information to the woman.
d. nontherapeutic response. The nurse is essentially giving the
message to the woman that labor cannot be tolerated without
medication.
During the interview portion of data collection, the nurse collects
_________ data.

a. Physical Answer: D
b. Historical
c. Objective
d. Subjective
When evaluating a patient's pain, the nurse knows that an exam-
ple of acute pain would be:

a. Arthritic pain Answer: C

b. Fibromyalgia
c. Kidney Stones
d. low back pain
A female patient does not speak English well, and the nurse needs
to choose an interpreter. Which of the following would be the most
appropriate choice?

a. A trained interpreter Answer: A

b. A male family member
c. A female family member
d. A volunteer college student from the foreign language studies
department
The nurse is preparing to conduct a health history. Which of these
statements best describes the purpose of a health history?

a. To provide an opportunity for interaction between patient and

nurse
b. To provide a form for obtaining the patient's biographic infor- Answer: D
mation
c. To document the normal and abnormal findings of a physical
assessment
d. To provide a data base of subjective information about the
patient's past and current health

A patient has had arthritic pain in her hips for several years since
a hip fracture. She is able to move around in her room and
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has not offered any complaints so far this morning. However, when
asked, she states that her pain is "bad this morning" and rates
it an 8 on a 0 to 10 scale. What does the nurse suspect?

a. She is addicted to her pain medications and cannot obtain pain

relief Answer: D
b. She does not want to trouble the nursing staff with her com-
plaints
c. She is not in pain but rates it high to receive pain medication
d. she has experienced chronic pain for years and has adapted
to it.
When performing a physical assessment, the technique the nurse
will always use first is:

a. palpation Answer: B
b. inspection
c. percussion
d. auscultation
A woman who has lived in the United States for a year after moving
from Europe has learned to speak English
and is almost finished with her college degree. She now dresses
like her peers and says that her family in Europe
would hardly recognize her. This nurse recognizes that this situa-
tion illustrates which concept? Answer: A

a. Assimilation
b. Heritage consistency
c. Biculturalism
d. Acculturation
When the nurse asks a 68-year-old patient to stand with feet
together and arms at his side with his eyes closed, he
starts to sway and moves his feet farther apart. The nurse would
document this finding as a(n):
Answer: D
a. ataxia
b. lack of coordination
c. negative Homans' sign
d. positive Romberg sign
During an examination, the nurse can assess mental status by
which activity?

a. examining the patient's electroencephalogram

b. Observing the patient as he or she performs an IQ test Answer: C
c. Observing the patient and inferring health or dysfunction
through an assessment of behaviors
d. Only examining the patient's response to a specific set of
questions
A woman brings her 70 year old husband to the clinic for an ex-
amination. She is particularly worried because after a recent fall,
he seems to have lost a great deal of his memory of recent events.
Which statement reflects the nurse's best course of action? The
nurse should:

a. plan to perform a complete mental status examination including Answer: A

the cranial nerves and cerebellar function
b. refer him to a neurologist
c. plan to integrate the mental status examination into the history
and physical examination
d. reassure his wife that memory loss after a physical shock is
normal and will subside soon

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The nurse is preparing to do a mental status assessment. Which
statement is true regarding the mental status assessment?

a. a patient's family is the best resource for information about the

patient's coping skills
b. it is usually sufficient to gather mental status information during Answer: B
the health history interview
c. it takes an enormous amount of extra time to integrate the
mental status examination into the health history interview
d. it is usually necessary to perform a complete mental status
examination to get a good idea of the patient's level of functioning
A 19-year-old woman comes to the clinic at the insistence of
her brother. She is wearing black combat boots and a black lace
nightgown over the top of her other clothes. Her hair is dyed pink
with black streaks throughout. She has several pierced holes in
her nares and ears and is wearing an earring through her eyebrow
and heavy black makeup.
The nurse concludes:
Answer: D
a. she probably doesn't have any problems at all
b. she is just trying to shock people and her dress should be
ignored
c. she has manic syndrome because of her abnormal dress and
grooming
d. that more information should be gathered to decide whether her
dress is appropriate
During the history, a patient tells the nurse that "it feels like the
room is spinning around me." The nurse would document this as:

a. vertigo Answer: A
b. syncope
c. dizziness
d. seizure activity
A patient has been in the intensive care unit for 10 days. He has
just been moved to the medical-surgical unit, and the admitting
nurse
is planning to perform a mental status examination on him. During
the tests of cognitive function the nurse would expect that he:
Answer: C
a. may display some disruption in thought content
b. will state " I am so relieved to be out of intensive care"
c. will be oriented to place and person but may not be certain of
the date
d. may show evidence of come clouding of his level of conscious-
ness
The nurse places a key in the hand of a patient and he identifies it
correctly. What term would the nurse use to describe this finding?

a. extinction Answer: B
b. stereognosis
c. graphesthesia
d. tactile discrimination

During an assessment of the cranial nerves, the nurse finds the

following: asymmetry when the patient smiles or frowns, uneven
lifting of eyebrows, sagging of the lower eyelids, and escape of air
when the nurse presses against the right puffed cheek.
Answer: B
This would indicate dysfunction of which of these cranial nerves?

a. motor component of IV
b. motor component of VII

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c. motor and sensory components of XI
d. motor component of X and sensory component of VII
The nurse is testing superficial reflexes on an adult patient. When
stroking up the lateral side of the sole and across the ball of the
foot,
the nurse notices the plantar flexion of the toes. How should the
nurse document this finding?
Answer: C
a. positive Babinski sign
b. plantar reflex abnormal
c. plantar reflex present
d. plantar reflex "2+" on a scale from "0-4+"

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