Health Assessment Final Review

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination because he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then

C) Acute alcohol intoxication
During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person's movements should be smooth and accur

During an internal examination of a woman during her first prenatal visit, the nurse finds that the cervix is soft. This is known as _____ sign.
A) Hegar's
B) Chadwick's
C) Homans'
D) Goodell's

B) Chadwick's
Increased vascularity, congestion, and edema cause the cervix to soften (Goodell's sign) and become bluish purple (Chadwick's sign). The uterus becomes globular in shape, softens, and flexes easily over the cervix (Hegar's sign). This causes

The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?
A) The pulse is more difficult to palpate because of the stiffness of the blood vessels.
B) An increased respiratory rate an

B) An increased respiratory rate and a shallower inspiratory phase are expected findings.
Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. The examiner may notice a shallower inspiratory phase and an increased respirator

Lymphedema is:
A) the indentation left after the examiner depresses the skin over swollen edematous tissue.
B) a thickening and loss of elasticity of the arterial walls.
C) an inflammation of the vein associated with thrombus formation.
D) the swelling of

D) the swelling of an extremity caused by an obstructed lymph channel.
Lymphedema is swelling of the limb caused by surgical removal of lymph nodes or damage to lymph nodes and vessels.

A full mental status examination should be completed if the patient:
A) has a change in behavior and the family is concerned.
B) develops dysphagia.
C) is newly diagnosed with type 2 diabetes mellitus.
D) complains of insomnia.

A) has a change in behavior and the family is concerned.
A full mental status examination is indicated if there is any abnormality in affect or behavior, and in the following situations: family members concerned about a person's behavioral changes; brain

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central

A) she may have macular degeneration.
Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a g

Percussion of the chest is:
A) a useful technique for identifying small lesions in lung tissue.
B) helpful only in identifying surface alterations of lung tissue.
C) is not influenced by the overlying chest muscle and fat tissue.
D) normal if a dull note

B) helpful only in identifying surface alterations of lung tissue.
Percussion detects only the outer 5 to 7 cm of tissue; it will not penetrate to reveal any change in density deeper than that.

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and ex

D) Spastic hemiparesis
With spastic hemiparesis, the arm is immobile against the body. There is flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder, which does not swing freely. The leg is stiff and extended and circumducts wi

A 75-year-old man has a history of hypertension and was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure?
A) Assess blood pressure and pulse in the supine, sitting, and st

A) Assess blood pressure and pulse in the supine, sitting, and standing positions.
Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volu

The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse keeps in mind that characteristics of a cancerous mass include which of the following? Selec

A) Nontender mass
D) Hard, dense, and immobile
F) Irregular, poorly delineated border
Cancerous breast masses are solitary, unilateral, nontender, masses. They are solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. The

During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to:
A) an enlarged liver.
B) an enlarged spleen.
C) distended bowel.
D) excessive diarrhea.

A) an enlarged liver.
The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.

During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?
A) Document the findings in the patient's record.
B) Wait 10 minutes and auscultate the sound again.
C) Ask how the patient is feeling.
D)

D) Ask another nurse to double-check the finding.
If an abnormal finding is not familiar, then the nurse may ask another examiner to double-check the finding. The other responses do not help to identify the unfamiliar sound.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:
A) examine the tender area first.
B) examine the tender area last.
C) avoid palpating th

A) examine the tender area first.
The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is done b

When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg the Korotkoff sounds muffle. At 92 mm Hg the Korotkoff sounds disappear. How should the nurse record this patien

D) 200/100/92
In adults, the last audible sound indicates diastolic pressure best. When a variance greater than 10 to 12 mm Hg exists between phases IV and V, record both phases along with the systolic reading (e.g., 142/98/80).

When planning a cultural assessment, the nurse should include which component?
A) Family history
B) Chief complaint
C) Medical history
D) Health-related beliefs

D) Health-related beliefs
Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient's history.

A patient saying, "My ear aches," is an example of:
A) objective data.
B) complete data.
C) subjective data.
D) diagnostic testing data.

C) subjective data.
A patient saying, "My ear aches," is an example of subjective data.

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?
A) 2
B) 3
C) 4
D) 5

D) 5
Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.

A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows that which statement about breast cancer in males is true?
A) Breast masses in m

C) One percent of all breast cancer occurs in men.
One percent of all breast cancer occurs in men. Early spread to axillary lymph nodes occurs due to minimal breast tissue.

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that:
A) nonpitting, hard edema occurs with lymphatic obstruction.
B) alterations in arterial function will cause

A) nonpitting, hard edema occurs with lymphatic obstruction.
Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, the edema is nonpitting and feels hard to the touch (brawny edema).

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are:
A) musical in quality.
B) usually pathological.
C) expected near the major airways.
D) similar to bronchial sounds except

C) expected near the major airways.
Bronchovesicular sounds are heard over major bronchi where fewer alveoli are located: posteriorly, between the scapulae, especially on the right; anteriorly, around the upper sternum in the first and second intercostal

A woman in her 25th week of gestation comes to the clinic for her prenatal visit. The nurse notices that her face and lower extremities are swollen, and her blood pressure is 154/94 mm Hg. She states that she has had headaches and blurry vision but though

B) Preeclampsia
Classic symptoms of preeclampsia include elevated blood pressure (greater than 140 systolic or 90 diastolic mm Hg in a woman with previously normal blood pressure) and proteinuria. Onset and worsening symptoms may be sudden, and subjective

A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as:
A) radial drift.
B) ulnar deviation.
C) swan neck deformity.
D) Dupuytren's

B) ulnar deviation.
Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance caused by chronic rheumatoid arthritis. Radial drift is not seen.

During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sound across the quadrants. This type of sound indicates:
A) constipation.
B) ai

B) air-filled areas.
A musical or drum-like sound (tympany) is the sound heard when percussion occurs over an air-filled viscus, such as the stomach or intestines.

During an assessment the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse should expect a normal findi

D) color returning to the feet within 20 seconds of assuming a sitting position.
In this test it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Marked elevational pallor as well as d

The nurse is asking questions about a patient's health beliefs. Which questions are appropriate? Select all that apply.
A) "What is your definition of health?"
B) "Does your family have a history of cancer?"
C) "How do you describe illness?"
D) "What did

A) "What is your definition of health?"
C) "How do you describe illness?"
D) "What did your mother do to keep you from getting sick?"
F) "How do you keep yourself healthy?"
The questions listed are appropriate questions for an assessment of a patient's he

A major characteristic of dementia is:
A) impaired short-term and long-term memory.
B) hallucinations.
C) sudden onset of symptoms.
D) cognitive deficits that are substance-induced.

A) impaired short-term and long-term memory.
Dementia is the presence of cognitive deficits; the deficits include memory impairment (impaired ability to learn new information or to recall previously learned information).

Crepitation is an audible sound that is produced by:
A) roughened articular surfaces moving over each other.
B) tendons or ligaments that slip over bones during motion.
C) joints that are stretched when placed in hyperflexion or hyperextension.
D) flexion

A) roughened articular surfaces moving over each other.
Crepitation is an audible and palpable crunching or grating that accompanies movement. It occurs when the articular surfaces in the joints are roughened.

What the clinician discovers by inspecting, palpating, percussing, and auscultating during the physical exam is best described as:
A) a medical diagnosis.
B) a nursing diagnosis.
C) subjective data.
D) objective data.

D) objective data.
What the clinician discovers by inspecting, palpating, percussing, and auscultating during the physical exam is best described as objective data.

The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?
A) It assesses how the individual is coping with life at home.
B) It determines how children are meeting developmental milestones.

D) It helps to determine how a person is managing day-to-day activities.
The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.

Kyphosis of the spine is common with aging. To compensate, older adults will:
A) increase their center of gravity.
B) extend their heads and jaws forward.
C) stiffen their gait.
D) shuffle.

B) extend their heads and jaws forward.
The older adult may show an increased anterior cervical (concave or inward) curve when the head and jaw are extended forward to compensate for kyphosis of the spine.

When the nurse is performing a testicular examination on a 25-year-old man, which of these findings is considered normal?
A) Nontender subcutaneous plaques
B) A scrotal area that is dry, scaly, and nodular
C) Testes that feel oval and movable and are slig

C) Testes that feel oval and movable and are slightly sensitive to compression
Testes normally feel oval, firm and rubbery, smooth, and equal bilaterally and are freely movable and slightly tender to moderate pressure. The scrotal skin should not be dry,

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature�97� F; pulse�48 beats per minute; respirations�14 per minute; blood pressure�104/68 mm Hg. Which statement is true about thes

B) These are normal vital signs for a healthy, athletic adult.
In the adult, a heart rate less than 50 beats per minute is called bradycardia. This occurs normally in the well-trained athlete whose heart muscle develops along with the skeletal muscles.

Physical appearance includes statements that compare appearance with:
A) mood and affect.
B) stated age.
C) gait.
D) nutrition.

B) stated age.
Feedback: CORRECT
Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features.

The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply.
A) Symmetri

B) Asymmetric joint involvement
C) Pain with motion of affected joints
D) Affected joints are swollen with hard, bony protuberances
In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of th

A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with the data collection?
A) Collect histor

D) Perform life-saving measures and not ask any history questions until he is transferred to the intensive care unit.
The emergency data base calls for a rapid collection of the data base, often compiled concurrently with life-saving measures. The other r

While auscultating heart sounds, the nurse hears a murmur. Which of these should be used to assess this murmur?
A) An electrocardiogram
B) The bell of the stethoscope
C) The diaphragm of the stethoscope
D) Palpation with the palm of the nurse's hand

B) The bell of the stethoscope
The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds.

A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurse's best course of action?
A) The nurse should focus on performing a full cardiac

A) The nurse should focus on performing a full cardiac assessment.
Wide cultural variation exists in the manner in which certain symptoms and disease conditions are perceived, diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental exp

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
A) Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessmen

D) Examine body areas appropriate to the problem and then complete the assessment after the problem has resolved.
It may be necessary in this situation to alter the position of the patient during the examination and to collect a mini data base by examinin

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition?
A) Rickets
B) Dehydration
C) Mental retardation
D) Increased intracranial pressure

B) Dehydration
Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on fontanels. Increased intracranial pressure would cause tense or bulging, and possibly pulsating fontanels.

The nurse is reviewing for a class in age-related changes in the eye. Which of these physiological changes is responsible for presbyopia?
A) Degeneration of the cornea
B) Loss of lens elasticity
C) Decreased adaptation to darkness
D) Decreased distance vi

B) Loss of lens elasticity
The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of these reflects correct procedure?
A) Pull the pinna down.
B) Pull the pinna up and back.
C) Tilt the child's head slightly toward the examiner.
D) Have the child touch h

A) Pull the pinna down.
For an otoscopic examination, pull the pinna down on an infant and a child under 3 years of age. The other responses are not part of the correct procedure.

While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this:
A) child

C) is a normal finding for a well child of this age.
Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas, but are discrete, movable,

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
B) A male family member
C) A female family member
D) A volunteer college stud

A) A trained interpreter
Whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same gender is pre

The nurse is performing an assessment. Which of these findings would cause the greatest concern?
A) A painful vesicle inside the cheek for 2 days
B) The presence of moist, nontender Stensen's ducts
C) Stippled gingival margins that adhere snugly to the te

D) An ulceration on the side of the tongue with rolled edges
An ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. Risk of early metastasis is present because of rich lymphatic drainag

When assessing the pupillary light reflex, the nurse should use which technique?
A) Shine a penlight from directly in front of the patient and inspect for pupillary constriction.
B) Ask the patient to follow the penlight in eight directions and observe fo

C) Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction.
To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

The nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse?
A) It is palpable in all adults.
B) It occurs with the onset of diastole.
C) Its location may be indicative of heart size.
D) It should norm

C) Its location may be indicative of heart size.
The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an

The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply.
A) Inspiratory wheezes noted in left lower lobes
B) H

A) Inspiratory wheezes noted in left lower lobes
C) Non productive cough
E) Patient reports dyspnea upon exertion
F) Rate of respirations 16 breaths per minute
Clustering related cues helps the nurse see relationships among the data. The cues related to t

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?
A) It is responsible for the production of cerumen.
B) It remains open except when swallowing or yawning.
C) It allows passage of air betwe

D) It helps equalize air pressure on both sides of the tympanic membrane.
The eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (e.g., during altitude changes in an airplane). T

While measuring a patient's blood pressure, the nurse uses proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply.
A) The person supports his or her own arm dur

A) The person supports his or her own arm during the blood pressure reading.
B) The blood pressure cuff is too narrow for the extremity.
D) The cuff is wrapped loosely around the arm.
E) The person is sitting with his or her legs crossed.