Chapter 16- Health Assessment Nursing School Test Banks

 

1.

A parent of a school age child is told her child has normal vision. The school nurse explains the childs vision is

A)

20/20

B)

20/40

C)

20/60

D)

20/200

Ans:

A

Feedback:

Normal vision is associated with at or near 20/20, full field of vision, and tricolor vision (red, green, blue).

2.

Peripheral cyanosis and clubbing of the nails are symptoms of

A)

Normal aging

B)

Increased cholesterol

C)

Hypertension

D)

Chronic hypoxia

Ans:

D

Feedback:

Hypoxia of the tissues changes normal pink-color skin to a grayish or bluish color.

3.

A nurse auscultates the right carotid artery in an elderly client and identifies a bruit. What does this assessment finding mean?

A)

It is normal

B)

It is distended

C)

It is dissecting

D)

It is inflamed

Ans:

B

Feedback:

Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel.

4.

To assess an adult clients hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the

A)

Front of the ear

B)

Mastoid process

C)

Top of the head

D)

Affected ear

Ans:

B

Feedback:

Strike the tuning fork and place its stem firmly against the mastoid process.

5.

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called

A)

Inflammation

B)

Arthritis

C)

Crepitus

D)

Fremitus

Ans:

C

Feedback:

Problems with the temporal mandibular joint include pain or a grating feeling called crepitus.

6.

When performing a cranial nerve assessment on an adult client, the nurse assesses the trigeminal nerve by

A)

Asking the client to smile

B)

Eliciting the clients gag reflex

C)

Having the client turn his head

D)

Eliciting the clients blink reflex

Ans:

D

Feedback:

To assess the trigeminal or cranial nerve V, the nurse should elicit the blink reflex with a cotton swab.

7.

To assess a clients visual accommodation, the nurse has the client

A)

Stand 20 feet from the Snellen chart

B)

Sit still while a penlight is shined at the pupil

C)

Look straight ahead with one eye covered

D)

Look at a close object, then at a distant object

Ans:

D

Feedback:

Accommodation can be tested by having the client look at a close object and then look at a distant object.

8.

While assessing a 48-year-old clients near vision, you can anticipate the client will state that her vision is

A)

Clear

B)

Blurred

C)

Clouded

D)

20/20

Ans:

B

Feedback:

Visual problems with close objects occur more frequently after the age of 40.

9.

When percussing the liver, the sound should be

A)

Resonant

B)

Hyperresonant

C)

Dull

D)

Flat

Ans:

C

Feedback:

The percussion of the abdomen is tympanic, hyperinflated lung tissue is hyperresonant, normal lung tissue is resonant, the liver is dull, and bone is flat.

10.

During a health assessment, the nurse uses deep palpation to assess a clients

A)

Skin turgor

B)

Finger nodules

C)

Perspiration

D)

Liver

Ans:

D

Feedback:

The purpose of deep palpation is to locate organs, determine their size, and detect abnormal masses.

11.

A nurse collects objective data on a client during a health assessment that includes the clients

A)

Blood pressure

B)

Fatigue level

C)

Presence of pain

D)

Symptoms of nausea

Ans:

A

Feedback:

Fatigue, pain, and nausea are subjective symptoms. Blood pressure is measured through auscultation and is an objective assessment.

12.

To obtain data about an adult clients sexuality and reproductive pattern, the nurse should ask the client

A)

How often do you have sexual intercourse?

B)

What arouses you when you have intercourse?

C)

How many children do you have, both living and dead?

D)

Has anything changed your sexual performance?

Ans:

D

Feedback:

The sexual assessment is not meant to illuminate nonexistent problems. Rather, the client is, in effect, given permission and encouragement to present sexually related questions.

13.

To obtain subjective data about a newly admitted clients sleep pattern, the nurse

A)

Inspects the clients eyes for redness

B)

Asks the client what promotes sleep

C)

Documents the clients affect and yawning

D)

Determines how frequently the client naps

Ans:

B

Feedback:

The assessment of sleep and rest focuses on the clients normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep.

14.

To assess subjective data related to a clients elimination pattern, the nurse

A)

Reviews the latest laboratory report of the urine

B)

Asks the client about changes in elimination patterns

C)

Notes the frequency, amount, and time the client voids

D)

Palpates the abdomen for pain or distention

Ans:

B

Feedback:

Focus the interview on the clients normal urinary and bowel patterns, noting any recent changes.

15.

A client had a cerebrovascular accident yesterday and is currently comatose. What type of scale should the nurse use to weigh the patient?

A)

Bathroom scale

B)

Large floor scale

C)

Chair scale

D)

Bed scale

Ans:

D

Feedback:

A bed scale is used for clients who are too weak or immobile to use other scales safely.

16.

What percentage of weight change in 6 months is considered abnormal?

A)

1%

B)

2%

C)

5%

D)

10%

Ans:

D

Feedback:

A 10% change in weight in 6 months is considered abnormal.

17.

To gather subjective data on a clients nutrition and metabolic pattern, the nurse should

A)

Weigh the client and measure his height

B)

Ask the client for a 24-hour diet recall

C)

Examine the hygiene of the clients teeth

D)

Inspect the clients abdomen for symmetry

Ans:

B

Feedback:

Interview questions to focus a nutritionmetabolism assessment might include asking the client to tell you what has been eaten in the last 24 hours.

18.

A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 1 to 10 when he is asked to turn. The nurse should

A)

Avoid a position change that requires turning

B)

Have the client turn from side to side and assess pain

C)

Have the client lay on his right side, then palpate the area

D)

Elevate the legs, bending at the knee while the client is supine

Ans:

A

Feedback:

Addressing pain early in the health assessment allows the nurse to individualize the rest of the assessment, avoiding positioning and techniques that are especially uncomfortable for the client.

19.

Upon admission to the hospital, the client states, I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy. This statement reflects the clients

A)

Symptoms

B)

Review of systems

C)

Chief complaint

D)

Objective assessment

Ans:

C

Feedback:

The first subject discussed in a client interview is the clients specific reason for seeking care. The subject is often called the clients chief complaint or chief concern.

20.

When examining a client upon admission to the hospital, it is important to

A)

Provide privacy and confidentiality

B)

Assess for fear and anxiety

C)

Assess in a semi-private room

D)

Have the family present

Ans:

A

Feedback:

Privacy and confidentiality are important concerns for the client.

21.

A nurse is using the assistance of an interpreter. When interviewing a client who does not speak English, the nurse should

A)

Assess the clients vital signs first

B)

Interpret the effect of deep palpation

C)

Inspect the symmetry of the facial features

D)

Observe the clients body language

Ans:

D

Feedback:

When using an interpreter, the nurse should observe the cues the client expresses with body language, and listen to the tone of voice.

22.

An intensive care unit nurse reports the clients condition to the nurse on the medical unit. This is a(an)

A)

Primary source

B)

Secondary source

C)

General report

D)

Informational report

Ans:

B

Feedback:

Secondary data sources include sources of data other than the client, such as the chart or other healthcare providers.

23.

Which framework is used during the focused assessment?

A)

Functional health assessment

B)

Head-to-toe framework

C)

Conceptual framework

D)

Body systems framework

Ans:

D

Feedback:

Body systems approach is used during the focused assessment of an acutely or critically ill client to determine function of a particular body system.

24.

The nurse assesses the clients lung sounds following the clients period of coughing. This is a(an) example of

A)

Subjective data

B)

Objective data

C)

Focused data

D)

Comprehensive data

Ans:

B

Feedback:

Objective data can be directly observed or measured, such as vital signs or appearance.

25.

A client states, I have trouble sleeping. I only sleep about 2 hours and then I wake up. This is

A)

Subjective data

B)

Objective data

C)

Focused data

D)

Comprehensive data

Ans:

A

Feedback:

Subjective data are those symptoms, feelings, perceptions, preferences, values, and information that only the client can state and validate.

26.

During a nurses visit to the clients home, the client states, I have pain in my right knee. The nurse assesses the clients right knee. This is a

A)

Focused assessment

B)

Spiritual assessment

C)

Social assessment

D)

Comprehensive assessment

Ans:

A

Feedback:

Often, nurses must select the most important interviewing questions or assessment techniques to use and perform a focused health assessment based on the clients problem.

27.

When a client enters the acute care facility, the nurse should perform a

A)

Focused health assessment

B)

Spiritual health assessment

C)

Physical health assessment

D)

Comprehensive health assessment

Ans:

D

Feedback:

A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living.

Page 1

Leave a Reply