Chapter 32: Health Assessment and Physical Examination Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. The position that maximizes the nurses ability to assess the clients body for symmetry is:

a.

Sitting

b.

Supine

c.

Prone

d.

Dorsal recumbent

ANS: a

a. Sitting upright provides full expansion of lungs and provides better visualization of symmetry of upper body parts.

b. The supine position maximizes the nurses ability to assess pulse sites.

c. The prone position is used only to assess extension of the hip joint.

d. The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles.

REF: Text Reference: p. 681

2. The nurse is examining a client with dark skin. In assessing for pallor, the nurse will specifically look at the:

a.

Buccal mucosa of the mouth

b.

Dorsal surface of the hands

c.

Ear lobe

d.

Sclera

ANS: a

a. Pallor is more easily seen in the face, buccal mucosa of the mouth, conjunctiva, and nail beds.

b. The palmar surface of the hands may be used to detect color hues in dark-skinned clients.

c. The ear lobe is not a good site to assess for color changes such as pallor, in dark-skinned clients.

d. The best site to inspect for jaundice, not pallor, is the sclera.

REF: Text Reference: p. 690

3. A female client is seen in the outpatient clinic for numerous cuts, bruises, and apparent burns. In a discussion with the client, the nurse finds that the injuries are inconsistent with the stated cause. The client also states that she is having trouble sleeping and she appears anxious. Based on these findings, the nurse suspects that the client may be experiencing:

a.

Substance abuse

b.

Domestic violence

c.

Vascular disease

d.

Mental illness

ANS: b

b. Injuries and trauma that are inconsistent with the reported cause, multiple injuries including bruises, cuts, and burns, and behavioral findings of difficulty sleeping and appearing anxious are all indicators of possible domestic violence.

a. The findings are not consistent with substance abuse. Indicators of substance abuse may include frequent missed appointments or emergency department visits, having a history of changing doctors, history of activities that place them at risk for HIV infections, complaints of insomnia or chest pain, and a family history of addiction. People who abuse substances may have cuts, burns (especially of the fingers), needle marks, homemade tattoos, or increased vascularity of the face.

c. These findings are not indicative of vascular disease. Symptoms of vascular disease may include edema, color changes of the lower extremities, and weakened pedal pulses.

d. These findings are not indicative of mental illness. The client is coherent.

REF: Text Reference: p. 684

4. A client in the clinic has been having severe headaches and some visual disturbances. The nurse performs an eye examination. Which of the following is true concerning the procedure for this assessment?

a.

To evaluate the lower eyelids, the nurse uses a syringe with sterile water.

b.

The clients lacrimal apparatus is best assessed by using a dull object to stimulate her normal reflex conditions.

c.

Accommodation is tested by asking the client to comply with the nurses requests.

d.

The red reflex should be assessed with the ophthalmoscope.

ANS: d

d. To visualize internal eye structures, the nurse uses an ophthalmoscope to focus on the red reflex.

a. To evaluate the lower eyelids, the nurse asks the client to open the eyes for inspection. A syringe and sterile water are not necessary for this assessment.

b. The lacrimal apparatus is best assessed by inspecting for edema and redness and palpating it gently to detect tenderness. Normally it cannot be felt.

c. Accommodation is tested by asking the client to gaze at a distant object and then at a test object held by the nurse approximately 10 cm from the clients nose. The pupils normally converge and accommodate by constricting when looking at close objects.

REF: Text Reference: p. 703

5. In preparing to conduct a physical examination on a client, the nurse plans to:

a.

Perform painful procedures at the end of the examination

b.

Take long, detailed notes of all the findings during the examination

c.

Keep the TV or radio on to distract the client throughout the examination

d.

Assess only the dominant side of the body in the examination

ANS: a

a. In organizing a physical examination, the nurse should perform painful procedures near the end of the examination.

b. The nurse should record quick notes during the examination to avoid keeping the client waiting. Observations can be completed at the end of the examination.

c. The TV or radio should be turned off so as to not distract the client throughout the examination, and to provide an environment conducive to auscultation.

d. Both sides of the body should be assessed for comparison to determine symmetry. A degree of asymmetry is normal in the dominant versus nondominant arm.

REF: Text Reference: p. 682

6. The client has an enlarged thyroid gland and is currently admitted to a medical nursing unit. Which of the following is accurate regarding the procedure for a thyroid assessment for this client?

a.

Deep palpation should be used anterior and posterior

b.

Swallowing sips of water causes the isthmus of the thyroid gland to rise

c.

The posterior approach is used with the fingers placed over the trachea

d.

The diaphragm of the stethoscope is best for auscultation of bruits

ANS: b

b. During assessment of the thyroid gland, the client holds a cup of water and takes a sip to swallow once instructed by the nurse. As the client swallows, the isthmus of the thyroid gland rises. The nurse should feel whether it is enlarged. Normally the thyroid gland is small, smooth, and free of nodules.

a. Light, gentle palpation is needed to feel any abnormalities.

c. For the posterior approach, both of the nurses hands are placed around the neck, with two fingers of each hand on the sides of the trachea just beneath the cricoid cartilage.

d. The bell of the stethoscope is best for auscultation of bruits.

REF: Text Reference: p. 715

7. The nurse is auscultating the clients lungs and notes normal vesicular sounds as:

a.

Medium-pitched blowing sounds with inspiration equaling expiration

b.

Loud, high-pitched, hollow sounds with expiration longer than inspiration

c.

Soft, breezy, low-pitched sounds with longer inspiration

d.

Sounds created by air moving through small airways

ANS: c

c. Normal vesicular sounds are soft, breezy, and low-pitched. The inspiratory phase is 3 times longer than the expiratory phase.

a. Medium-pitched blowing sounds with inspiration equaling expiration are bronchovesicular breath sounds.

b. Loud, high-pitched, hollow sounds with longer expiration are bronchial breath sounds.

d. Vesicular sounds are created by air moving through smaller airways. Abnormal breath sounds result from air passing through narrowed airways.

REF: Text Reference: p. 720

8. The nurse could best auscultate the point of maximum impulse (PMI) in an 8-year-old at the:

a.

Fourth intercostal space, left of the midclavicular line

b.

Fifth intercostal space, left of the midclavicular line

c.

Second intercostal space, right of the midclavicular line

d.

Third intercostal space, right of the midclavicular line

ANS: b

b. By age 7 years, a childs PMI is in the same location as the adults (i.e., the fifth intercostal space, left of the midclavicular line).

a. The PMI of an 8-year-old child is more likely to be located at the fifth intercostal space, left of the midclavicular line.

c. The PMI is not located to the right of the midclavicular line.

d. The PMI of an infant is at the third or fourth intercostal space, left of the midclavicular line.

REF: Text Reference: p. 723

9. The nurse suspects that the client may have vascular disease. During the examination, the nurse is alert to the clients complaints of:

a.

Headache, dizziness, and tingling of body parts

b.

Diplopia, floaters, and headaches

c.

Leg cramps, numbness of extremities, and edema

d.

Pain and cramping in the lower extremities relieved by walking

ANS: c

c. Leg cramps, numbness or tingling in extremities, sensation of cold hands or feet, pain in legs, or swelling or cyanosis of feet, ankles, or hands is indicative of vascular disease.

a. Headache, dizziness, and tingling of body parts are more likely associated with a neurologic problem, not vascular disease.

b. Diplopia, floaters, and headaches are indicative of an eye problem, not vascular disease.

d. Pain and cramping in the lower extremities are usually worsened with activity in vascular disease.

REF: Text Reference: p. 727

10. A 21-year-old woman asks when she should perform breast self-examination during the month. The nurse should inform the client:

a.

Any time you think of it.

b.

At the same time each month.

c.

On the first day of your menstrual period.

d.

Two to three days after your menstrual period.

ANS: d

d. The best time for a BSE is 2 to 3 days after the menstrual period ends, when the breast is no longer swollen or tender from hormone elevations.

a. The woman should check her breasts the same time each month, 2 to 3 days after the menstrual period ends.

b. This is partially true. The client should also be informed to perform the BSE 2 to 3 days after the menstrual period ends.

c. This is not the best time for a woman to perform a BSE. The breasts will be enlarged and tender from hormone elevations.

REF: Text Reference: p. 735

11. During an assessment of the clients integument, the nurse notes a flat, nonpalpable change in skin color that is smaller than 1 cm. This finding is documented by the nurse as a:

a.

Macule

b.

Papule

c.

Vesicle

d.

Nodule

ANS: a

a. This finding is consistent with the definition of a macule.

b. A papule is a palpable, circumscribed, solid elevation in skin, smaller than 0.5 cm.

c. A vesicle is a circumscribed elevation of skin filled with serous fluid, smaller than 0.5 cm.

d. A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5 to b.0 cm.

REF: Text Reference: p. 692

12. The nurse asks a client to explain the meaning of the phrase, Every cloud has a silver lining. This part of the examination is designed to measure:

a.

Knowledge

b.

Judgment

c.

Association

d.

Abstract thinking

ANS: d

d. Interpreting abstract ideas or concepts, such as in explaining the meaning of this phrase, reflects the capacity for abstract thinking. The client with altered mentation will likely interpret the phrase literally or merely rephrase the words.

a. An example of assessing knowledge would be asking the client the reason for seeking health care. This example is not designed to measure knowledge.

b. The nurse is not attempting to measure judgment. An example of assessing judgment would be to ask the client what he or she would do if he or she suddenly became ill when alone at home.

c. The nurse is not attempting to measure association. An example of assessing association would be to ask the client to complete a phrase, such as a dog is to a beagle as a cat is to a _____.

REF: Text Reference: p. 763

13. Measurement of the clients ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?

a.

Optic

b.

Facial

c.

Trigeminal

d.

Oculomotor

ANS: c

c. The trigeminal nerve is tested by lightly touching the cornea with a wisp of cotton, by assessing the corneal reflex, and by measuring sensation of light pain and touch across the skin of the face.

a. The optic nerve is tested by using the Snellen chart or asking the client to read printed material.

b. The facial nerve is tested by having the client smile, frown, puff out cheeks, raise and lower eyebrows while you look for asymmetry. Having the client identify salty or sweet taste on the front of the tongue also tests the facial nerve.

d. The oculomotor nerve is tested by assessing directions of gaze, and testing papillary reaction to light and accommodation.

REF: Text Reference: p. 764

14. Assessment of the clients skin reveals a fluid-filled circumscribed elevation of 0.4 cm. The nurse identifies this as a:

a.

Nodule

b.

Macule

c.

Vesicle

d.

Wheal

ANS: c

c. This finding is consistent with the definition of a vesicle.

a. A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5 to b.0 cm.

b. A macule is a flat, nonpalpable change in skin color, smaller than 1 cm.

d. A wheal is an irregularly shaped, elevated area or superficial localized edema that varies in size.

REF: Text Reference: p. 692

15. The expected appearance of the oral mucosa in a light-skinned adult is:

a.

Pinkish-red, smooth, and moist

b.

Light pink, rough, and dry

c.

Cyanotic, with rough nodules

d.

Deep red, with rough edges

ANS: a

a. Normal mucosa in a light-skinned adult is glistening, pinkish-red, soft, moist, and smooth.

b. Oral mucosa may appear more dry in the older adult because of reduced salivation, but is not rough.

c. Cyanotic mucosa with rough nodules would be an abnormal finding.

d. Oral mucosa should not appear deep red with rough edges in a light-skinned adult.

REF: Text Reference: p. 711

16. In the assessment of a 90-year-old client, the nurse documents an exaggeration of the posterior curvature of the thoracic spine as:

a.

Lordosis

b.

Osteoporosis

c.

Scoliosis

d.

Kyphosis

ANS: d

d. Kyphosis is an exaggeration of the posterior curvature of the thoracic spine (hunchback)

a. Lordosis is an increased lumbar curvature (swayback).

b. Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone.

c. Scoliosis is a lateral curvature of the spine.

REF: Text Reference: p. 755

17. If a low-pitched murmur is suspected with prior assessment, the best position for the client to auscultate the apical site is:

a.

Sitting up

b.

Standing

c.

Lying on the left side

d.

Dorsal recumbent

ANS: c

c. Extra heart sounds or heart murmurs are heard more easily with the client lying on the left side (lateral recumbent) with the stethoscope at the apical site.

a. Sitting upright is used for assessing lung expansion and symmetry of the upper extremities.

b. Standing is not the best position for auscultating a heart murmur.

d. The dorsal recumbent position is best used for abdominal assessment.

REF: Text Reference: p. 726

18. As part of the examination, the nurse will be assessing the clients balance. The test that should be administered is the:

a.

Weber test

b.

Allen test

c.

Romberg test

d.

Rinne test

ANS: c

c. The Romberg test assesses the clients balance.

a. The Weber test assesses for unilateral deafness.

b. The Allen test assesses for patency of the arteries of the hand (usually before arterial puncture).

d. The Rinne test compares bone-conduction hearing with air-conduction hearing.

REF: Text Reference: p. 766

19. Part of the neurological examination is evaluating the response of the cranial nerves. To test cranial nerve VIII, the nurse should:

a.

Ask the client to read printed material

b.

Assess the directions of the gaze

c.

Assess the clients ability to hear the spoken word

d.

Ask the client to say ah

ANS: c

c. To test cranial nerve VIII (auditory), the nurse should assess the clients ability to hear the spoken word.

a. To test cranial nerve II (optic), the nurse should assess the clients ability to read printed material.

b. To test cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), the nurse should assess the clients directions of gaze.

d. To assess cranial nerve X (vagus), the nurse should ask the client to say ah.

REF: Text Reference: p. 764

20. A student nurse is working with a client who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. The student expects to hear:

a.

Coarse crackles and bubbling

b.

High-pitched musical sounds

c.

Dry, grating noises

d.

Loud, low-pitched rumbling

ANS: b

b. Wheezes are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration.

a. Coarse crackles and bubbling are not descriptive of wheezes.

c. Dry, grating noises are heard with a pleural friction rub.

d. Loud, low-pitched rumbling is characteristic of rhonchi.

REF: Text Reference: p. 721

21. The nurse instructs the male client that the protocol for testicular self-examination is to:

a.

Perform the examination annually after age 35 years

b.

Use both hands to roll the testicles and feel the consistency

c.

Perform the examination before bathing or showering

d.

Contact the physician if a cordlike structure is felt on the top and back of the testicle

ANS: b

b. The nurse instructs the male client that the protocol for testicular self-examination is to use both hands to roll the testicle gently, feeling for lumps, thickening, or a change in consistency (hardening).

a. All men 15 years and older should perform the testicular self-examination monthly.

c. The examination should be performed after a warm bath or shower when the scrotal sac is relaxed.

d. A cordlike structure on the top and back of the testicle is a normal finding. It is the epididymis.

REF: Text Reference: p. 752

22. The nurse uses olfaction in the clients assessment. If a sweet, fruity smell is noticed in the oral cavity, the nurse suspects:

a.

Diabetic acidosis

b.

Gum disease

c.

Stomatitis

d.

Malabsorption syndrome

ANS: a

a. A sweet, fruity smell noticed in the oral cavity is indicative of diabetic acidosis.

b. Halitosis of the oral cavity is indicative of gum disease.

c. Stomatitis is characterized by oral pain, bad breath, inflammation, and oral ulcers in the mouth.

d. Foul-smelling stools in the infant are indicative of malabsorption syndrome.

REF: Text Reference: p. 678

23. A physical examination is to be performed by the nurse on a client that has cardiopulmonary disease. Knowing this about the client, the nurse is alert when checking the nails for the presence of:

a.

Clubbing

b.

Paronychia

c.

Beaus lines

d.

Splinter hemorrhages

ANS: a

a. Clubbing of the nails is caused by a chronic lack of oxygen such as in heart or pulmonary disease.

b. Paronychia is caused by local infection or trauma.

c. Beaus lines are caused by systemic illness such as severe infection or by injury to the nail.

d. Splinter hemorrhages are caused by minor trauma, subacute bacterial endocarditis or trichinosis (infection by the roundworm).

REF: Text Reference: p. 697

24. During the physical examination, the client tells the nurse that he has been told he has myopia. The nurse expects to find that the client:

a.

Is near-sighted

b.

Has decreased peripheral vision

c.

Has diminished night vision

d.

Experiences more glare, flashes, and floaters

ANS: a

a. Myopia is nearsightedness.

b. Peripheral vision is not reduced with myopia. The client with myopia is able to see close objects, but not distant objects. Peripheral vision may be decreased in open-angle glaucoma.

c. Diminished night vision may occur with cataracts, not myopia.

d. Problems with glare, flashes, and floaters may indicate eye disease, and the client should be referred to a physician.

REF: Text Reference: p. 699

25. The school-age child is brought to the school nurse after experiencing a nosebleed during a softball game. The appropriate intervention is for the nurse to:

a.

Have the child lean backward

b.

Apply pressure to the anterior nose

c.

Apply a warm cloth to the area

d.

Have the child close his mouth and blow his nose

ANS: b

b. The nurse should have the child who is experiencing a nosebleed sit up and lean forward to avoid aspiration of blood, apply pressure to the anterior nose with the thumb and forefinger as the child breathes through the mouth, and apply ice or a cold cloth to the bridge of the nose if pressure fails to stop bleeding.

a. The child should not lean backward, as this may cause the child to aspirate blood.

c. A cold cloth will slow bleeding and help blood to coagulate, not a warm cloth.

d. The child should breathe through the mouth. Blowing his nose may only continue the bleeding as it may disturb any clot formation.

26. An older adult client is visiting the physicians office for a check-up. The client asks the nurse how often the influenza and pneumonia vaccines should be taken. The nurse responds to the client that these vaccinations should be done:

a.

Every 6 months

b.

Annually

c.

Every 5 years

d.

Every 7 years

ANS: b

b. Older adults should be counseled to receive annual influenza and pneumonia vaccinations.

a. It is not necessary to receive these vaccinations every 6 months.

c. The influenza and pneumonia vaccines should be taken annually in the older adult because of the greater susceptibility to respiratory infection.

d. It is recommended that older adults receive the influenza and pneumonia vaccines annually because they have a greater susceptibility to respiratory infection.

REF: Text Reference: p. 722

27. A pregnant client is seen by the nurse in the antenatal clinic. On inspection, the nurse expects that this clients breasts will have:

a.

Softer tissue

b.

Flatter nipples

c.

Darkened areolae

d.

Diminished superficial veins

ANS: c

c. Normal changes of the breasts during pregnancy include the areola becoming darker and the diameter increasing.

a. Breast tissue becomes softer during menopause, not pregnancy.

b. Nipples become flatter in older adulthood.

d. Superficial veins become more prominent during pregnancy.

REF: Text Reference: p. 737

28. A client with vascular insufficiency is seen regularly in the medical clinic. The nurse notes that the client requires further instruction about her condition if the client:

a.

Walks regularly

b.

Wears knee-length stockings

c.

Elevates the feet when sitting

d.

Alternates periods of sitting and standing

ANS: b

b. The client with risk for or evidence of vascular insufficiency should not wear tight clothing over the lower body or legs, such as knee-length stockings.

a. Walking regularly is recommended for the client with vascular insufficiency.

c. The client with vascular insufficiency should elevate his or her feet when sitting.

d. The client with vascular insufficiency should avoid sitting or standing for long periods.

REF: Text Reference: p. 730

29. During the physical examination, the nurse should assess the clients glands by using the:

a.

Dorsum of the hand

b.

Pads of the fingers

c.

Palmar surface of the hand

d.

Fingertip grasp of the tissue

ANS: b

b. To assess the clients glands, the nurse should use the pads of the fingers and palpate gently.

a. The dorsum of the hand may be used to detect skin temperature, not to assess the clients glands.

c. The palmar surface of the hand is not used to assess the clients glands.

d. The nurse should not use a fingertip grasp of the tissue when assessing a clients glands.

REF: Text Reference: p. 713

30. The nurse is evaluating the client for conduction deafness in the right ear. In using Webers test, the nurse appropriately places the tuning fork and confirms this type of deafness when:

a.

Sound is not heard in either ear

b.

Sound is heard best by the client in the left ear

c.

Sound is heard best by the client in the right ear

d.

Sound is reduced and heard longer through air conduction

ANS: c

c. In conduction deafness, sound is heard best in the impaired ear.

a. Sound that is not heard in either ear is not indicative of conduction deafness.

b. Sound would not be heard best by the client in the left ear if there were conduction deafness in the right ear.

d. This option is describing the Rinnes test, not the Webers test. In conduction deafness, bone-conducted sound can be heard longer. In sensorineural loss, sound is reduced and heard longer through air.

REF: Text Reference: p. 708

3a. An inspection of the lower extremities is being performed. The presence of arterial insufficiency is suspected when the nurse observes:

a.

Increased hair growth

b.

Cooler skin temperatures

c.

Marked edema

d.

Brown pigmentation

ANS: b

b. In the presence of arterial insufficiency, the client has signs resulting from an absence of blood flow, such as pain, pallor, and decreased or absent pulses in the lower extremities. The lower extremities become dusky red when the extremities are lowered. They feel cool to touch because blood flow is blocked to the extremity.

a. Decreased hair growth or the absence of hair growth over the legs may indicate arterial insufficiency.

c. Marked edema is seen in venous insufficiency, not arterial insufficiency.

d. Brown pigmentation around the ankles is seen in venous insufficiency. Skin changes in arterial insufficiency include thin, shiny skin, decreased hair growth, and thickened nails.

REF: Text Reference: p. 734

3b. In the auscultation of the thorax, the nurse notes that the sounds heard over the trachea are expected to be:

a.

Soft, low-pitched, and breezy

b.

Loud, high-pitched, and hollow

c.

Moist, crackling, and bubbling

d.

High-pitched and musical

ANS: b

b. Sounds heard during auscultation over the trachea should be loud, high-pitched and hollow.

a. Soft, low-pitched, and breezy sounds are heard over the lungs periphery.

c. Moist, crackling, and bubbling sounds are adventitious sounds known as crackles and are caused by sudden reinflation of groups of alveoli and disruptive passage of air. They are most commonly heard in dependent lobes: right and left lung bases.

d. High-pitched and musical sounds are wheezes. Wheezes can be heard over all lung fields.

REF: Text Reference: p. 720

3c. During the neurological component of the physical examination, the nurse tests the function of the clients cranial nerves. In testing cranial nerve III, the nurse determines the clients ability to:

a.

Smile and frown

b.

Read printed material

c.

Identify sweet and sour tastes

d.

React to light with changes in pupil size

ANS: d

d. In testing cranial nerve III (oculomotor), the nurse determines the clients ability to react to light with changes in pupil size. Testing accommodation also will assess cranial nerve III.

a. In testing cranial nerve VII (facial), the nurse determines the clients ability to smile and frown.

b. In testing cranial nerve II (optic), the nurse determines the clients ability to read printed material.

c. In testing cranial nerve IX (glossopharyngeal), the nurse determines the clients ability to identify sweet and sour tastes.

REF: Text Reference: p. 764

Copyright 2005 by Mosby, Inc. All rights reserved.

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