Chapter 6: Health Assessment Nursing School Test Banks

MULTIPLE CHOICE

1. The nurse is visiting the patient for the first time this shift. She introduces herself and asks the patient several questions related to his condition. While doing so, and without being obvious, she is looking at the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth. Which assessment technique is the nurse using?

a.

Palpation

b.

Percussion

c.

Inspection

d.

Auscultation

ANS: C

Inspection is the visual examination of body parts or areas. An experienced nurse learns to make multiple observations, almost simultaneously, while becoming very perceptive of abnormalities. Palpation uses the sense of touch. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities. Auscultation is listening with a stethoscope to sounds produced by the body.

DIF: Cognitive Level: Application REF: Text reference: p. 108

OBJ: Describe the techniques used with each assessment skill. TOP: Inspection

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. The patient is admitted with fever and acute lower abdominal pain. He has taken Tylenol but says he still feels feverish. Before taking the patients temperature, the nurse may:

a.

touch the patients skin with the dorsum of her hand.

b.

touch the patients skin with the pads of her fingers.

c.

palpate the skin using the bimanual method.

d.

tap the patients skin using the fingertips.

ANS: A

The dorsum (back) of the hand is more sensitive to temperature variations. The pads of the fingertips detect subtle changes in texture, shape, size, consistency, and pulsation of body parts. Bimanual palpation involves one hand placed over the other while pressure is applied. The upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses. Seek the assistance of a qualified instructor before attempting deep palpation. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities.

DIF: Cognitive Level: Application REF: Text reference: p. 108

OBJ: Describe the techniques used with each assessment skill. TOP: Palpation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. What should the nurse do when preparing to complete an assessment for a 16-year-old patient?

a.

Focus on illness behaviors.

b.

Plan for a diminished energy level.

c.

Treat the patient as an individual.

d.

Have the parents present throughout.

ANS: C

Older children and adolescents tend to respond best when treated as adults and individuals and often can provide details about their health history and severity of symptoms. Routine examinations of children have a focus on health promotion and illness prevention, particularly in the care of well children with competent parenting and no serious health problems. The focus is on growth and development, sensory screening, dental examination, and behavioral assessment. Children who are chronically ill, disabled, in foster care, or foreign-born adopted may require additional assessment. The adolescent has a right to confidentiality. After talking with the parents about historical information, the nurse arranges to be alone with the adolescent to speak further privately and to perform the examination.

DIF: Cognitive Level: Application REF: Text reference: p. 112

OBJ: Describe how to conduct a physical examination on patients from diverse cultures.

TOP: Children and Adolescents KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. In providing a physical assessment of an 88-year-old patient, the nurse should:

a.

do it as quickly as possible to prevent fatigue.

b.

assume that the patient will have disabilities.

c.

prepare to perform a mental status examination.

d.

always do the exam in the small exam room to prevent chills.

ANS: C

Inclusion of a review of mental status is highly recommended when the nurse performs an examination of an older adult. Allow extra time, and be patient, relaxed, and unhurried with older adults. Do not assume that aging is always accompanied by illness or disability. Older adults are able to adapt to change and to maintain functional independence. Provide adequate space for an examination, particularly if the patient uses a mobility aid.

DIF: Cognitive Level: Application REF: Text reference: p. 112

OBJ: Describe how to conduct a physical examination on patients from diverse cultures.

TOP: Older Adults KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. The general survey begins with a review of the patients primary health problems and an evaluation of the patients vital signs, height and weight, general behavior, and appearance. It also provides information about the patients illness, hygiene, skin condition, body image, and emotional state. Which of the following cannot be delegated to nursing assistive personnel?

a.

Reporting subjective signs and symptoms

b.

Measuring the patients height and weight

c.

Monitoring I&O

d.

Obtaining initial vital signs

ANS: D

Because the initial set of vital signs are part of the general health assessment they must be taken by the nurse. After that, the NAP may take vital signs for a stable patient. The nurse directs NAP to report a patients subjective signs and symptoms to the nurse, to measure the patients height and weight, and to monitor oral intake and urinary output.

DIF: Cognitive Level: Application REF: Text reference: p. 113

OBJ: Identify data to collect from the nursing history before an examination.

TOP: Delegation Considerations KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. Petechiae are noted on the patient as a result of the nurse finding:

a.

bluish-black patches.

b.

tenting.

c.

pinpoint-sized red dots.

d.

large areas of raised, irritated skin.

ANS: C

Petechiae appear as tiny, pinpoint-sized, red or purple spots on the skin caused by small hemorrhages in the skin layers and may indicate a blood-clotting disorder, a drug reaction, or liver disease. Bluish-black patches are more indicative of malignant melanoma. With reduced turgor, the skin remains suspended or tented for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. Large areas of raised, irritated skin are not characteristic of petechiae.

DIF: Cognitive Level: Application REF: Text reference: p. 116

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Petechiae KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

7. The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices that the skin remains suspended for a longer than normal period. What could this indicate?

a.

Stage I pressure ulcer

b.

Increased blood flow to the area

c.

Localized vasodilation

d.

Dehydration

ANS: D

With reduced turgor, the skin remains suspended or tented for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. A stage I pressure ulcer may cause warmth and erythema (redness) of an area. Skin temperature reflects an increase or decrease in blood flow. Normal reactive hyperemia (redness) is a visible effect of localized vasodilation, the bodys normal response to lack of blood flow to underlying tissue.

DIF: Cognitive Level: Analysis REF: Text reference: p. 117

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Assessment of Skin Hydration KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

8. The nurse is preparing to examine a patient who has chronic lung disease. She realizes that the patient most likely will need to be in which position for the examination?

a.

Sitting upright

b.

Supine

c.

Side-lying

d.

Prone

ANS: A

Position the patient sitting upright. This promotes full lung expansion during examination. Patients with chronic respiratory disease will likely need to sit up throughout the examination because of shortness of breath. Only if the patient is unable to tolerate sitting would a supine position or a side-lying position be used.

DIF: Cognitive Level: Analysis REF: Text reference: p. 128

OBJ: Describe proper positioning for the patient during each phase of the examination.

TOP: Positioning for Examination of Thorax and Lungs

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. Which of the following may a nursing assistant be responsible for determining?

a.

Vital signs

b.

Cranial nerve function

c.

Neck vein distention

d.

Auscultation of bowel sounds

ANS: A

Assistive personnel can be trained to count apical pulse and peripheral pulses after the nurses initial assessment. Assistive personnel need to be instructed to recognize temperature and color changes, along with changes in peripheral pulses. Comprehensive heart and neck vessel assessment should not be delegated to assistive personnel. However, assistive personnel should know to report the development of abdominal pain or changes in the patients bowel habits or dietary intake.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 113

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Delegation KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

10. The nurse is caring for a patient who is recovering from an acute myocardial infarction. While providing cardiac education, the nurse realizes that the patient needs more education when he:

a.

describes changes in his behavior that may improve cardiovascular function.

b.

describes the schedule, dosage, and purpose of his medication.

c.

states that he will take his medication when he has chest pain or when his heart rate is greater than 100.

d.

describes the benefits of taking his medication regularly.

ANS: C

The patient should not take medications for cardiovascular function intermittently. Medication should be taken on the regular prescribed schedule to prevent additional cardiac events. Describing changes in his behavior that may improve his cardiovascular function indicates that the patient understands steps he may take to improve his own health. The ability to accurately describe the schedule, dose, and purpose of his medication indicates that the patient understands his treatment. Understanding the benefits of taking his medication regularly should improve patient compliance with therapy.

DIF: Cognitive Level: Analysis REF: Text reference: p. 132

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cardiovascular Disease KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

11. Which of the following is an expected outcome for a patient after cardiac assessment?

a.

Apical pulse rate equals 58 beats per minute

b.

Carotid bruits present

c.

PMI palpable at left fifth intercostal space at midclavicular line

d.

Jugular veins distended with patient in sitting position

ANS: C

Locate the PMI by palpating with fingertips along the fifth intercostal space at the midclavicular line. Sinus bradycardia: Pulse rhythm is regular, but rate is slower than normal at 40 to 60 beats/min. Place bell of stethoscope over each carotid artery while auscultating for blowing sounds (bruit). Ask the patient to hold a breath for a few heartbeats so that respiratory sounds will not interfere with auscultation. Narrowing of the carotid artery lumen by arteriosclerotic plaques causes disturbance in blood flow. Blood passing through the narrowed section creates turbulence and emits a blowing or swishing sound. Normal veins are flat when the patient is sitting, and pulsations become evident as the patients head is lowered.

DIF: Cognitive Level: Analysis REF: Text reference: p. 133

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cardiovascular Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

12. Where is the pulmonic area for auscultation found?

a.

Second intercostal space on the right side

b.

Second intercostal space on the left side

c.

Third intercostal space (Erbs point)

d.

Fourth intercostal space along the sternum

ANS: B

The pulmonic area is at the second intercostal space on the left side. The aortic area is at the second intercostal space on the patients right side. The second pulmonic area is found by moving down the left side of the sternum to the third intercostal space, also referred to as Erbs point. The tricuspid area is located at the fourth left intercostal space along the sternum.

DIF: Cognitive Level: Application REF: Text reference: p. 134

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Heart Sounds KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

13. While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart failure, the nurse is unable to palpate the PMI with the patient lying supine. What might her next step be?

a.

Have the patient turn onto his left side.

b.

Have the patient lean forward.

c.

Have the patient move to a sitting position.

d.

Palpate the PMI to the right of the midclavicular line.

ANS: A

If palpating the PMI is difficult, turn the patient onto the left side. This maneuver moves the heart closer to the chest wall. Different positions help to clarify the types of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). In the presence of serious heart disease, the PMI will be located to the left of the midclavicular line if related to an enlarged left ventricle. In chronic lung disease, the PMI is often to the right of the midclavicular line as a result of right ventricular enlargement.

DIF: Cognitive Level: Application REF: Text reference: p. 135

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cardiovascular Disease KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. Which is the best position in which to place the patient to hear low-pitched cardiovascular sounds?

a.

Supine

b.

Sitting up

c.

Dorsal recumbent

d.

Left lateral recumbent

ANS: D

Different positions help to clarify types of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). Supine is a common position to hear all sounds. Left lateral recumbent is the best position to hear low-pitched sounds.

DIF: Cognitive Level: Application REF: Text reference: p. 135

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cardiovascular Disease KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. What technique should the nurse implement for assessment of the carotid artery?

a.

Massaging the arteries briskly

b.

Using the diaphragm of the stethoscope

c.

Palpating each carotid artery separately

d.

Placing the patient in a supine position

ANS: C

Palpate each carotid artery separately with index and middle fingers around the medial edge of the sternocleidomastoid muscle. Ask the patient to raise the chin slightly, keeping the head straight. Note rate and rhythm, strength, and elasticity of the artery. Also note if the pulse changes as the patient inspires and expires. Do not vigorously palpate or massage the artery. Stimulation of the carotid sinus may cause a reflex drop in heart rate and blood pressure. Place the bell of the stethoscope over each carotid artery, auscultating for a blowing sound (bruit). To assess venous pressure, have the patient recline at a 45-degree angle and slowly recline into the supine position, avoiding neck hyperextension or flexion. Measure the distance between the angle of Louis and the highest point of vein pulsation.

DIF: Cognitive Level: Application REF: Text reference: p. 138

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Assessment of Carotid Artery KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16. Which of the following is an unexpected finding after a cardiac assessment?

a.

A pulse rate of 72 beats per minute

b.

Jugular vein pulsation with the patient supine

c.

PMI found at the midclavicular line

d.

A sustained swishing sound during systole or diastole

ANS: D

Murmurs are sustained swishing or blowing sounds heard at the beginning, middle, or end of systole or diastole. They are caused by increased blood flow through a normal valve, forward flow through a stenotic valve or into a dilated vessel or chamber, or backward flow through a valve that fails to close. Expected outcomes following completion of procedure: Heart rate is between 60 and 100 beats per minute (adolescent through adult) and without extra sounds or murmurs; jugular veins distend when patient lies supine and flatten when patient is in sitting position; and point of maximal impulse (PMI) is palpable at fifth intercostal space at left midclavicular line in the adult.

DIF: Cognitive Level: Analysis REF: Text reference: p. 138

OBJ: Communicate abnormal findings to appropriate personnel.

TOP: Murmurs KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

17. Which technique is most appropriate for a nurse to implement during the assessment of the abdomen?

a.

Assessing painful areas first

b.

Auscultating for 5 minutes over each quadrant

c.

Positioning the patient in a supine position with the arms behind or over the head

d.

Palpating painful masses or organ enlargement deeply and firmly

ANS: B

To auscultate bowel sounds, place the diaphragm of the stethoscope lightly over each of the four abdominal quadrants. Listen 5 minutes over each quadrant before deciding that bowel sounds are absent. Painful areas are assessed last. Manipulation of a body part can increase the patients pain and anxiety and can make the remainder of the assessment difficult to complete. Placing the arms under the head or keeping the knees fully extended can cause the abdominal muscles to tighten. Tightening of muscles prevents adequate palpation. If masses are palpated, note size, location, shape, consistency, tenderness, mobility, and texture.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 148

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Abdominal Assessment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18. How should the nurse document an exaggeration of the posterior curvature of the thoracic spine found during the assessment of a 90-year-old patient?

a.

Lordosis

b.

Osteoporosis

c.

Scoliosis

d.

Kyphosis

ANS: D

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

Lordosis is an increased lumbar curvature (swayback). Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone. Scoliosis is a lateral curvature of the spine.

DIF: Cognitive Level: Application REF: Text reference: p. 157

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Curvature of the Spine KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

19. The patient is diagnosed with Bells palsy. The nurse assesses the patient and notices drooping of the patients right eye and the right side of his mouth. When the functions of the following nerves are compared, the most likely cause of these symptoms would be a dysfunction of the:

a.

seventh cranial nerve.

b.

trigeminal nerve (CN V).

c.

oculomotor nerve (CN III).

d.

glossopharyngeal nerve (CN IX).

ANS: A

Assess cranial nerve (CN) VII (facial) by noting facial symmetry. Have the patient frown, smile, puff out their cheeks, and raise their eyebrows. Expressions should be symmetrical; Bells palsy causes drooping of the upper and lower face; cerebrovascular accident (CVA) causes asymmetry. Assess cranial nerve CN V (trigeminal) by applying light sensation with a cotton ball to symmetric areas of the face. Sensations should be symmetric; unilateral decrease or loss of sensation is possibly due to a CN V lesion or a lesion in higher sensory pathways. Assess CN III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement (EOM) functioning. Ask the patient to follow the movement of your finger through the six cardinal positions of gaze; measure pupillary reaction to light reflex and accommodation using a penlight. These cranial nerves are most likely to be affected by increasing intracranial pressure (ICP), which causes a change in pupil response or pupil size; sometimes pupils change shape (more oval) or react sluggishly. ICP impairs EOMs. Damage to CN IX causes impaired swallowing; damage to CN X causes loss of gag reflex, hoarseness, and a nasal voice. When the palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis.

DIF: Cognitive Level: Synthesis REF: Text reference: p. 159

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cranial Nerves KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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

a.

Abducens

b.

Facial

c.

Trigeminal

d.

Oculomotor

ANS: C

The trigeminal nerve is tested by applying light sensation with a cotton ball to symmetric areas of the face. Sensations should be symmetric; unilateral decrease or loss of sensation may be caused by a CN V lesion. Assess CN III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement (EOM) functioning. Ask the patient to follow the movement of your finger through the six cardinal positions of gaze; measure pupillary reaction to light reflex and accommodation using a penlight. The facial nerve is tested by having the patient smile, frown, puff out their cheeks, and raise and lower their eyebrows while you look for asymmetry. The oculomotor nerve is tested by assessing directions of gaze and by testing pupillary reaction to light and accommodation.

DIF: Cognitive Level: Application REF: Text reference: p. 159

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cranial Nerves KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

21. The nurse is assessing the neurologic status of a patient. She uses the handle end of a reflex hammer to stroke the lateral aspect of the sole of the foot. She notes that the great toe dorsiflexes and the other toes spread out like a fan. What does this indicate?

a.

A positive Rombergs test

b.

A negative Babinskis reflex

c.

A hyperactive patellar tendon reflex

d.

A normal reflex in a child younger than age 2

ANS: D

After the soles of the feet are stroked, if Babinskis reflex is present, the great toe will dorsiflex, accompanied by fanning of the other toes. This indicates CNS dysfunction. Dorsiflexion of the great toe and fanning of the others are normal findings in a child younger than age 2. Rombergs test: Have the patient stand with feet together, arms at sides, once with eyes open and once with eyes closed (for 20 to 30 seconds each time). Protect the patients safety by standing at their side; observe for swaying. Plantar response (Babinskis reflex): Using the handle end of the reflex hammer, stroke the lateral aspect of the sole, from the heel to the ball of the foot. The toes should flex inward and downward. Knee reflex: Palpate the patellar tendon just below the patella. Tap the pointed end of the reflex hammer briskly on the tendon. Knee reflex is the most common DTR assessment performed. The normal response is knee extension.

DIF: Cognitive Level: Synthesis REF: Text reference: p. 159

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Babinskis Reflex KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

22. How does a nurse appropriately measure intake and output?

a.

Recording 50% of ice chip consumption

b.

Checking urinary output every 24 hours

c.

Emptying the chest tube drainage every 2 hours

d.

Subtracting liquid medications from the total intake

ANS: A

All liquids consumed must be counted including liquids with meals, gelatin, custards, ice cream, popsicles, sherbets, and ice chips (recorded as 50% of measured volume [e.g., 100 mL of ice chips equals 50 mL of water]) for the intake record. Liquid medicines such as antacids are counted as fluid intake, as are fluids with medications. The output record must include all fluids leaving the body. Instruct the patient (or family) to call the nurse to empty contents of the urinal, urine hat, or commode each time it is used so the fluid may be measured. Blood collected in a wound drain is also counted. Chest tube drainage is emptied ONLY when the container is nearly full. A closed system is necessary to maintain lung reexpansion.

DIF: Cognitive Level: Application REF: Text reference: p. 162

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Intake KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

23. Which skin condition would cause a nurse to suspect chickenpox?

a.

Wheals

b.

Nodules

c.

Pustules

d.

Vesicles

ANS: D

A vesicle is a circumscribed elevation of skin filled with serous fluid, smaller than 1 cm (e.g., herpes simplex, chickenpox). A wheal is an irregularly shaped, elevated area of superficial localized edema that varies in size (e.g., hive, mosquito bite); it is not characteristic of chickenpox. A nodule is an elevated solid mass, deeper and firmer than a papule, 1 to 2 cm (e.g., wart), and not characteristic of chickenpox. A pustule is a circumscribed elevation of skin similar to a vesicle but filled with pus; it varies in size (e.g., acne, staphylococcal infection) and is not characteristic of chickenpox.

DIF: Cognitive Level: Application REF: Text reference: p. 118

OBJ: Discuss normal physical findings for patients across the life span.

TOP: Primary Skin Lesions KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

24. Which patient position maximizes the nurses ability to assess the patients body for symmetry?

a.

Sitting

b.

Supine

c.

Prone

d.

Dorsal recumbent

ANS: A

Sitting upright provides full expansion of the lungs and allows better visualization of symmetry of upper body parts. The supine position maximizes the nurses ability to assess pulse sites. The prone position is used only to assess extension of the hip joint. The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles.

DIF: Cognitive Level: Application REF: Text reference: p. 111

OBJ: Discuss normal physical findings for patients across the life span.

TOP: Positions for Physical Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

25. During assessment of a patient with anemia, a nurse is alert for the presence of:

a.

pallor.

b.

jaundice.

c.

cyanosis.

d.

erythema.

ANS: A

Pallor is a decrease in color caused by a reduced amount of oxyhemoglobin resulting from decreased blood flow caused by anemia or shock. Jaundice is caused by increased deposit of bilirubin in tissues caused by liver disease or destruction of red blood cells; it is not characteristic of anemia. Cyanosis is caused by an increased amount of deoxygenated hemoglobin due to heart or lung disease or a cold environment; it is not characteristic of anemia. Erythema is caused by increased visibility of oxyhemoglobin due to dilation or increased blood flow because of fever, direct trauma, blushing, or alcohol intake; it is not characteristic of anemia.

DIF: Cognitive Level: Application REF: Text reference: p. 116

OBJ: Discuss normal physical findings for patients across the life span.

TOP: Skin Color Variations KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

26. A nurse is documenting a patients breath sounds. Crackles are heard as:

a.

loud, low-pitched, coarse sounds.

b.

high-pitched, musical squeaks.

c.

dry, grating sounds on inspiration.

d.

high-pitched, fine sounds at the end of inspiration.

ANS: D

Fine crackles are high-pitched, fine, short, interrupted crackling sounds heard during the end of inspiration; they usually are not cleared with coughing. Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration that may be cleared by coughing. Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration and do not clear with coughing. Pleural friction rub has a dry, grating quality heard best during inspiration; it does not clear with coughing and is heard loudest over the lower lateral anterior surface.

DIF: Cognitive Level: Application REF: Text reference: p. 126

OBJ: Discuss normal physical findings for patients across the life span.

TOP: Adventitious Breath Sounds KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

27. A student nurse is working with a patient 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

Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration. Coarse crackles and bubbling are not descriptive of wheezes. Dry, grating noises are heard with a pleural friction rub. Loud, low-pitched rumbling is characteristic of rhonchi.

DIF: Cognitive Level: Application REF: Text reference: p. 126

OBJ: Discuss normal physical findings for patients across the life span.

TOP: Adventitious Breath Sounds KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

28. A nurse is documenting a patients breath sounds. Rhonchi are heard as:

a.

loud, low-pitched, coarse sounds.

b.

high-pitched, musical squeaks.

c.

dry, grating sounds on inspiration.

d.

high-pitched, fine sounds at the end of inspiration.

ANS: A

Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration; they may be cleared by coughing. Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration and do not clear with coughing. Pleural friction rub has a dry, grating quality heard best during inspiration and does not clear with coughing; it is heard loudest over the lower lateral anterior surface. Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during the end of inspiration; they usually are not cleared with coughing.

DIF: Cognitive Level: Application REF: Text reference: p. 126

OBJ: Discuss normal physical findings for patients across the life span.

TOP: Adventitious Breath Sounds KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. The purpose of the physical assessment is to: (Select all that apply.)

a.

compare the patients status with previous findings.

b.

help the nurse gather additional data.

c.

help select the best nursing measures.

d.

teach patients about better health promotion.

ANS: A, B, C, D

In acute care settings, you perform a brief physical assessment at the beginning of each shift to identify changes in the patients status for comparison with the previous assessment. After gathering data, the nurse groups significant findings into patterns of data that reveal actual or risk nursing diagnoses. Each abnormal finding directs the nurse to gather additional data. The information is useful in selecting the best nursing measures to manage the patients health problems. During the physical assessment is an ideal time to offer patient teaching and encourage promotion of health practices, such as breast and genital self-examination.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 105

OBJ: Discuss the purposes of physical assessment.

TOP: Purpose of the Physical Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. The nurse is preparing to examine a comatose patient on a ventilator. Before beginning the procedures, she: (Select all that apply.)

a.

speaks to the patient to minimize anxiety.

b.

drapes the body parts not being examined.

c.

encourages the patient to ask questions.

d.

uses medical terms to let the patient know that she is professional.

ANS: A, B

Minimize patients anxiety and fear by conveying an open, receptive, and professional approach. Using simple terms, thoroughly explain what you will do, what the patient should expect to feel, and how the patient can cooperate. Even if the patient appears unresponsive, it still is essential to explain your actions. Provide access to body parts while draping areas that are not being examined.

DIF: Cognitive Level: Application REF: Text reference: p. 111

OBJ: List techniques to promote the patients physical and psychological comfort during an examination. TOP: Preparing the Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The patient has come to the clinic complaining of bleeding from what she calls a mole on her neck. She states that her mother died from skin cancer at a fairly early age because she was fair-skinned and had a lot of exposure to the sun. Because of this, the patient has been going for tanning sessions regularly for several years to keep her dark and to protect her from the sun. The nurse prepares to examine the mole while being especially watchful for: (Select all that apply.)

a.

uneven shape of the mole (asymmetry).

b.

ragged or blurred edges of the mole border.

c.

pigmentation that is not uniform.

d.

size of the mole.

ANS: A, B, C, D

The warning signs of skin cancer using the ABCD mnemonic include: A for Asymmetrylook for uneven shape; B for Border irregularitylook for edges that are blurred, notched, or ragged; C for Colorpigmentation is not uniform; blue, black, brown variegated, tan, or areas of unusual color such as pink, white, gray, or red; and D for Diametergreater than the size of a typical pencil eraser. Also, identify any skin lesion or nevi that starts to bleed or ooze or feels different (swollen, hard, lumpy, itchy, or tender to the touch).

DIF: Cognitive Level: Analysis REF: Text reference: p. 116

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Melanoma KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. While performing a physical examination, the nurse incorporates health promotion by teaching the patient about how to reduce the risk of lung cancer. The nurse explains that besides cigarette smoking, exposure to other substances may lead to this disease. Some of these substances are: (Select all that apply.)

a.

arsenic.

b.

asbestos.

c.

radiation.

d.

air pollution.

ANS: A, B, C, D

Explain to patients that exposure to radiation, arsenic, and asbestos from occupational, medical, and environmental sources; air pollution; history of tuberculosis; and second-hand smoke contribute significantly to lung cancer.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 131

OBJ: Discuss ways to incorporate health promotion and health teaching into an assessment.

TOP: Lung Cancer KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. In teaching the patient about prevention of cervical cancer, the nurse teaches the patient about the risk factors for cervical cancer. Risk factors for cervical cancer include which of the following? (Select all that apply.)

a.

History of human papillomavirus (HPV) infection

b.

Multiple sex partners

c.

Smoking

d.

Multiple pregnancies

ANS: A, B, C, D

Determine whether the patient has a history of human papillomavirus (HPV), condyloma acuminatum, herpes simplex, or cervical dysplasia; has multiple sex partners; smokes cigarettes; or has had multiple pregnancies. These are risk factors for cervical cancer.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 151

OBJ: Discuss ways to incorporate health promotion and health teaching into an assessment.

TOP: Cervical Cancer KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. The patient is 3 days post abdominal surgery. The nurse uses her stethoscope to listen for bowel sounds. This assessment technique is known as _________________.

ANS:

auscultation

Auscultation is listening with a stethoscope to sounds produced by the body.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 109-110

OBJ: Describe the techniques used with each assessment skill. TOP: Auscultation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. The female nurse is preparing to assess and possibly change a scrotal dressing on a 34-year-old patient. Before changing the dressing, she should ______________.

ANS:

have a third person of the patients gender come into the room

Have a third person of the patients gender in the room during assessment of genitalia. This prevents the patient from accusing the nurse of behaving in an unethical manner.

DIF: Cognitive Level: Application REF: Text reference: p. 111

OBJ: Make environmental preparations before conducting an assessment.

TOP: Preparing the Patient KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The nurse is providing health education to a group of adolescent females. The topic is Preventing Skin Cancer. As part of the health promotion education, the nurse recommends that they avoid tanning under direct sun at midday and avoid _________________.

ANS:

tanning beds

Do not use indoor sunlamps or tanning beds because these are sources of UV radiation.

DIF: Cognitive Level: Analysis REF: Text reference: p. 105

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Melanoma KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. ________________ is a major cause of lung cancer, cerebrovascular disease, heart disease, and chronic lung disease.

ANS:

Smoking

Smoking is a major cause of lung cancer, heart disease, and chronic lung disease (emphysema and chronic bronchitis). Smoking accounts for 29% of all lung cancer deaths in the United States.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 127

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Smoking KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity

5. When performing an assessment of the cardiovascular system, the nurse evaluates the skin and nails of the patient. Inadequate tissue perfusion is known as ______________.

ANS:

ischemia

Inadequate tissue perfusion results in inadequate delivery of oxygen and nutrients to cells, a condition called ischemia. This is caused by constriction of vessels or by occlusion (blockage) from clot formation.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 132

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Ischemia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6. The patient has been immobile at home after having had leg trauma in an automobile accident and is now being admitted with calf pain and localized swelling of the calf muscle. One test that is contraindicated in assessment of this patient is testing for _____________.

ANS:

Homans sign

Homans sign is no longer considered a reliable indicator for the presence or absence of DVT and should not be considered a reliable test. Trauma to the vein or muscle, reduced mobility, and increased blood clotting are reliable risk factors. If the calf is swollen, tender, or red, notify the patients health care provider for further assessment and evaluation. If there is a strong suspicion of DVT, testing for Homans sign is contraindicated. If a clot is present, it may become dislodged from its original site during this test. This could result in a pulmonary embolism.

DIF: Cognitive Level: Analysis REF: Text reference: p. 140

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Deep Vein Thrombosis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. The patient has been in the ICU following an acute myocardial infarction 3 days earlier. During an initial assessment of the patient, the nurse detects a heart murmur that the patient did not have previously. The nurse should __________________.

ANS:

notify the physician

Impaired blood flow through the heart indicates the need for immediate medical attention. Some murmurs are benign.

DIF: Cognitive Level: Analysis REF: Text reference: p. 138

OBJ: Communicate abnormal findings to appropriate personnel.

TOP: Murmurs KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. The patient is noted to have difficulty swallowing. The nurse realizes that the most probable cause of this difficulty is damage to cranial nerve ______.

ANS:

IX

Damage to CN IX causes impaired swallowing; damage to CN X causes loss of gag reflex, hoarseness, and nasal voice. When the palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis.

DIF: Cognitive Level: Synthesis REF: Text reference: p. 159

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Cranial Nerves KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

9. When breast self-examination is done, it should be done once a month. For women who menstruate, the best time is ______________.

ANS:

2 or 3 days after a period ends

For women who menstruate, the best time to do BSE is 2 or 3 days after a period ends, when the breasts are least likely to be tender or swollen. Women who no longer menstruate should pick a day, such as the first day of the month, to regularly do a BSE.

DIF: Cognitive Level: Application REF: Text reference: p. 106

OBJ: Identify self-screening assessments commonly performed by patients.

TOP: Breast Self-Examination KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. Increased visibility of oxyhemoglobin caused by dilation or increased blood flow is known as ________________.

ANS:

erythema

Red skin (erythema) is caused by increased visibility of oxyhemoglobin caused by dilation or increased blood flow.

DIF: Cognitive Level: Application REF: Text reference: p. 116

OBJ: Discuss normal physical findings for patients across the life span.

TOP: Skin Color Variations KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

11. A late sign of decreased oxygen levels may cause a change in skin color known as _________.

ANS:

cyanosis

Bluish (cyanosis) coloring of the skin is caused by hypoxia (late sign of decreased oxygen levels).

DIF: Cognitive Level: Application REF: Text reference: p. 116

OBJ: Discuss normal physical findings for patients across the life span.

TOP: Skin Color Variations KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

12. ____________ is a yellow-orange skin color seen with increased deposit of bilirubin in tissues.

ANS:

Jaundice

Jaundice, a yellow-orange skin color, is seen with increased deposits of bilirubin in tissues.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 116

OBJ: Discuss normal physical findings for patients across the life span.

TOP: Skin Color Variations KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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