Final Exam winter 2025 Health Assessment

The "lub dub" heart sounds indicate:

- The electrical activity of the heart

- closing of the heart valves

-opening of the alveoli

closing of the heart valves

The patient is asked to not turn his head and focus on an object (example your finger or a pencil) you are holding. The object is 12 inches from the patient's face. The nurse moves the object through the six cardinal positions of gaze in a clockwise direction. This assessment is:

- assessing for infection

- assessing for near vision

- the visual acuity test

- assessing the cardinal fields of gaze

assessing the cardinal fields of gaze

The nurse is assessing a client with pitting edema. The client depresses the skin with one finger and notes a 6mm 'pit'. The nurse is sure to document the degree of pitting as:

- 1+

- 2+

- 3+

- 4+

3+

Match the correct question with the appropriate letter of the COLDSPA Mnemonic:

C - Character: "What does the symptom feel like?"

O - Onset: "When did the symptom start?"

L - Location: "Where is the symptom located?"

D - Duration: "How long does the symptom last?"

S - Severity: "How severe is the symptom?"

P - Pattern: "Is there any pattern to the symptom?"

A - Associated factors: "Are there any other factors associated with the symptom?"

C - how does it feel look sound smell?

O - when did it begin?

L - where is it? does it radiate?

D - how long does it last?

S - how bad is it?

P - what makes it better/ worst?

A - what other sx occur with it?

After the nurse inspects the patients mouth, doff gloves, perform hand hygiene, and don new glovers before examining the nose.

True or False

True

During health assessment of mouth, buccal mucosa, and throat the nurse uses a tongue depressor and a penlight to inspect the uvula, hard and soft palate, and pharynx. T/F

True

The nurse is prepared to perform a health assessment on a 76 year old patient. The nurse has identified self; hand hygiene has been performed; gloves are donned the patient has been identified using two patient identifiers; the curtains are pulled for privacy. The nurse has assessed the patient's head and hair and is beginning to assess the eyes , ear, nose, and throat. When the patient begins to c/o tightness and pain in his chest and shortness of breath. Correct actions by the nurse include:

- continue with the health assessment, document findings

- tell the patient the exam will be finished in less than fifteen minutes, document findings

-advise the patient to take a few deep breaths; he is probably nervous about the exam

- stop the exam, call for help, provide help to the patient, be prepared to perform cpr if needed, document

stop the exam, call for help, provide help to the patient, be prepared to perform cpr if needed, document

Purpose of the bony structures inside the nose( upper, middle, and lower, turbinates):

- Regulate airflow

- warm and humidify air inhaled

-only allow oxygen to be inhaled

- stop all toxic gases from reaching the lungs

- prevent nasal cancer

- warm and humidify air inhaled

To inspect the internal nose the nurse will use a ____ with a wide-tipped attachment

otoscope

The following cranial nerve identifies temperature from the face?

trigeminal nerve

The bell part of the stethoscope is used to detect low frequency sounds like heart murmurs and some bowel sounds; diaphragm filters those sounds out? T/F

True

The nurse is to perform a health assessment on a patient and gives instructions about the Romberg Test. The patients states she does not want to perform the test even though the nurse explained the reasons for the test. Appropriate actions by the nurse include:

advise that the exam

The patient has been pronounced dead by the physician. Assessment of pupillary response from the deceased patient will be:

- fixed and constructed

-fixed and showing a color change

- fixed and dilated

-an elongated shape

fixed and dilated

A normal prostate is described as which of the following? Select all that apply:

-heart shaped

-movable and non tender to palpation

-flat with no groove

-firm and fixed to palpation

-feels elastic and rubbery

-heart shaped

- movable and non tender to palpation

- feels elastic and rubbery

The "Dub" heart sound (S2) indicates the closure of:

-tricuspid and mitral valve

-alveoli

- S.A. node

-aortic and pulmonic semilunar valves

aortic and pulmonic semilunar valves

The review of systems including the thorax/lungs and the heart and neck are examples of _______ and _______ nursing concepts?

physiological and functional or cardiovascular and respiratory

A group of students is preparing for a quiz on breast assessment and the assessment findings that are associated with breast cancer. the students demonstrate understanding of the material when they identify which of the following?

-irregular firm lumps

- dimpling and nipple retraction

-redness and warmth with smooth surface

-breast fullness and pain

- orange peel like appearance

- Irregular firm hard lumps

- Dimpling and nipple retraction

- Orange-peel-like appearance

The instrument used to examine the eye is called:

-reflex hammer

-ophthalmoscope

-speculum

-otoscope

ophthalmoscope

During the health assessment of the sinuses the nurse palpates the sinuses on the left side of the face and forehead first, and then palpates the right side of the face and forehead. T/F

False

This area is where heart sounds and heart murmurs can be heard; S1 and S2 can be heard; and completeness of valve closure can be heard.

-mitral and pulmonic

-tricuspid and pulmonic

-erb's point

-tricuspid and aortic

Erb's point

The nurse is completing the general survey. In addition to observing the client's overall appearance, the nurse would assess which of the following?

-mental status

-cognitive abilities

-vital signs

-thought processes

vital signs

Which organ is not part of the brain stem?

-Pons

- Medulla oblongata

- Thalamus

- Midbrain

thalamus

A client has large pendulous breasts. What would be most appropriate to ensure better access while examining the clients breasts for retraction and dimpling?

-have the client stand and lean forward

-have the client lie on her side

- have the client sit and then lean forward

- have the client lie on her back

have the client sit and then lean forward

The spleen is located in which quadrant of the abdomen

-RUQ

-RLQ

-LUQ

-LLQ

LUQ

The "Lub" heart sound (S1) is loud and correlates with closure of the atrioventricular mitral and tricuspid valve closing simultaneously at start of systole. true or false

true

When performing a clients head to toe assessment, during which part would the nurse assess the motor function of the cranial nerve VII?

- mental status examination

-head and face assessment

-ears assessment

- examination of mouth and throat

head and face assessment

The nurse is assessing the skin condition and color of an African-American client. Which of the following would the nurse consider to be an abnormal finding?

-evenly distributed color

-light to medium dark brown skin

-ashen gray skin color

ashen gray skin color

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which principle?

-the client has the right to refuse the assessment

-obtaining permission enhances therapeutic rapport

- the client will be more willing to disclose after giving permission

-the clients level of comfort will be increased by granting explicit consent

the client has the right to refuse the assessment

The nurse is inspecting the patients mouth and teeth. The patient complains that his tongue is painful.

The nurse notices white crusty lesions on the patients tongue. During the SBAR assessment it is appropriate for the nurse to:

- use hydrogen peroxide mixed with to wash mouth

According to the textbook for this course African American have the world's highest rates for hypertension. Hispanic males have the highest Low-Density Lipoprotein (LDL- to much cholesterol in the body) cholesterol worldwide. T/F

True

After teaching a group of young women about breasts self-examination, the nurse determines that the teaching was successful when the women state that they will palpate their breasts using which pattern? (Multiple Response)

-a circular pattern

-a clockwise pattern

-a wedge pattern

-an up and down pattern

an up and down pattern, a circular pattern, a wedge pattern

Which of the four (4) assessment techniques are used in both male and female breast self exam (BSE)? (Multiple Response)

-inspection

-palpation

-percussion

-auscultation

inspection, palpation

Malignant masses or tumors are most often found in the upper outer quadrant of the breast? T/F

True

When interviewing a client who might have been abused, what is the first and foremost thing for the nurse to consider?

- to have social services present

- the clients physical and emotional

the clients physical and emotional safety

The patient states "I think I kept my contact lenses in too long". This statement is:

-subjective data

-objective data

subjective data

The nurse observes a client's entire body posture to be somewhat stiff, with his shoulders elevated upward toward the ears. The nurse would interpret this to indicate that the client is experiencing:

-confusion

-anxiety

-powerlessness

-restlessness

anxiety

The nurse is performing a health assessment on a 46-year old male who states "for three days I have had pain and swelling in my right leg; I think I pulled a muscle. My wife has been rubbing alcohol.". During the assessment the nurse found the right calf measurement is greater than the left; the right calf is swollen, red, and the patient c/o pain when it is touched. Correct actions by the nurse include:

-Document findings as cellulitis, refer to primary physician

-Document findings as Deep Vein Thrombus (DVT), refer to primary physician

- Document findings, advise the patient not to rub his legs, do not use rubbing alcohol or anything on his leg, refer to primary physician

-Document findings, advise the patient to apply an elastic ace wrap on the leg, refer to the primary physician

Document findings, advise the patient not to rub his legs, do not use rubbing alcohol or anything on his leg, refer to primary physician

When using the penlight to examine the eye the nurse is examining the:

-optic fibers

- virtuous humor of the eye

-pupillary response to light

-extraocular movement

pupillary response to light

Which health assessment tool is used to examine hearing?

-tuning fork

-otoscope

-tooth pick

-reflex hammer

tuning fork

The nurse is reviewing a clients spirituality using the SPIRIT Spiritual assessment too. What would the nurse assess addressing the letter "P"? - powers, -spiritual prognosis, -personal spirituality, -prayer

personal spirituality

A nurse has completed a comprehensive assessment of a client and has begun the process of data analysis. Data analysis should allow the nurse to produce which direct result?

nursing diagnoses

After the nurse inspects the patients mouth, doff gloves, perform hand hygiene, and don new gloves before examining the nose.

T/F

true

At 0930 the nurse meets the patient to perform a health assessment. The patient is awake, oriented to time, place person, and thing. He stated, " I get a physical exam every year.". The patient is sitting on the exam table. At 1015 he slumped to the left side, made mumbling sounds; the right side of his face is drooped. The signs and symptoms of a stroke is identified by

-Cerebellar Ataxia score

-Motor and cerebellar assessment score

-FAST

-Braden Scale score

FAST

An adult male is brought to the emergency department by paramedics. The nurse notices the patient is: unconscious and posturing. His arms, wrist, and fingers are flexed; arms adducted; lower extremities extended, internally rotated with plantar flexion of feet. The patient is exhibiting ________.

a. Decerebrate Posturing

b. Cerebellar Ataxia

c.Spastic Hemiparesis

d. Decorticate Posturing

Decerebrate Posturing

Afferent nerve fibers carry an impulse toward the brain; efferent nerves carry the impulse toward the organ T/F

True

Erb's Point is located at the 3rd intercostal space, close to left side of the sternum T/F

True

The Rinne test compares air and bone conduction T/F

True

Which of the following descriptions about the lungs are correct? (Multiple Response)

- The lungs are symmetrical in size

- The right lung is shorter than the left because of the underlying liver

-The right lung has 2 lobes and the left lung has 3 lobes

- The base of the lungs ist at T12 with expansion

The base of the lungs ist at T12 with expansion

The right lung is shorter than the left because of the underlying liver

When assessing the carotid arteries, the nurse is to assess both (left and right) simultaneously by placing the index and middle fingers medial to the sternocleidomastoid muscle on the neck. T/F

False

Hearing loss is not common in adults over age 65 years

T/F

False

To inspect the patient's nose for patency of air flow,the nurse occludes one nostril at a time and ask the patient to sniff or exhale T/F

True

The nurse has reviewed the clients information and discussed the clients treatment plan with the oncologist, The nurse is preparing teaching for the client and daughter. The nurse should instruct the client and daughter to _______ and emphasize the impact of _______. - avoid compression stocking, monitor fluid intake, prepare for lifelong treatment

lymphedema and avoid compression stocking

There are four (4) pairs of paranasal sinuses located in the skull. Which sinuses are accessible to the provider during examination? (Multiple Responses)

-ethmoidal

-frontal

-maxillary

-sphenoidal

frontal and maxillary

A nurse in a clinic performs a head-to-toe assessment on a 62-year-old male client. The assessment reveals the following: alert and cooperative, lungs diminished in the bases, increased secretions in the larger airway, respirations 22 breaths/min, pulses 1+, capillary refill greater than 3 seconds, abdomen soft and nontender, skin warm and dry with cool lower extremities, and client moves all extremities well with full range of motion.

- the nurse should first address the clients ______ by the clients______

respiratory function and cardiovascular

A student nurse is performing a focused abdominal assessment of a hospitalized client. The nursing instructor determines proper assessment techniques when the nursing student perform s the assessment in what order?

Inspect, palpate, auscultate and percuss

inspect, auscultate, percuss, palpation

Identify and rank tonsils with the grading scale from 1 to 4

-Tonsils are midway between tonsilar pillars and uvula

-tonsils are visible

-tonsils touch each other

-tonsils touch the uvula

Tonsils are midway between tonsillar pillars and uvula- Grade 2

Tonsils are visible - Grade 1

Tonsils touch each other - Grade 4

Tonsils touch the uvula - Grade 3

The nurse shines a penlight into patients eyes to elicit response from the cranial nerve?

i olfactory

xi spinal accessory

iv trochlear

iii oculomotor

iii oculomotor

Afferent fibers carry impulse toward the brain; efferent nerves carry the impulse toward the organ T/F

true

To test Cranial Nerve I, the nurse can use an object, such as cut lemon and ask the patient to identify the smell without looking at the object. T/F

True

A 33 year old female client seeks medical attention at a community clinic for an intermittent frontal headache. The nurse prepares to assess the client's sinuses. To palpate the sinuses, the nurse will sit ______ and press up on the _________ under the brow bone. Then, the nurse will palpate over the cheek bones to assess the __________. Afterward, the nurse will tap lightly over the sinus area to assess for _____.

facing the client,

frontal sinuses,

maxillary sinuses,

tenderness To palpate the sinuses, the nurse will sit facing the client and press up on the frontal sinuses under the brow bone. Then, the nurse will palpate over the cheek bones to assess the maxillary sinuses. Afterward, the nurse will tap lightly over the sinus areas to assess for tenderness

Before performing an examination of the mouth, which of the following should the nurse do first?

-ask the patent to brush their teeth

- wear gloves

-ask the patient if they have eaten or drank anything in the last thirty minutes

-ask the patient to drink one glass of water

wear gloves

A client comes to the clinic complaining of pain of his ears. He states that even a slight movement of the ear causes extreme pain. Upon inspection, the nurse notes swollen red pinna and outer canal. The client states that he notices the symptoms a few days after he went swimming in the lake. Which of the following conditions is the client most likely suffering from?

Otitis media

Otitis externa

Cellulitis

Frostbite

Otitis externa

Match the following Skeletal muscle movements.

Circumduction

[Choose ]

Hyperextension

[Choose ]

Abduction

[ Choose ]

Adduction

[ Choose )

Dorsiflexion

[ Choose )

Eversion

Circumduction

circular motion

Hyperextension

joint bends greater than 180 degrees

Abduction

moving away from midline of the body

Adduction

moving toward midline of the body

Dorsiflexion

toes draw upward to ankle

Eversion

straightening the extremity at the joint increasing the angle of the joint

The nurse is palpating the breasts of a woman. She is aware that most tumors are found in a particular quadrant of the breast. Which particular quadrant will the nurse pay extra attention to?

Upper outer quadrant

Upper inner quadrant

Lower outer quadrant

Lower inner quadrant

upper outer quadrant

The nurse performing an examination of the client makes several observations.

Which of the following observations warrants additional evaluation?

Walk is smooth and even

Wears a coat over wool clothes on a rainy winter day

The client smiles when talking to the nurse and looks out the window with hands clasped tightly

Body structure is symmetrical

The client smiles when talking to the nurse and looks out the window with hands clasped tightly.

A nurse is receiving report from the nurse at the end of the shift. Documented in the client's EHR is pulse: 88 bpm. +3.

What is the correct interpretation of +3?

Full, bounding

Normal

Weak

Absent

Full, bounding

Which of the following client situations would the nurse interpret as requiring an emergency assessment?

A client with severe sunburn

A client needing an employment physical

A client who took a drug overdose

A client who wants a pregnancy test

A client who took a drug overdose

What is one way nurses use critical thinking in regard to the nursing process?

Critical thinking helps nurses decide which parts of the nursing process are not needed in regard to a particular client

Nurses do not need to think critically; they just need to follow the doctor's orders

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

Critical thinking allows nurses to make decisions regarding client care without involving the client in decisions

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?

Collect Objective data

Validate the data

Collect subjective data

Document the data

collect subjective data

The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process?

• Each step is independent of the others.

- It is ongoing and contínuous.

• It is used primarily in acute care settings,

- It involves independent nursing actions.

It is ongoing and contínuous.

The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first?

Obtain basic biographic data.

Consult clinical resources explaining the client's diagnosis.

Validate information with the client.

Review the client's medical record.

Review the client's medical record.

Assessment of a client's breasts reveals tenderness on palpation and diffuse redness. What collaborative problem is most clearly suggested by these data?

O RC: Breast cancer

O RC: Benign breast disease

O RC: Hematoma

O RC: Infection

RC: Infection

When palpating a female client's axillae, which action is most appropriate?

Have the client hold the arm of the side being examined slightly away from the body.

Tell the client to raise her arm on the side being examined up over her head

Hold the client's elbow of the side being examined with one hand.

Have the client lean forward from the waist with arms outstretched.

Hold the client's elbow of the side being examined with one hand.

During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would interpret this finding as suggestive of what?

Spastic hemiparesis

Parkinsonian gait

Cerebellar ataxia

Scissors gait

Cerebellar ataxia

A nurse teaches a male client how to perform testicular self-examination. The nurse should instruct the client to perform the self-examination at which frequency?

Weekly

Bimonthly

Monthly

Quarterly

monthly

When assessing a client's mental status, what would the nurse assess?

(Multiple Response)

Remote memory

Coping skills

Speech

Abstract reasoning.

Judgment

Remote memory

Speech

Abstract reasoning.

Judgment