Health Assessment - Exam 3 Review Questions

The wife of a 65-year-old client tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe.

A) frontal

B) parietal

C) occipital

D) temporal

A

A CLIENT WAS ADMITTED TO THE ED WITH SLURRED SPEECH. THE NURSE NOTES THAT THIS COULD BE DUE TO DYSFUNCTION OF WHAT CRANIAL NERVE(S)?

A) Cranial Nerve I

B) Cranial Nerve V

C) Cranial Nerves IX and X

D) Cranial Nerve III

C

The nurse is assessing a client who may have suffered a stroke. Which of these statements is true concerning areas of the brain?

A) The cerebellum is the center for speech and emotions.

B) The hypothalamus controls temperature and regulates sleep.

C) The basal ganglia are responsible for controlling voluntary movements.

D) Motor pathways of the spinal cord and brainstem synapse in the thalamus.

B

The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The client:

A) demonstrates ability to hear normal conversation.

B) sticks tongue out midline without tremors or deviation.

C) follows an object with both eyes without nystagmus or strabismus.

D) moves the head and shoulders against resistance with equal strength.

D

During the history, a client tells the nurse that "it feels like the room is spinning around me." The nurse would document this as:

A) vertigo.

B) syncope.

C) dizziness.

D) seizure activity

A

A female client is in the clinic with weakness in her left arm and leg that she has noticed for the past week. which type of neurologic examination would be most appropriate for this client?

A) Glasgow Coma Scale

B) Neurologic Recheck Examination

C) Neurologic Screening Examination

D) Complete Neurologic Examination

D

During a neurological assessment, the nurse finds the following: asymmetry when the client smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air from one side only when the nurse presses against the puffed cheeks. This would indicate dysfunction of which of these cranial nerves?

A) Motor component of IV

B) Motor component of VII

C) Motor and sensory components of XI

D) Motor component of X and sensory component of VII

B

A female client tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. The nurse suspects this could be due to dysfunction of which area of the brain?

A) Thalamus

B) Brainstem

C) Cerebellum

D) Extrapyramidal tract

C

During the assessment of THE Biceps reflexes, the nurse finds that a client's responses are normal bilaterally. The Nurse would be Correct in documenting this finding As ____+

A) 3+

B) 1+

C) 2+

D) 4+

C

A GRADUATE NURSE ASKS A MORE EXPERIENCED NURSE WHEN SHE SHOULD COMPLETE A NEURO ASSESSMENT DURING THE COURSE OF HER SHIFT. AN APPROPRIATE RESPONSE WOULD BE:

A) Neuro assessments should not be performed while assessing other body systems.

B) Neuro assessments can be performed covertly.

C) Neuro assessments should only be performed on admission.

D) Neuro assessments should only be performed when a client complains of a headache.

B

A NURSE IS CONDUCTING A COMPLETE NEUROLOGICAL EXAM ON A CLIENT WHO REPORTS DIFFICULTY WITH SPEECH. WHAT OTHER QUESTIONS WOULD BE IMPORTANT FOR THE NURSE TO ASK THIS CLIENT?

SELECT ALL THAT APPLY

A) When did you first notice this symptom?

B) How long did the symptoms last?

C) Can you describe the symptoms?

D) Any problems forming words?

A, B, C, D

A CLIENT TELLS THE NURSE HE IS HAVING NUMBNESS ON THE LEFT SIDE OF HIS FACE. THE NURSE ASKS HIM TO CLOSE HIS EYES AND TOUCHES A COTTON BALL TO HIS FOREHEAD, CHIN, AND BOTH CHEEKS. THE NURSE IS TESTING THE FUNCTION OF WHICH CRANIAL NERVE?

A) Cranial Nerve III

B) Cranial Nerve IV

C) Cranial Nerve V

D) Cranial Nerve VII

C

A NURSE SUSPECTS THAT HER CLIENT MAY HAVE SUFFERED A STROKE. WHICH TOOLS CAN THE NURSE USE TO CONFIRM HER SUSPICIONS?

A) R.A.C.E

B) NIH Scale

C) F.A.S.T

D) Both B and C

D

A NURSE RECEIVING REPORT ON A CLIENT ADMITTED WITH SYMPTOMS OF A STROKE ASKS WHEN THE CLIENT'S SYMPTOMS BEGAN. SHE KNOWS THIS INFORMATION IS IMPORTANT IN ORDER TO: SELECT ALL THAT APPLY

A) Reduce long term brain damage

B) Reduce disability

C) Provide appropriate treatment

D) Save the person's life

A, B, C, D

A FEMALE CLIENT CALLS OUT TO THE NURSE STATING, "I SEE SPIDERS ON MY ARM." THE NURSE SUSPECTS THE CLIENT IS DISPLAYING SYMPTOMS OF DELIRIUM. WHICH TOOL SHOULD THE NURSE USE WHEN ASSESSING THIS CLIENT?

A) The Glasgow Coma Scale

B) The Neurologic Recheck Examination

C) The Confusion Assessment Method (CAM)

D) The Complete Neurologic Examination

C

YOU ARE CARING FOR A CLIENT ADMITTED WITH C/O DIZZINESS. WHAT QUESTIONS ARE APPROPRIATE TO ASK TO ELICIT HEALTH HISTORY INFORMATION REGARDING THE CLIENT'S NEURO SYSTEM?

SELECT ALL THAT APPLY

A) Do you experience weakness?

B) Do you experience numbness or tingling?

C) Have you encountered any environmental or occupational hazards?

D) Have you ever had a stroke or spinal cord injury?

A, B, C, D

AFTER ASSESSING A CLIENT'S GAIT, A NURSE HAS THE CLIENT STAND WITH HIS EYES CLOSED TO PERFORM THE ROMBERG TEST IN ORDER TO ASSESS FUNCTION OF WHAT AREA OF HIS BODY?

A) Cerebellum

B) Temporal Lobe

C) Spinal Cord

D) Broca's Area

A

THE NURSE IS ASSESSING A CLIENT'S VISUAL ACUITY USING THE SNELLEN CHART. THE CLIENT'S VISION IS 20/20. THIS INDICATES THAT THERE IS NORMAL FUNCTION OF WHICH CRANIAL NERVE?

A) Cranial Nerve IV

B) Cranial Nerve II

C) Cranial Nerve VII

D) Cranial Nerve V

B

THE NURSE IS PERFORMING AN ORAL ASSESSMENT AND ASKS THE CLIENT TO STICK OUT HIS TONGUE AND SAY "AHH." SHE NOTES THAT HIS UVULA DEVIATES TO ONE SIDE. SHE SUSPECTS THERE MAY BE DAMAGE TO WHICH CRANIAL NERVE?

A) Cranial Nerve IX

B) Cranial Nerve XII

C) Cranial Nerve X

D) Cranial Nerve VII

C

A CLIENT'S WIFE TELLS THE NURSE THAT SHE IS CONCERNED BECAUSE SHE NOTICED HER HUSBAND HAS BEEN HAVING DIFFICULTY HEARING NORMAL CONVERSATION. THE NURSE SUSPECTS THE CLIENT MAY HAVE CRANIAL NERVE VIII DAMAGE. WHAT TESTS WOULD BE APPROPRIATE FOR THE NURSE TO USE TO CONFIRM SUSPICIONS OF DECREASED HEARING ACUITY? SELECT ALL THAT APPLY

A) Whispered Voice Test

B) Weber Test

C) Rinne Test

D) Romberg Test

A, B, C

THE NURSE IS PERFORMING A NEUROLOGICAL ASSESSMENT ON A 60 YEAR OLD CLIENT WHO SUFFERED A STROKE AND IS EXPERIENCING LEFT-SIDED WEAKNESS. SHE ASKS THE CLIENT TO STICK HER TONGUE OUT AND MOVE IT FROM SIDE TO SIDE. THE NURSE NOTES THE CLIENT'S TONGUE DEVIATES TO THE LEFT SIDE AND SUSPECTS DAMAGE TO WHICH CRANIAL NERVE?

A) Cranial Nerve IX

B) Cranial Nerve XII

C) Cranial Nerve VIII

D) Cranial Nerve V

B

THE NURSE IS USING THE DIAGNOSTIC POSITIONS TEST TO ASSESS HER CLIENT'S EXTRAOCULAR EYE MOVEMENTS. SHE NOTES PARALLEL TRACKING OF BOTH EYES. SHE WOULD BE CORRECT IN DOCUMENTING NORMAL FINDINGS FOR WHICH CRANIAL NERVE(S)?

A) Cranial Nerve VII

B) Cranial Nerve I

C) Cranial Nerve II

D) Cranial Nerves III, IV & VI

D

WHICH OF THE FOLLOWING ARE COORDINATION AND SKILLED MOVEMENT ASSESSMENTS USED TO TEST CEREBELLAR FUNCTION? SELECT ALL THAT APPLY

A) Finger-to-finger test

B) Stereognosis

C) Patting the thighs

D) Finger-to-nose test

A, C, D

WHICH OF THE FOLLOWING STATEMENTS IS TRUE REGARDING THE OLFACTORY NERVE (CN I)?

A) The Olfactory Nerve is tested by having the client shrug their shoulder.

B) The Olfactory Nerve is tested by having the client say "light, tight, dynamite."

C) The Olfactory Nerve is tested by having the client smell a familiar substance like coffee, lemon or vanilla.

D) The Olfactory Nerve is tested by having the client stick the tongue out.

C

WHICH OF THE FOLLOWING ARE EXPECTED CHANGES THAT CAN BE SEEN IN THE OLDER ADULT DUE TO THE LOSS OF NEURONS IN THE BRAIN AND SPINAL CORD LIMITATION?

SELECT ALL THAT APPLY

A) Improvement in fine coordination and agility.

B) Decreased muscle strength and agility.

C) Decreased reaction time.

D) Progressive decrease in cerebral blood flow.

B, C, D

A NURSE IS ASSESSING A CLIENT RECENTLY DIAGNOSED WITH PARKINSON'S DISEASE. WHAT ABNORMAL BODY MOVEMENTS ARE TYPICALLY ASSOCIATED WITH THIS DISEASE?

A) Myoclonus

B) Fasciculations

C) Resting tremors

D) Tics

C

THE NURSE IS ASSESSING THE CLIENT'S POSITION SENSE BY MOVING THE CLIENT'S FINGERS AND TOES IN THE UP, DOWN, AND NEUTRAL POSITION. THE CLIENT IS ABLE TO IDENTIFY WHICH POSITION THE NURSE IS MOVING THE LIMBS. THE TEST IS CALLED:

A) Graphesthesia

B) Extinction

C) Point location

D) Kinesthesia

D

A CLIENT comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _____ and proceeds with the examination by _____.

A) XI; palpating the anterior and posterior triangles

B) XI; asking the CLIENT to shrug her shoulders against resistance

C) XII; percussing the sternomastoid and submandibular neck muscles

D) XII; assessing for a positive Romberg sign

B

The nurse is assessing the ear of an adult client. How should the nurse perform the examination?

A. Pull the pinna down and insert scope

B. Insert the scope straight into the ear

C. Pull the pinna up and back and insert the scope

D. Tilt the scope to the angle of the ear

C

Which of the following would be considered subjective data?

A. The patient states that he has clear discharge coming out of his ears.

B. You note that the patient's ears are equal size and shape.

C. The patient is unable to hear the words on the Whispered Voice Test.

D. The patient's ear drum is a pearl gray color.

A

The nurse is assessing a client who has a hearing impairment. How should the nurse communicate with this client?

A) Use a low tone and speak slowly.

B) Use a normal tone of voice and speak slowly.

C) Speak loudly with a normal rate.

D) Face the client and speak slowly.

D

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:

A) light pink with a slight bulge.

B) pearly gray and slightly concave.

C) pulled in at the base of the cone of light.

D)whitish with a small fleck of light in the superior portion.

B

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:

A) auricle.

B) concha.

C) outer meatus.

D)mastoid process.

A

A client with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the client that the middle ear functions to:

A) maintain balance.

B) interpret sounds as they enter the ear.

C) conduct vibrations of sounds to the inner ear.

D) increase amplitude of sound for the inner ear to function.

C

The nurse is assessing a client who may have hearing loss. Which of these statements is true concerning air conduction?

A) It is the normal pathway for hearing.

B) It is caused by the vibrations of bones in the skull.

C) The amplitude of sound determines the pitch that is heard.

D) A loss of air conduction is called a conductive hearing loss.

A

In performing a whispered words test to assess hearing, which of these actions would the nurse do?

A) Shield the lips so that the sound is muffled.

B) Whisper a set of random numbers and letters and ask the patient to repeat them.

C) Ask the patient to place his finger in his ear to occlude outside noise.

D)Stand about 4 feet away to ensure that the patient can really hear at this distance.

B

The nurse is performing an ear examination of an 80-year-old client. Which of these would be considered a normal finding for the aging adult?

A) A high-tone frequency loss

B) Increased elasticity of the pinna

C) A thin, translucent membrane

D) A shiny, pink tympanic membrane

A

The nurse is examining a client's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

A) Sticky honey-colored cerumen is a sign of infection.

B) The presence of cerumen is indicative of poor hygiene.

C) The purpose of cerumen is to protect and lubricate the ear.

D) Cerumen is necessary for transmitting sound through the auditory canal.

C

A client has been shown to have sensorineural hearing loss. During the assessment, it would be important for the nurse to:

A) speak loudly so he can hear the questions.

B) assess for middle ear infection as a possible cause.

C) ask the patient what medications he is currently taking.

D) look for the source of the obstruction in the external ear.

C

The nurse is taking the history of a client who may have a perforated eardrum. What would be an important question in this situation?

A) "Do you ever notice ringing or crackling in your ears?"

B) "When was the last time you had your hearing checked?"

C) "Have you ever been told you have any type of hearing loss?"

D) "Was there any relationship between the ear pain and the discharge you mentioned?"

D

An 18-year-old is at the clinic for "a sore throat lasting 6 days." The nurse is aware that which of these findings would be consistent with an acute infection?

A) Tonsils 1+/1-4+ and pink, same color as oral mucosa

B) Tonsils 2+/1-4+ with small plugs of white debris

C) Tonsils 3+/1-4+ with large white spots

D) Tonsils 3+/1-4+ with pale coloring

C

The salivary gland that is the largest and located in the cheek in front of the ear is the _____ gland.

A) parotid

B) Stensen's

C) sublingual

D) submandibular

A

The nurse is assessing an 80-year-old client. Which of these findings would be expected for this client?

A) Hypertrophy of the gums

B) An increased production of saliva

C) A decreased ability to identify odors

D) Finer and less prominent nasal hair

C

A 92-year-old client has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

A) Epistaxis

B) Rhinorrhea

C) Dysphagia

D) Xerostomia

C

The nurse is doing an assessment on a 21-year-old client and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?

A)"Are you aware of having any allergies?"

B) "Do you have an elevated temperature?"

C) "Have you had any symptoms of a cold?"

D)"Have you been having frequent nosebleeds?"

A

Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X (Vagus)?

A)Observe the patient's ability to articulate specific words.

B)Observe the patient's ability to move the shoulders against resistance.

C)Have the patient stick out the tongue and observe for tremors or pulling to one side.

D)Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.

D

The nurse is assessing a client in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?

A)"We will need to get a biopsy and see what the cause is."

B)"This is an overgrowth of hair and will go away in a few days."

C)"This is a fungal infection caused by all the antibiotics you've received."

D)"This is probably caused by the same bacteria you had in your lungs."

C

The primary purpose of the ciliated mucous membrane in the nose is to:

A) warm the inhaled air.

B) filter out dust and bacteria.

C) filter coarse particles from inhaled air.

D) facilitate movement of air through the nares.

B

The nurse is palpating the sinus areas. If the findings are normal, then the client should report which sensation?

A) No sensation

B) Firm pressure

C) Pain during palpation

D) Pain sensation behind eyes

B

During an assessment of a 20-year-old client with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:

A) dehydration.

B) irritation by gastric juices.

C) a normal oral assessment.

D) side effects from nausea medication.

A

The two sinuses that can be directly palpated are?

A. Frontal and Sphenoid

B. Maxillary and Ethmoid

C. Frontal and Maxillary

D. Ethmoid and Sphenoid

C

When assessing the teeth and gums, which of the following would be a normal finding?

A. The teeth are white and the gums are coral pink

B. The gums are bleeding

C. The adult client has 22 total teeth

D. The upper and lower jaw are not aligned

A

A female client comes in to the clinic complaining of perianal itching. Which of the following would NOT be appropriate to assist the client in preparing for a perianal examination?

A) Instruct the client to inform you of any pain or discomfort during the exam.

B) Assume that the client has had a vaginal exam before and has no questions.

C) Ask the client if she would like a family member, friend or chaperone present.

D) Have the client empty her bladder.

B

The nurse is examining an older female client. Which of the following are expected changes that would be noted? Select all that apply

A) The vagina is narrow and has lost its elasticity

B) The labia & clitoris decrease in size

C) Thinning pubic hair

D) Decreased sexual drive

A, B, C

The nurse is inspecting a female client's perianal area. Which of the following assessment findings, if noted, would be considered abnormal?

A) Smooth and even colored sacrococcygeal area

B) Dark pink colored labia minora

C) Excoriation, inflammation or swelling

D) Moist, hairless anus

C

The nurse is performing an assessment of a male client. Which of these statements is true about the testes?

A) The lymphatics of the testes drain into the abdominal lymph nodes.

B) The vas deferens is located along the inferior portion of each testis.

C) The right testis is lower than the left because the right spermatic cord is longer.

D) The cremaster muscle contracts in response to cold and draws the testicles closer to the body.

D

A client states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse suspects that the client is experiencing:

A) dysuria

B) stress incontinence

C) hematuria

D) urge incontinence

B

After completing an assessment of a 60 year-old male client with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n):

A) annual proctoscopy.

B) colonoscopy every 10 years.

C) fecal test for blood every 6 months.

D) digital rectal examinations every 2 years

B

The nurse is describing how to perform a testicular self-examination to a client. Which of these statements is most accurate?

A) "A good time to examine your testicles is just before you take a shower."

B) "If you notice an enlarged testicle or a painless lump, call your health care provider."

C) "The testicle is pear-shaped and immovable. It feels firm and has a lumpy consistency."

D) "Perform a testicular exam at least once a week to detect the early stages of testicular cancer."

B

A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" A correct response would be:

A) "It depends. Do you smoke?"

B) "A Pap test needs to be performed annually until you are 65 years of age."

C) "If you have two consecutive normal Pap tests, then you can wait 5 years between tests."

D) "After age 30, if you have three consecutive normal Pap tests, then you may be screened every 3 years."

D

The nurse is examining an older male client. Which of the following is not an expected change that should be noted?

A) loss of libido

B) decreased pubic hair

C) decreased penis size

D) slowed time for erection

A

A nurse is performing an assessment on an uncircumcised male client. She retracts the foreskin and remembers to return the skin to its original position. This action is performed to prevent which of the following from occurring? Select all that apply

A) An erection

B) Tissue loss

C) Decreased circulation

D) Amputation

B, C, D

A 60 year old client expresses concerns about his sexual drive. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life can be attributed to:

A) Decreased sperm production.

B) Side effects of medications.

C) Increased sperm production.

D) Decreased pleasure from sexual intercourse

B

A female client has just been diagnosed with Human papillomavirus (HPV) and genital warts. The nurse should counsel her to receive regular examinations because this virus places her at a higher risk for which disease process?

A) Bladder Infection

B) Uterine Prolapse

C) Ovarian Cysts

D) Cervical Cancer

D

A nurse is providing a client with information on anal and rectal health. Which of the following should the nurse include in educating the client?

Select all that apply

A) Avoid straining during defecation

B) Eat a high fiber diet

C) Avoid lifting extremely heavy items

D) Keep anal area clean and dry

A, B, C, D

The nurse is examining a male client. The client appears apprehensive. Which of the following actions can the nurse employ to reduce the client's anxiety?

A) Use a soft, stroking touch

B) Be confident and relaxed

C) Talk to the client about his sexual practices

D) Perform the examination quickly

B

A 75 year old client with an enlarged prostate is concerned because he has trouble sleeping. He states, "I have to pee about 6 or 7 times a night and it just drips." A correct response would be:

A) "You probably have a bladder infection. We'll need to give you antibiotics."

B) This is a natural part of the aging process."

C) "This is the way the kidney removes bacteria from the body."

D) "You may want to cut back on drinking fluids about 3 hours before bedtime."

D

During the interview, a client reveals to the nurse that she has been having a large amount of vaginal discharge and itching. She is worried that it may be a sexually transmitted infection. An appropriate response to this would be:

A) "Oh, don't worry. Some cyclic vaginal discharge is normal."

B) "Have you been engaging in unprotected sexual intercourse?"

C) "I'd like some information about the discharge. What color is it?"

D) "Have you had any urinary incontinence associated with the discharge?"

C

During an examination of a 62 year old male, the nurse notices an immobile, tender nodule. A correct assessment of this finding is that this nodule is:

A)Normal

B) Abnormal

B