5011 multiple choice

Nursing Assessment - Multiple Choice Questions

What is the most important and basic technique in preventing and controlling transmission of infection in the clinical setting? A. Hand hygiene. B. Wearing latex gloves. C. Using eye protection. D. Gowning. *A

A student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding? A. Inform the client that the lump may be malignant B. Discuss treatment options with the client C. Consult with a clinical instructor D. Ask another student nurse to confirm the finding. *C

A nurse is performing a complete physical assessment of a patient with known MRSA infection who has also been diagnosed with pneumonia and has a productive, purulent cough. Which pieces of personal protective equipment should the nurse wear? A. Gloves, mask, and gown. B. Gloves and gown. C. Mask and protective eye goggles. D. Gown only. *A

Which assessment technique is performed for every body part and body system? A. Inspection B. Measurement C. Diagnosis D. Reflex *A

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? A. Percuss the region before auscultating B. Palpate the region before auscultating C. Assist the client to a sitting position D. Reduce all environmental noise *D

The nurse has completed the physical examination of a hospitalized client who is lying in a supine position in the bed. The nurse puts the bed rails in the upright position. In order to ensure client safety, what is the most important thing the nurse should do prior to leaving the room? A. Turn off the lights B. Offer the client a blanket C. Draw the curtain D. Lower the bed height *D

When would a nurse NOT be required to wear gloves? A. While checking blood pressures at a health fair. B. While providing wound care. C. While administering an injection. D. While drawing blood. *A

The nursing instructor is discussing standard precautions with a group of students. Which of the following is NOT a component of standard precautions? A. Surgical mask worn within 3 feet of patients. B. Hand hygiene before, after, and between direct contact with patients. C. Respiratory hygiene and cough etiquette. D. Safe disposal of needles and sharp instruments. *A

The nurse is performing a Braden assessment on a 62-year-old male. The nurse notes that the patient responds to verbal commands, eats most of every meal, and is incontinent at times, resulting in skin that is occasionally moist. The patient cannot bear weight and must be assisted into the chair, makes occasional slight changes in position but is unable to do so independently, and occasionally slides down when in the chair and bed. How would the nurse record the Braden score? A. 16 B. 12 C. 9 D. 21 *A

A young adult patient comes to the clinic for evaluation. During skin assessment, the nurse notes considerable skin tenting and decreased turgor. Why does this finding require further assessment? A. Decreased turgor indicates dehydration. B. Decreased turgor indicates malnutrition. C. Decreased turgor indicates Vitamin B12 deficiency. D. Decreased turgor indicates trauma. *A

The nurse is preparing to interview a client who speaks a language that is different from the dominant language. To ensure mutual understanding, what is the best action for the nurse to take prior to the interview? A. Request that a trained interpreter be available during the interview. B. Prepare short and simple questions. C. Plan to have the client to repeat back in their own words what was asked. D. Arrange for extra time to develop the nurse–client relationship. *A

While assessing the nails of an older adult, the nurse observes clubbing. The nurse should further evaluate the patient for signs and symptoms of which condition? A. Hypoxia B. Trauma C. Anemia D. Infection *A

Which of the following assessments provides insight into the functioning of CN VIII? A. Test the patient's hearing for lateralization and bone and air conduction. B. Ask the patient to shrug both shoulders against resistance. C. Ask the patient to smile, frown, and close both eyes tightly. D. Test the patient's ability to identify a familiar scent. *A

A nurse is assessing pupillary responses in his patient and finds a unilateral dilated pupil that is unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the abnormal pupillary response? A. CN III B. CN I C. CN V D. CN VI *A

Mr. Nabokov asks why the nurse needs to perform a nursing health assessment. What would be the most appropriate response? A. "It helps us evaluate your health status, risk factors, and educational needs which are used to develop a plan of care." B. "I'm not sure, but that's how we've always done it." C. "It's a tool we use to evaluate the care we provide." D. "It reduces the workload for the healthcare provider." *A

Nurse Karla understands the importance of subjective data to the health history. Subjective data includes which of the following? A. Symptoms reported by the patient. B. Symptoms observed by the nurse. C. Vital signs. D. History documented in the chart. *A

While the nurse examines a client's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse? A. Myopia B. Presbyopia C. Direct reaction D. Consensual reaction *D

When assessing cranial nerves X, which of the following would the nurse consider as a normal finding? A. Uvula and soft palate rising bilaterally. B. Asymmetrical soft palate. C. Stationary soft palate on phonation. D. Deviation of the uvula. *A

The nurse is preparing to perform a focused respiratory assessment on her patient. The nurse should be cognizant of which of the following anatomical characteristics of the lungs? A. The right lung has three lobes, whereas the left lung has two lobes. B. The lungs are structurally symmetrical but function differently. C. The right lung is approximately one-third larger than the left lung. D. The lower lobes of both lungs are oriented closer to the anterior chest wall. *A

A client is being monitored in the intensive care unit after a cerebral aneurysm rupture. The nurse assesses pupil size and knows that pupil size assesses which cranial nerve... A. Cranial nerve IV B. Cranial nerve III C. Cranial nerve VII D. Cranial Nerve XI *B

While a client is saying the letter E during the assessment of transmitted voice sounds, the nurse auscultates the letter A. Which pathological process does this finding suggest to the nurse? A. Chronic obstructive pulmonary disease B. Emphysema C. Pneumonia D. Pneumothorax *C

Ms. Nguyen has experienced a stroke. Upon assessment, the nurse identifies no eye or verbal responses, but Ms. Nguyen does withdraw from painful stimuli. How would the nurse score these responses using the Glasgow Coma Scale? A. 6 B. 8 C. 10 D. 12 *A

While assessing her post-operative patient, the nurse notes that the respiratory rate is eight breaths per minute with a regular depth and rhythm. How would the nurse describe this respiratory pattern? A. Bradypnea B. Tachycardia C. Apnea D. Hyperventilation *A

Which part of the hand is most appropriate for the nurse to use when assessing for tactile fremitus in a patient? A. Ulnar Surface B. Dorsal Surface C. Fingerpads D. Fingernails *A

Nurse Florence is assessing her patient's orientation as part of the neurological examination. Which question would be most appropriate to ask? A. "Can you tell me where you are right now?" B. "Can you tell me about your mood today?" C. Does schizophrenia run in your family? D. "Have you ever been institutionalized?" *A

While percussing over the anterior and posterior thorax in a healthy patient, the nurse should anticipate hearing which tone over the majority of the lung fields? A. Resonance B. Dullness C. Hyperresonance D. Tympany *A

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding? A. Right knee +1; Left knee 0 B. Right knee +2; Left knee +1 C. Right knee +3; Left knee +2 D. Right knee +4; Left knee +3 *B

Where is the point of maximal impulse (PMI) normally located? A. Left 5th intercostal space 7 to 10 cm lateral to the sternum. B. Left 5th intercostal space 12 to 14 cm lateral to the sternum. C. Left 5th intercostal space in the anterior axillary line. D. Left 5th intercostal space in the mid axillary line. *A

To assess abduction of the shoulder joints, what should the nurse ask her patient to do? A. Bring your arms out to the side and and bring the hands together overhead. B. Bring both hands forward in front of the body. C. Bring the hands to the small of the back. D. Bring the hands to meet in prayer at the chest. *A

While assessing the knee joint, the nurse considers the typical motions associated with that joint, which include: A. Flexion B. Abduction C. Circumduction D. Inversion *A

The area of the anterior chest wall that overlays the heart and great vessels is called what? A. Precordium B. Myocardium C. Epicardium D. Endocardium *A

While assessing his patient, Nurse Umar presses down on his patient's arm with the tip of his thumb, holds for a few seconds, and releases. Nurse Umar observes the result depicted below. What is the nurse assessing? A. Pitting Edema B. Capillary Refill Time C. Ecchymosis D. Pulse Pressure *A

Ms. Apple reports difficulty sleeping, stating that she uses three pillows to sleep and cannot breathe comfortably when lying flat. How would this symptom be described? A. Orthopnea B. Tachypnea C. Sleep Apnea D. Bradypnea *A

Mr. Nabokov is able to actively move the right arm against gravity but not against resistance. How should the nurse document this finding using the muscle strength grading scale? A. 3/5 B. 1/5 C. 2/5 D. 4/5 *A

A nursing student is assessing his patient for peripheral vascular disease in the lower extremities. Which of the following lower-extremity characteristics would be most important to assess? A. Size, symmetry, and skin colour B. Muscle bulk and tone C. Lower extremity strength D. Nodules in joints *A

When describing the cardiac cycle to a group of nursing students, the instructor correlates heart sounds with events in the cardiac cycle. Which heart sound would be associated with the beginning of systole? A. S1 B. S2 C. S3 D. S4 *A

During assessment, the nurse observes that a child's urethral meatus is located on the underside of the penis. What is the term for this structural difference? A. Hypospadias B. Phimosis C. Circumcision D. Torsion *A

Which description below best matches Tanner Stage 3 development in a child with penile anatomy? A. Penis elongated; coarse, curly, pubic hair sparsely distributed over pubic symphysis. B. Scrotum and testes slightly enlarged; sparse, long, downy pubic hair. C. Penis increased in width; abundant pubic hair but not extending to thighs. D. Penis of adult size; dark, curly, abundant pubic hair extending to thighs. *A

Nurse Misha notes that their patient has tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding related to which organ? A. Kidney B. Liver C. Pancreas D. Spleen *A

A 78 year-old patient presents to the clinic with concern that the foreskin is trapped behind the corona and cannot be replaced over the glans. On examination, the glans is noted to be tight, swollen, and exquisitely painful. What is this condition called? A. Phimosis B. Priapism C. Paraphimosis D. Monsoon Syndrome *C

When performing an abdominal assessment, which is the correct order of assessments? A. Inspection, Palpation, Percussion, Auscultation B. Auscultation, Palpation, Percussion, Inspection C. Inspection, Auscultation, Percussion, Palpation D. Palpation, Auscultation, Percussion, Inspection *C

While palpating in the right upper abdominal quadrant, the nurse identifies an enlarged area. Which organ is the nurse most likely palpating? A. Liver B. Pancreas C. Kidney D. Gallbladder *A

The nurse is percussing over the abdomen. Which sound would the nurse expect to hear over the majority of the abdomen? A. Tympany B. Borborygmi C. Resonance D. Dullness *A

Which abdominal quadrant contains the gallbladder? A. RUQ B. LUQ C. RLQ D. LLQ *A

The nurse is assessing a client's abdomen as shown. Which technique is the nurse using? A. Two-handed deep palpation B. Percussion C. Hooking D. Light palpation *A

Which of the following situations require the use of soap and water for hand hygiene instead of alcohol-based hand sanitizer? Select all that apply. A. Hands are visibly soiled with blood or other body fluids. B. Exposure to spore-forming organisms such as Clostridium difficile. C. After removing gloves. D. Before applying sterile gloves and inserting an invasive device. E. After contact with inanimate objects in the patient's environment. *A,B

The nurse is preparing to assess her patient's cerebellar function. Which of the following would the nurse include? Select all that apply. A. Rapid Alternating Movements B. Finger to Nose Testing C. Deep Tendon Reflexes D. Cranial Nerves E. Heel to Shin Testing F. Muscle Strength G. Gait H. Discriminative Sensations *A,B,E,G

While the nurse is preparing to begin a physical examination of a client, the nurse notes that the bed is in the lowest position, the client is in a side-lying position, the television is on at a loud volume, and the lights are dimmed. How should the nurse proceed with the assessment? Select all that apply. A. Adjust the bed to a comfortable height. B. Turn off the television. C. Ask the client to reposition for the exam as necessary. D. Keep the lights dim. E. Lower the bed when the exam is completed. *A,B,C,E