Maternal Anatomy & Physiology Quizzes

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Health assessment

Health assessment of patients

1 / 29

1. In order to localize a symptom, which direction should the nurse give a client?

1. Point to where the symptom occurs

2. Come back when you are experiencing the symptom

3. Bring someone in with you who has witnessed you having the symptom

4. Tell me which body part is affected by the symptom.

A: This gives the examiner an understanding of where the problem may be without the possibility of confusion due to terminology used by the client for various body parts. There are times when a client may need to return during the time a symptom is being experienced but this is not primarily to localize the symptom. There are also times such as in the case of loss of consciousness or a seizure when a witness can provide valuable information but again, this is not primarily directed at localizing the symptom.

2 / 29

2. When assessing the abdomen of a client who is complaining of diarrhea, which finding would the nurse expect?

1. Absent bowel sounds

2. ypoactive bowel sounds

3. Hyperactive bowel sounds

4. Normal bowel sounds

C: Hypoactive bowel sounds may be a result of ileus or abdominal infection

3 / 29

3. When testing a client’s ability to identify odors, the nurse is assessing the function of which cranial nerve?

1. Facial

2. Trigeminal

3. Olfactory

4. Spinal accessory

C: The sensory function of the facial nerve relates to taste. The trigeminal nerve mediates light touch sensation. The spinal accessory nerve is a motor nerve tested by asking the client to turn the head against the resistance of the examiner’s hand placed against the side of his or her chin and face and to shrug the shoulders against the resistance of the examiner’s hands on them.

4 / 29

4. The physician prepares to interview a patient for a history but finds the patient in obvious pain. Which action by the physician is the best at this time?

1. Delay the interview until the patient is free of pain

2. Administer pain medication before initiating the interview

3. Gather as much information as quickly as possible by using closed-ended questions that require brief answers

4. Ask only those questions pertinent to the specific problem and completethe interview when the patient is more comfortable

D: Data is required regarding the immediate problem, but gathering additional information can be delayed. The patient should not receive pain medication before pertinent information related to allergies or the nature of the problem is obtained. Questions that require brief answers do not elicit adequate information for a health profile.

5 / 29

5. When a client complains of right knee pain, which areas should the nurse examine?

1. Only the right knee

2. The right ankle, the right knee and the right hip

3. The left lower abdominal quadrant and the left knee

4. The right leg and left arm

B: Pain in the right knee may be referred from the right hip or right ankle.

6 / 29

6. The physician is performing an assessment of a client’s abdomen. Upon palpation, the physician feels an abnormal lump in the left upper quadrant that is extremely painful for the client. The physician is likely palpating which of the following?

1. Inflamed spleen

2. Inflamed appendix

3. Enlarged liver

4. Bilious gallbladder

A: The spleen is located in the left upper quadrant (LUQ). If it is enlarged or inflamed it will be extremely painful for the client. The physician must be careful because the spleen could rupture upon palpation. The appendix is located in the right lower quadrant (RLQ). The liver is located in the right upper quadrant (RUQ). The gallbladder is located in the right upper quadrant (RUQ).

7 / 29

7. Which action is correct for the nurse to take when examining the ear of an 18-month-old boy?

1. Pulling the ear back and down

2. Pulling the ear back and up

3. Pulling the ear forward

4. Looking into the ear without pulling it in any direction

A: An infant’s ear canal is positioned lower than older children and adults.

8 / 29

8. What is the correct sequence of examination techniques that should be used when assessing the patient’s abdomen?

1. Inspection, palpation, auscultation, percussion

2. Palpation, percussion, auscultation, inspection

3. Auscultation, inspection, percussion, palpation

4. Inspection, auscultation, percussion, palpation

D: The usual sequence of physical assessment techniques is inspection, palpation, percussion, and auscultation. However, because palpation and percussion can alter bowel sounds, in abdominal assessment the sequence should be inspection, auscultation, percussion, and palpation.

9 / 29

9. A client is being cared for after a traumatic brain injury. During an initial assessment, the nurse performs the Glasgow Coma Scale and gives the client a score of 8. Which of the following responses from the nurse is appropriate to manage the client’s respiratory rate?

1. Prepare for intubation

2. Administer oxygen via non-rebreather mask

3. Administer oxygen via nasal cannula

4. Remove oxygen and assess the client's pulse oximetry

A: The Glasgow Coma Scale is a method of determining the neurological state of a client who has suffered an injury that could impact brain function. The lower the level determined with the GCS, the more likely the client has a significant brain injury and is most likely unconscious and not responding. A GCS score less than 9 indicates that the client is impaired enough that he may not be able to breathe on his own without assisted ventilation. When the score is less than 9, the nurse should prepare for intubation (which will be at the discretion of the provider)._x000D__x000D_A non-rebreather mask would not be enough to sustain ventilation in this client. Oxygen via nasal cannula is not enough to sustain ventilation in a client with a GCS score <9. A room air trial is inappropriate for a client with a GCS score <9. This client needs breathing support.

10 / 29

10. While the nurse is obtaining a health history, the patient tells the nurse, “I am so tired, I can hardly function.” What is the nurse’s best action at this time?

1. Stop the interview and leave the patient alone to be able to rest

2. Arrange another time with the patient to complete the interview

3. Question the patient further about the characteristics of the symptoms

4. Reassure the patient that the symptoms will improve when treatment has had time to be effective

C: When a patient describes a feeling, the nurse should ask about the factors surrounding the situation to clarify the aetiology of the problem. An incorrect nursing diagnosis may be made if the statement is taken literally and its meaning is not explored with the patient. A sense of “being tired and unable to function” does not necessarily indicate a need for rest or sleep, and there is no way to know that treatment will relieve the problem.

11 / 29

11. When listening to a client’s heart sounds during auscultation, which sounds would most likely be heard using the bell of the stethoscope?

1. S1

2. S2

3. S3

4. High-frequency murmurs

C: There are two sides of the stethoscope that the nurse may use with auscultation: the bell and the diaphragm. The bell side is used to hear low-pitched sounds, while the diaphragm is used for high-pitched sounds. The bell is used to assess the S3 and S4 heart sound, as these are low-pitched sounds. S1, S2 sounds and high-frequency murmurs are best heard with the diaphragm of the stethoscope.

12 / 29

12. When shining a light in a client’s eye, which reaction would the nurse interpret as normal? The pupils:

1. Contract

2. Dilate

3. Move to the left

4. Oscillate laterally

A: Light causes the direct and consensual reactions of the pupil the light is shined on and the other pupil. The pupils should not dilate, move, or oscillate when light is shined on one or both.

13 / 29

13. Which test is the nurse performing when a vibrating tuning fork is placed on top of a client’s head and the client is asked if sound is heard equally in both ears?

1. Rinne test for bone and air conduction

2. Romberg for balance

3. Test for extinction

4. Weber test for sound lateralization

D: For the Rinne test, the vibrating tuning fork is placed on the mastoid. No tuning forks are used in the Romberg test and in the test for extinction.

14 / 29

14. When performing a physical examination, what approach is most important for the nurse to use?

1. A head-to-toe approach to avoid missing an important area

2. The same systematic, efficient sequence for all examinations

3. A sequence that is least revealing and embarrassing for the patient

4. An approach that allows time to collect the nursing history data while performing the examination

B: A nurse should use the same efficient sequence in each examination to avoid forgetting a procedure, a step in the sequence, or a body part. However, a specific method is not required. Patient’s safety, comfort, and privacy are considerations but are not the priorities. The nursing history data should be collected in an interview to avoid prolonging the examination.

15 / 29

15. A nurse needs to assess posterior lung sounds in a client. In which position would it be most appropriate to place this client?

1. High Fowler's

2. Semi-Fowler's

3. Dorsal recumbent

4. Sims' position

A: To assess the back and listen to posterior lung sounds, the nurse should place the client in the high Fowler's position. In this position, the client is sitting up with the head of the bed at a 90-degree angle. The high Fowler's position is used for performing an assessment that would require the client to sit up, such as the face and head, chest, and back.

16 / 29

16. During a skin assessment, a client asks a question about what the skin does. The nurse’s response would be based on the knowledge that the functions of the skin are EXCEPT?

1. temperature regulation

2. sensory perception

3. identification of the individual

4. regulation of hormonal function

D: The skin regulates temperature through changes in its blood flow and through sweating. The skin provides sensory information through its nerve endings. Fingerprints allow for the identification of individuals.

17 / 29

17. The following assessment tools can be used to assess the cardiovascular system EXCEPT?

1. Watch

2. Stethoscope

3. Reflex hammer

4. Blood pressure cuff

C: The watch is used to assess pulses, the stethoscope is used to hear pulses and heart sounds, and the BP cuff is used to assess BP. The percussion (reflex) hammer is used to assess reflexes.

18 / 29

18. Which is the best approach to gathering information about diet as part of a client assessment?

1. You don’t eat much fatty food, do you?

2. Tell me about your diet.

3. Do you like potato chips?

4. Do you eat three meals each day?

B: This is an open-ended question that allows the client to describe the answer and say more than “yes” or “no.”

19 / 29

19. The nurse is caring for a client who arrives at the emergency department after falling down multiple times. Upon initial assessment, the client states, “I am so dizzy I can’t stay standing up.” What is the nurse’s first priority?

1. Get an EKG (ECG)

2. Check Vital Signs

3. Carry out full neurological exam

4. Draw blood

B: The nurse will prioritize using the ABCs, or airway, breathing, then circulation. However, while obtaining vital signs, the nurse will also notify the provider to get an EKG (ECG). The EKG will happen right after vital signs are obtained._x000D__x000D_While dizziness can be caused by an arrhythmia of the heart, the nurse will be obtaining vital signs while initiating contact with the provider in order to get an EKG (ECG) ordered._x000D__x000D_A full neurological exam and drawing blood can be performed after vital signs and EKG checks are complete.

20 / 29

20. Which test is an indicator of coordination?

1. Rinne test

2. Weber test

3. Corneal reflex response

4. Rapid alternating movement test

D: Weber and Rinne are both hearing tests and corneal reflex response is an eye test.

21 / 29

21. During a presentation at a health fair, a client asks about the cause of presbyopia. On which information should the nurse’s response be based?_x000D_Presbyopia results when the___

1. lens becomes less flexible.

2. iris does not open fully

3. retina is covered by a cataract.

4. optic blood vessels are engorged.

A: Presbyopia is age-related and occurs when the lens loses the flexibility to change, making it hard to focus on close objects. In fact, the term “presbyopia” comes from a Greek word which means “old eye.” The other options are unrelated to the development of presbyopia

22 / 29

22. When assessing an adolescent, which structures would the nurse examine last?

1. Head, eyes, ears, nose, and throat

2. Neurological

3. Musculoskeletal

4. Genitourinary

D: Developing adolescents find the genitourinary exam the most difficult.

23 / 29

23. What is an example of a pertinent negative finding during a physical examination?

1. Chest pain that does not radiate to the arm

2. Elevated blood pressure in a patient with hypertension

3. Pupils that are equal and react to light and accommodation

4. Clear and full lung sounds in a patient with chronic bronchitis

D: Abnormal lung sounds are usually associated with chronic bronchitis, and their absence is a negative finding. Chest pain is a positive finding, and radiation is not expected for all chest pain. Elevated BP in hypertension is a positive finding, and pupils that are equal and react to light and accommodation are normal findings.

24 / 29

24. A client with right heart failure asks what the right side of the heart does. The nurse’s response is based on the fact that the right ventricle pumps deoxygenated blood through the___

1. pulmonary veins to the aorta.

2. aorta to the left atrium.

3. pulmonary arteries to the left ventricle

4. pulmonary arteries to the lungs.

D: Blood flows from the right atrium through the tricuspid valve to the right ventricle through the pulmonic valve to the pulmonary arteries to the lungs, then back into the pulmonary veins to the left atrium, through the mitral valve to the left ventricle and through the aortic valve to the aorta and out to the body. The pulmonary arteries are the only arteries in the body that carry deoxygenated blood while the pulmonary veins are the only veins in the body that carry oxygenated blood.

25 / 29

25. When using an ophthalmoscope to assess a 3-year old girl’s eyes, for what does the nurse look?

1. Optic disk

2. Macula

3. Red reflex

4. Fovea centralis

C: Often children will not remain stationary long enough to view further structures in the eye. Being able to view the red reflex rules out a congenital cataract.

26 / 29

26. In which situation would it be most appropriate to perform a comprehensive health history assessment on a client?

1. A client being seen for complaints of fatigue

2. A client seeking care for a broken arm

3. A client being seen for a follow-up appointment after surgery

4. A client who needs an adjustment on his asthma medications

A: A comprehensive health history assessment collects data about the client's entire health history and any medications, surgical procedures, or family health issues that are present. It is most appropriate when the provider does not know the client, such as when a new client is seen at a health clinic, or when the client needs help with a general concern that could have many causes, such as fatigue. A focused assessment concentrates on the client's current issue, while a follow-up assessment is important after a client has been seen for the same issue.

27 / 29

27. Which type of abuse is the nurse most likely to discover when assessing the elderly?

1. Physical abuse

2. Emotional abuse

3. Neglect

4. Social

C: Neglect is the most common type of abuse against the elderly. Often, the elderly person does not want those close to them to help with physical functions or their caregivers may not be willing to perform incontinence and personal care.

28 / 29

28. During palpation of a client’s abdomen to check for an abdominal aortic aneurysm during a physical assessment, which part of the hand would the nurse most likely use to palpate for this finding?

1. Pads of the fingers

2. Dorsum of the hand

3. Palmar surface

4. Ball of the hand

A: When assessing a client through palpation, the nurse may use different parts of the hand to find differing signs related to the client's condition. The pads of the fingers are best used for palpating pulsations such as with an abdominal aortic aneurysm, edema, and crepitus, as well as determining moisture content of the skin. The dorsal aspect of the hand is commonly used to assess skin temperature.

29 / 29

29. What is the term used for assessment data that the patient tells you about?

1. Focused

2. Objective

3. Subjective

4. Comprehensive

C: Subjective data or symptoms are obtained by interview during history taking. These data can be described only by the patient or caregiver. Objective data or signs are data that are obtained on physical examination. Comprehensive data are obtained from a detailed health history and physical examination of 1 or more body systems.

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Health assessment

Health assessment of patients

1 / 29

1. A nurse needs to assess posterior lung sounds in a client. In which position would it be most appropriate to place this client?

1. High Fowler's

2. Semi-Fowler's

3. Dorsal recumbent

4. Sims' position

2 / 29

2. During a skin assessment, a client asks a question about what the skin does. The nurse’s response would be based on the knowledge that the functions of the skin are EXCEPT?

1. temperature regulation

2. sensory perception

3. identification of the individual

4. regulation of hormonal function

3 / 29

3. When shining a light in a client’s eye, which reaction would the nurse interpret as normal? The pupils:

1. Contract

2. Dilate

3. Move to the left

4. Oscillate laterally

A: Light causes the direct and consensual reactions of the pupil the light is shined on and the other pupil. The pupils should not dilate, move, or oscillate when light is shined on one or both.

4 / 29

4. When performing a physical examination, what approach is most important for the nurse to use?

1. A head-to-toe approach to avoid missing an important area

2. The same systematic, efficient sequence for all examinations

3. A sequence that is least revealing and embarrassing for the patient

4. An approach that allows time to collect the nursing history data while performing the examination

5 / 29

5. During a presentation at a health fair, a client asks about the cause of presbyopia. On which information should the nurse’s response be based?_x000D_Presbyopia results when the___

1. lens becomes less flexible.

2. iris does not open fully

3. retina is covered by a cataract.

4. optic blood vessels are engorged.

6 / 29

6. When assessing an adolescent, which structures would the nurse examine last?

1. Head, eyes, ears, nose, and throat

2. Neurological

3. Musculoskeletal

4. Genitourinary

D: Developing adolescents find the genitourinary exam the most difficult.

7 / 29

7. During palpation of a client’s abdomen to check for an abdominal aortic aneurysm during a physical assessment, which part of the hand would the nurse most likely use to palpate for this finding?

1. Pads of the fingers

2. Dorsum of the hand

3. Palmar surface

4. Ball of the hand

8 / 29

8. When using an ophthalmoscope to assess a 3-year old girl’s eyes, for what does the nurse look?

1. Optic disk

2. Macula

3. Red reflex

4. Fovea centralis

C: Often children will not remain stationary long enough to view further structures in the eye. Being able to view the red reflex rules out a congenital cataract.

9 / 29

9. What is the term used for assessment data that the patient tells you about?

1. Focused

2. Objective

3. Subjective

4. Comprehensive

10 / 29

10. In order to localize a symptom, which direction should the nurse give a client?

1. Point to where the symptom occurs

2. Come back when you are experiencing the symptom

3. Bring someone in with you who has witnessed you having the symptom

4. Tell me which body part is affected by the symptom.

11 / 29

11. When listening to a client’s heart sounds during auscultation, which sounds would most likely be heard using the bell of the stethoscope?

1. S1

2. S2

3. S3

4. High-frequency murmurs

12 / 29

12. What is an example of a pertinent negative finding during a physical examination?

1. Chest pain that does not radiate to the arm

2. Elevated blood pressure in a patient with hypertension

3. Pupils that are equal and react to light and accommodation

4. Clear and full lung sounds in a patient with chronic bronchitis

13 / 29

13. While the nurse is obtaining a health history, the patient tells the nurse, “I am so tired, I can hardly function.” What is the nurse’s best action at this time?

1. Stop the interview and leave the patient alone to be able to rest

2. Arrange another time with the patient to complete the interview

3. Question the patient further about the characteristics of the symptoms

4. Reassure the patient that the symptoms will improve when treatment has had time to be effective

14 / 29

14. The nurse is caring for a client who arrives at the emergency department after falling down multiple times. Upon initial assessment, the client states, “I am so dizzy I can’t stay standing up.” What is the nurse’s first priority?

1. Get an EKG (ECG)

2. Check Vital Signs

3. Carry out full neurological exam

4. Draw blood

15 / 29

15. The physician prepares to interview a patient for a history but finds the patient in obvious pain. Which action by the physician is the best at this time?

1. Delay the interview until the patient is free of pain

2. Administer pain medication before initiating the interview

3. Gather as much information as quickly as possible by using closed-ended questions that require brief answers

4. Ask only those questions pertinent to the specific problem and completethe interview when the patient is more comfortable

16 / 29

16. When testing a client’s ability to identify odors, the nurse is assessing the function of which cranial nerve?

1. Facial

2. Trigeminal

3. Olfactory

4. Spinal accessory

17 / 29

17. A client is being cared for after a traumatic brain injury. During an initial assessment, the nurse performs the Glasgow Coma Scale and gives the client a score of 8. Which of the following responses from the nurse is appropriate to manage the client’s respiratory rate?

1. Prepare for intubation

2. Administer oxygen via non-rebreather mask

3. Administer oxygen via nasal cannula

4. Remove oxygen and assess the client's pulse oximetry

18 / 29

18. In which situation would it be most appropriate to perform a comprehensive health history assessment on a client?

1. A client being seen for complaints of fatigue

2. A client seeking care for a broken arm

3. A client being seen for a follow-up appointment after surgery

4. A client who needs an adjustment on his asthma medications

19 / 29

19. Which is the best approach to gathering information about diet as part of a client assessment?

1. You don’t eat much fatty food, do you?

2. Tell me about your diet.

3. Do you like potato chips?

4. Do you eat three meals each day?

B: This is an open-ended question that allows the client to describe the answer and say more than “yes” or “no.”

20 / 29

20. When assessing the abdomen of a client who is complaining of diarrhea, which finding would the nurse expect?

1. Absent bowel sounds

2. ypoactive bowel sounds

3. Hyperactive bowel sounds

4. Normal bowel sounds

C: Hypoactive bowel sounds may be a result of ileus or abdominal infection

21 / 29

21. Which type of abuse is the nurse most likely to discover when assessing the elderly?

1. Physical abuse

2. Emotional abuse

3. Neglect

4. Social

22 / 29

22. When a client complains of right knee pain, which areas should the nurse examine?

1. Only the right knee

2. The right ankle, the right knee and the right hip

3. The left lower abdominal quadrant and the left knee

4. The right leg and left arm

B: Pain in the right knee may be referred from the right hip or right ankle.

23 / 29

23. Which action is correct for the nurse to take when examining the ear of an 18-month-old boy?

1. Pulling the ear back and down

2. Pulling the ear back and up

3. Pulling the ear forward

4. Looking into the ear without pulling it in any direction

A: An infant’s ear canal is positioned lower than older children and adults.

24 / 29

24. The following assessment tools can be used to assess the cardiovascular system EXCEPT?

1. Watch

2. Stethoscope

3. Reflex hammer

4. Blood pressure cuff

C: The watch is used to assess pulses, the stethoscope is used to hear pulses and heart sounds, and the BP cuff is used to assess BP. The percussion (reflex) hammer is used to assess reflexes.

25 / 29

25. Which test is the nurse performing when a vibrating tuning fork is placed on top of a client’s head and the client is asked if sound is heard equally in both ears?

1. Rinne test for bone and air conduction

2. Romberg for balance

3. Test for extinction

4. Weber test for sound lateralization

D: For the Rinne test, the vibrating tuning fork is placed on the mastoid. No tuning forks are used in the Romberg test and in the test for extinction.

26 / 29

26. What is the correct sequence of examination techniques that should be used when assessing the patient’s abdomen?

1. Inspection, palpation, auscultation, percussion

2. Palpation, percussion, auscultation, inspection

3. Auscultation, inspection, percussion, palpation

4. Inspection, auscultation, percussion, palpation

27 / 29

27. Which test is an indicator of coordination?

1. Rinne test

2. Weber test

3. Corneal reflex response

4. Rapid alternating movement test

D: Weber and Rinne are both hearing tests and corneal reflex response is an eye test.

28 / 29

28. The physician is performing an assessment of a client’s abdomen. Upon palpation, the physician feels an abnormal lump in the left upper quadrant that is extremely painful for the client. The physician is likely palpating which of the following?

1. Inflamed spleen

2. Inflamed appendix

3. Enlarged liver

4. Bilious gallbladder

29 / 29

29. A client with right heart failure asks what the right side of the heart does. The nurse’s response is based on the fact that the right ventricle pumps deoxygenated blood through the___

1. pulmonary veins to the aorta.

2. aorta to the left atrium.

3. pulmonary arteries to the left ventricle

4. pulmonary arteries to the lungs.

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The average score is 0%

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