Medoceo
Health assessment
Health assessment of patients
1 / 29
1. 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?
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).
2 / 29
2. In order to localize a symptom, which direction should the nurse give a client?
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.
3 / 29
3. 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?
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.
4 / 29
4. When using an ophthalmoscope to assess a 3-year old girl’s eyes, for what does the nurse look?
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.
5 / 29
5. When performing a physical examination, what approach is most important for the nurse to use?
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.
6 / 29
6. When testing a client’s ability to identify odors, the nurse is assessing the function of which cranial nerve?
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.
7 / 29
7. 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?
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.
8 / 29
8. 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?
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.
9 / 29
9. Which action is correct for the nurse to take when examining the ear of an 18-month-old boy?
A: An infant’s ear canal is positioned lower than older children and adults.
10 / 29
10. When assessing an adolescent, which structures would the nurse examine last?
D: Developing adolescents find the genitourinary exam the most difficult.
11 / 29
11. When a client complains of right knee pain, which areas should the nurse examine?
B: Pain in the right knee may be referred from the right hip or right ankle.
12 / 29
12. When listening to a client’s heart sounds during auscultation, which sounds would most likely be heard using the bell of the stethoscope?
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.
13 / 29
13. Which is the best approach to gathering information about diet as part of a client assessment?
B: This is an open-ended question that allows the client to describe the answer and say more than “yes” or “no.”
14 / 29
14. 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?
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.
15 / 29
15. When assessing the abdomen of a client who is complaining of diarrhea, which finding would the nurse expect?
C: Hypoactive bowel sounds may be a result of ileus or abdominal infection
16 / 29
16. When shining a light in a client’s eye, which reaction would the nurse interpret as normal? The pupils:
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.
17 / 29
17. Which type of abuse is the nurse most likely to discover when assessing the elderly?
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.
18 / 29
18. A nurse needs to assess posterior lung sounds in a client. In which position would it be most appropriate to place this client?
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.
19 / 29
19. What is the correct sequence of examination techniques that should be used when assessing the patient’s abdomen?
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.
20 / 29
20. 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___
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.
21 / 29
21. 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?
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.
22 / 29
22. What is the term used for assessment data that the patient tells you about?
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.
23 / 29
23. What is an example of a pertinent negative finding during a physical examination?
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. 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?
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.
25 / 29
25. Which test is an indicator of coordination?
D: Weber and Rinne are both hearing tests and corneal reflex response is an eye test.
26 / 29
26. In which situation would it be most appropriate to perform a comprehensive health history assessment on a client?
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. 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___
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
28 / 29
28. The following assessment tools can be used to assess the cardiovascular system EXCEPT?
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.
29 / 29
29. 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?
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.
Enter email address to receive exam results with explanations. This is the sole reason for taking your email address, and it is not mandatory to provide it.
Your score is
The average score is 0%
Restart quiz
1. 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___
2. 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?
3. What is the correct sequence of examination techniques that should be used when assessing the patient’s abdomen?
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?
5. In order to localize a symptom, which direction should the nurse give a client?
6. In which situation would it be most appropriate to perform a comprehensive health history assessment on a client?
7. What is an example of a pertinent negative finding during a physical examination?
8. Which is the best approach to gathering information about diet as part of a client assessment?
9. When using an ophthalmoscope to assess a 3-year old girl’s eyes, for what does the nurse look?
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?
11. When shining a light in a client’s eye, which reaction would the nurse interpret as normal? The pupils:
12. When assessing the abdomen of a client who is complaining of diarrhea, which finding would the nurse expect?
13. Which action is correct for the nurse to take when examining the ear of an 18-month-old boy?
14. A nurse needs to assess posterior lung sounds in a client. In which position would it be most appropriate to place this client?
15. Which type of abuse is the nurse most likely to discover when assessing the elderly?
16. 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?
17. When assessing an adolescent, which structures would the nurse examine last?
18. 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?
19. When performing a physical examination, what approach is most important for the nurse to use?
21. 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?
22. 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?
23. The following assessment tools can be used to assess the cardiovascular system EXCEPT?
24. When a client complains of right knee pain, which areas should the nurse examine?
25. 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?
26. When testing a client’s ability to identify odors, the nurse is assessing the function of which cranial nerve?
27. When listening to a client’s heart sounds during auscultation, which sounds would most likely be heard using the bell of the stethoscope?
28. What is the term used for assessment data that the patient tells you about?
29. Which test is an indicator of coordination?
Post Comment
