Assessments

Question 1

The best example of Holistic data collection by a nurse?

Answer 1

• blood pressure
• nutritional intake
• Assessing for depression
• how conditions affect family gatherings

Question 2

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

Answer 2

comprehensive

Question 3

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client?

Answer 3

AIRWAY 

REMEMBER THE MNEMONIC: A, B, C, D, E
~~~~~~~
A-Airway
~~~

B-Breathing

C-Circulation

D-Disability

E-Exposure.

Question 4

A student nurse is learning to document an initial assessment. What would the
instructors tell the student that accurate documentation of this specific assessment best provides?

Answer 4

A baseline for comparison with future findings

Accurate documentation provides a baseline so that changes are noted between assessments.

Question 5

Which is an “ABCDE” characteristic of malignant melanoma?

Answer 5

A: asymmetrical
B: borders (irregular) 
C: color (variations)
D: diameter (exceeding 1/8 to 1/4 of an inch)
E: elevated.

Question 6

An important function of the skin?

Answer 6

Synthesis of vitamin D

Question 7

What is the expected moisture and texture of the skin of a client with hypothyroidism?

Answer 7

Dry and rough

Question 8

The nurse notes that a client’s nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?

Answer 8

pulse oximetry

A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia.

Question 9

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Answer 9

Head-to-toe

A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data.

Question 10

What will be the nurse’s initial role when conducting a health assessment with a client reporting abdominal pain?

Answer 10

Collecting data regarding the nature of the pain

Question 11

What is one of the broad goals within nursing?

Answer 11

To treat human responses

Question 12

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

Answer 12

Ongoing or partial

Question 13

The client has a murmur. This is what type of data?

Answer 13

Objective

Question 14

What is Objective data?

Answer 14

data that is measurable

Question 15

What is Subjective data?

Answer 15

what the client states, feels or senses.

Question 16

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

Answer 16

Primary

(Primary prevention involves strategies aimed at preventing problems. Immunizations, health teaching, safety precautions, and nutrition counseling are examples.)

Question 17

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

Answer 17

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

Question 18

Which type of question is asked first by the nurse in order to attain a full description of the client’s symptoms and to generate and test diagnostic hypotheses?

Answer 18

open-ended questions to encourage the client to tell his or her story

Question 19

Learning about the effects of the illness does what for the nurse and the client?

Answer 19

Gives them the opportunity to create a complete and congruent picture of the problem

Question 20

In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question?

Answer 20

Some herbal supplements may interact with prescribed medications.

Question 21

A nurse is performing percussion on a client’s back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?

Answer 21

Resonance

(Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields.)

Question 22

During palpation of a client’s organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing

Answer 22

deep palpation

(Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches).

Question 23

During the physical examination of your client, you auscultate the sound of the client’s breathing. What area of the client are you assessing?

Answer 23

Lungs

To assess the client’s breathing sounds, the nurse auscultates the lungs using the stethoscope.

Question 24

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?

Answer 24

Balance

Question 25

Which of the following techniques are used in a physical assessment?

Answer 25

Inspection
Palpation
Auscultation

Question 26

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

Answer 26

Light palpation

Question 27

A nurse is palpating a child’s forehead for signs of fever. Which part of the hand should the nurse use?

Answer 27

Dorsal surface

Question 28

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?

Answer 28

Knee–chest

Question 29

One disadvantage of the open-ended assessment form is that it

Answer 29

requires a lot of time to complete

Question 30

The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?

Answer 30

Client safety increases

Question 31

A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect?

Answer 31

The client’s occupation
The client’s family history of cancer
The client’s weight-lifting routine

Question 32

The nurse is preparing to notify the physician of a change in the client’s condition. Which format would be most appropriate for the nurse to use for this communication?

Answer 32

SBAR

(Verbal communication of a change in a client’s condition would be most effective if the nurse used SBAR as it provides a standardized format and structure for communication.)

Question 33

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Answer 33

Ashen gray

The skin of a dark-skinned client with cyanosis would be ashen gray.

Question 34

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Answer 34

Ashen gray

The skin of a dark-skinned client with cyanosis would be ashen gray.

Question 35

A client’s blood pressure is affected by

Answer 35

cardiac output, 
distensibility of the arteries, 
blood volume, 
blood velocity,
viscosity

Question 36

A client has arrived to the clinic for a routine physical examination. Prior to assessing the client’s blood pressure, what should the nurse do?

Answer 36

Ask the client to sit quietly in a chair for 5 minutes

Question 37

What is considered a vital sign?

Answer 37

temperature
pulse
respiration
blood pressure

Question 38

A nurse observes that a young man’s arm span appears to be greater than his height. Which condition should the nurse suspect in this client?

Answer 38

Marfan syndrome

Question 39

What is the purpose of using critical thinking skills during assessment?

Answer 39

to complete a comprehensive database

Question 40

A patient without distress, makes a statement of severe abdominal pain just as the nurse begins the respiratory assessment. What is the nurse’s best course of action?

Answer 40

determine the location, duration and severity of the pain

Question 41

A patient reveals an allergy to adhesives used in tapes during the health history. What is the nurse’s most appropriate action?

Answer 41

Ask for a description of the reaction

Question 42

Which documentation represents subjective data obtained during a review of system?

Answer 42

Denies color change

Subjective data is what the patients perceives.

Question 43

Subjective data is

Answer 43

what the patients perceives

Question 44

Objective data is

Answer 44

Visual observations by the nurse

Question 45

During a review of systems, the patient reports a productive cough. Which would be the most appropriate follow up question?

Answer 45

What color is the sputum?

Question 46

How can you determine reliability of a patient’s responses during an interview?

Answer 46

The Patient provides consistent information (indicating reliability)

Question 47

The nurse needs to obtain a radial pulse from a patient. To obtain the correct measure, what must the nurse do?

Answer 47

Place the tips of the first two fingers over the groove along the thumb side of the patient’s wrist.

(Fingertips are the most sensitive parts of the hand to palpate arterial pulsation.)

Question 48

The patient is being admitted to the emergency department with complaints of shortness of breath. The patient has had chronic lung disease for many years but still smokes. Which is the nurse’s best action?

Answer 48

Assess lung sounds

Question 49

A patient has a pulse rate of 44 and a blood pressure within established normal’s. Which aspect of the patient history would be a cause for the low heart rate?

Answer 49

participates in multiple triathlon’s yearly

(Extensive physical training can make the heart more efficient allowing for a lower heart rate while maintaining adequate blood pressure and perfusion.)

Question 50

The nurse is caring for a patient who complains of feeling light-headed and “woozy.” The nurse checks the patient’s radial pulse and finds that it is irregular. The patient’s blood pressure is 100/72. It was 113/80 an hour earlier. Which action should the nurse take first?

Answer 50

Perform an apical pulse assessment

The patient’s irregular pulse needs to be assessed more thoroughly and directly with an apical pulse assessment.

Question 51

After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. Why is this done?

Answer 51

Temperatures vary depending on the route used.

Question 52

A patient care technician reports that a patient’s blood pressure is abnormally low. What is the nurse’s best action?

Answer 52

Retake the blood pressure himself and assess the patient’s condition.

(When in doubt always perform the task yourself)

Question 53

The nurse is assessing the patient and his family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which of the following issues would be considered risk factors? (Select all that apply.)

Cigarette smoking
Obesity
Heavy alcohol consumption
Low blood cholesterol levels
Recent weight loss

Answer 53

Cigarette smoking
Obesity
Heavy alcohol consumption

Question 54

When recording the patient’s respiratory status, what must be recorded? (Select all that apply.)

Only normal findings
Only in the graphic section
Character of respirations
Respiratory rate
Amount of oxygen therapy

Answer 54

Character of respirations
Respiratory rate
Amount of oxygen therapy

Question 55

Having misplaced his stethoscope, a nurse borrows a colleague’s stethoscope. He next enters the patient’s room and identifies himself, washes his hands with soap, and states the purpose of his visit. He performs proper identification of the patient before he auscultates her lungs. Which critical health assessment step was not performed?

Running warm water over stethoscope for patient comfort
Using alcohol-based hand disinfectant
Cleaning stethoscope with alcohol
Obtaining husband’s permission

Answer 55

Cleaning stethoscope with alcohol

The stethoscope should be cleaned before use on each patient to prevent transfer of bacteria and viruses

Question 56

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which action is appropriate?

Ask the patient about the color of her stools.
Assess first the spots that are most tender.
Recommend that the patient take more laxatives.
Avoid sexual references such as possible pregnancy.

Answer 56

Ask the patient about the color of her stools.

Black or tarry stools (melena) indicate gastrointestinal alteration.

Question 57

Which is the purpose of asking a patient what “A stitch in time save nine” means during a mental status exam?

Recent memory.
Knowledge.
Long-term memory.
Abstract thinking.

Answer 57

Abstract thinking

Question 58

While assessing the skin of a young adult patient, the nurse notes the skin snaps back in to place immediately after being pinched up. Which would be the most appropriate documentation?

delayed
nonelastic
brisk
poor

Answer 58

brisk

(Skin turgor can be documented as brisk, elastic for skin that snaps back in less than a second; non elastic, delayed or tenting may be used if skin does not snap back quickly.)

Question 59

A patient in the emergency department is complaining of left lower abdominal pain. The comprehensive abdominal examination would include, in proper order, which of the following?

Percussion, inspection, auscultation

Inspection, palpation, percussion

Inspection, palpation, auscultation

Inspection, auscultation, palpation

Answer 59

Inspection, auscultation, palpation

Palpation should always be performed last for an abdominal assessment.

Question 60

Which is the best position for a complete physical assessment on a weak, geriatric patient with pneumonia?

right side lying

on the stomach

on the back

left side, right leg bent

Answer 60

on the back

(This is the most normally relaxed position. It will not compromise the patient’s breathing because it is likely compromised with pneumonia. If the patient becomes short of breath easily, raise the head of the bed. This position would be easiest for an elderly weak person to get into position for an examination.)

Question 61

Which is the term used for breath sounds created by air moving through large lung airways?

Bronchial.

Bronchovesicular.

Rhonchi.

Wheezes.

Answer 61

Bronchovesicular

Bronchovesicular breath sounds are created by air moving through large airways.

Question 62

Bronchovesicular breath sounds are created by

Answer 62

air moving through large airways

Question 63

Vesicular sounds are created by

Answer 63

air moving through smaller airways

Question 64

Bronchial sounds are created by

Answer 64

air moving through the trachea close to the chest wall

Question 65

Rhonchi are abnormal lung sounds that are:

Answer 65

loud, low-pitched, rumbling coarse sounds heard during inspiration or expiration that sometimes clear by coughing

Question 66

Which is the best place to assess for hypoxia for an African American patient?

earlobe
nailbeds
lower extremities
oral mucosa

Answer 66

oral mucosa

Question 67

When assessing heart sounds at the fifth intercostal space, the nurse hears a whooshing sound. Which is the probable cause of this sound?

dysfunction of the mitral valve
beginning of systolic phase
opening of the aortic valve
a third heart sound

Answer 67

dysfunction of the mitral valve

(A whooshing sound at the fifth intercostal space is a murmur; a prolapsed valve allows regurgitation that is heard as a whooshing sound.)

Question 68

Documentation of capillary refill includes “greater than 4 seconds”. Which is associated with this documentation?

inadequate perfusion
lower body temperature
impaired gas exchange
incorrect documentation

Answer 68

inadequate perfusion

(Capillary refill is an assessment of perfusion of the most distal aspects of the extremities. Lower body temperature can cause poor perfusion, the note still indicates inadequate perfusion. Poor perfusion can lead to impaired gas exchange.)

Question 69

During inspection of the patient’s ears, the nurse whispers “Can you hear me?” The patient does not respond. What is the nurse’s best use of this data?

document the patient is hard of hearing
face the patient when speaking
speak very loudly from behind the patient
report the finding to the physician

Answer 69

face the patient when speaking

(The nurse should face the patient when speaking. While documentation should be made, it should state patient is unable to hear a whisper, not that patient is hard of hearing.)

Question 70

During a focused respiratory assessment, the nurse finds the following: lung sounds with fine crackles in bilateral bases, occasional expiratory wheeze, rate of 24, moderate depth, no retractions, chest is symmetrical, mucous membranes are pale pink. What additional data would be needed prior to taking action?

oxygen saturation
bilateral pulses
capillary refill
smoking history

Answer 70

oxygen saturation

(Oxygen saturation is needed to determine the best course of action whether it is simply putting the head of the bed up, getting a breathing treatment or providing oxygen.)

Question 71

Which findings would indicate a compromised radial artery? Select all that apply.

pale hand

cool fingers

delayed capillary refill

hairless palm

short nails

Answer 71

pale hand
cool fingers
delayed capillary refill

(A compromised radial pulse would lead to poor arterial flow to the hand. Symptoms would include pallor, coolness and delayed capillary refill.)

Question 72

While taking vital signs, the pulse oximeter emits an alarm. The O2 saturation is flashing with a reading of 82%. What is the nurse’s best action?

reposition the oximeter

obtain the reading later

ask the patient to be very still

observe the patient for signs of distress

Answer 72

observe the patient for signs of distress

(The best action is to determine if the patient is in any distress. Does the patient look like the O2 saturation is 82%? if not, proceeding to repositioning and eliminating other factors that interfere with an accurate reading would be appropriate, including keeping the patient still.)

Question 73

What is the priority problem based on the following assessment data: decreased hair growth on lower extremities, delayed capillary refill, toes cool to touch?

poor peripheral perfusion

impaired gas exchange

delayed wound healing

altered tissue integrity

Answer 73

poor peripheral perfusion

These are all symptoms of poor perfusion which could result in impaired gas exchange

Question 74

The nurse is assessing the neurologic system of an adult client. To test the client’s motor function of the facial nerve, the nurse should

ask the client to purse the lips.

ask the client to open the mouth and say “ah.”

note the presence of a gag reflex.

observe the client swallow a sip of water.

Answer 74

ask the client to purse the lips

(When testing motor function ask the client to smile, frown and wrinkle forehead, show teeth, puff out cheeks, and purse the lips.)

Question 75

A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?
•	 Glossopharyngeal (IX)
•	 Spinal accessory (XI)
•	 Hypoglossal (XII)
•	 Vagus (X)

Answer 75

Glossopharyngeal (IX)

Question 76

Which assessment procedure should a nurse institute to test a client for stereognosis?
• With eyes closed, move the client’s finger up or down and ask the direction
• Ask the client to identify the number of points touched with two ends of an applicator
• Use a blunt instrument to write a number in the client’s hand and ask them to identify it
• With eyes closed, ask the client to identify a familiar object that is placed in their hand

Answer 76

With eyes closed, ask the client to identify a familiar object that is placed in their hand

(To test a client for stereognosis, with the eyes closed, the nurse should ask the client to identify a familiar object that is placed in their hand.)

Question 77

The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates
•	 no verbal response.
•	 some impairment.
•	 severe impairment.
•	 deep coma.

Answer 77

some impairment

Question 78

Which of the following assessments is most likely to provide insight into the function of the client’s CN VIII?
• Ask the client to shrug both shoulders upward against the examiner’s hands.
• Test the client’s hearing for lateralization and bone and air conduction.
• Ask the client to raise his or her eyebrows, frown, and close both eyes tightly.
• Test the client’s ability to identify a familiar smell with his or her eyes closed.

Answer 78

Test the client’s hearing for lateralization and bone and air conduction.

(CN VIII is the acoustic nerve; function is thus tested by assessing the client’s hearing.)

Question 79

While assessing the pupils of a hospitalized adult client, the nurse observes that the client’s pupils are dilated to 6 mm. The nurse suspects that the client is exhibiting signs of
•	 alcohol abuse.
•	 oculomotor nerve paralysis.
•	 damage to the pons.
•	 cocaine abuse.

Answer 79

oculomotor nerve paralysis

Dilated pupil (6–7 mm) can indicate oculomotor nerve paralysis.

Question 80

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?
• Reflexes, sensory, motor/cerebellar, cranial nerves, mental status
• Cranial nerves, motor/cerebellar, sensory, reflexes, mental status
• Motor/cerebellar, sensory, reflexes, cranial nerves, mental status
• Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

Answer 80

Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

Question 81

Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? Select all that apply.
•	 Quitting smoking
•	 Eating a high-sodium diet
•	 Following a sedentary lifestyle
•	 Regularly exercising
•	 Maintaining a healthy weight

Answer 81

Quitting smoking
Regularly exercising
Maintaining a healthy weight

(Clients with obesity, in particular abdominal obesity, are at increased risk for ischemic stroke. Smokers are also at increased risk for stroke.)

Question 82

The nurse is assessing the neurologic system of an adult client. To test the client’s use of memory to learn new information, the nurse should ask the client
• “What did you have for breakfast?”
• “Can you repeat rose, hose, nose, clothes?”
• “Can you repeat brown, chair, textbook, tomato?”
• “How old were you when you began working?”

Answer 82

“Can you repeat brown, chair, textbook, tomato?”

Assess use of memory to learn new information. Ask the client to repeat four unrelated words.

Question 83

A nurse is assessing a client for abnormalities of gait due to a concern that the client is at increased risk for a fall. Which instruction should the nurse give the client first?
• “Walk on your toes then on your heels.”
• “Walk heel to toe.”
• “Hop on one spot.”
• “Walk across the room and back.”

Answer 83

“Walk across the room and back.”

Ask the client to walk across the room and walk back first because this will reveal deficits in the gait.

Question 84

The nurse documents “Romberg test positive” on a client’s medical record. What did the nurse most likely assess in this client?
•	 Poor brachial reflex
•	 Unsteady gait
•	 Weak hand grasps
•	 Swaying

Answer 84

Swaying

A positive Romberg test is when the client sways and moves the feet apart to prevent falling.

Question 85

A nurse assesses a client who presents to the health care clinic with suspected Bell's palsy. What finding should the nurse anticipate on examination?
•	 Drooping of the eyelids
•	 Paralysis of the lower lip
•	 Inability to wrinkle the forehead
•	 Limited lateral gaze of the eyes

Answer 85

Inability to wrinkle the forehead

(Bell’s palsy is a peripheral injury to cranial nerve VII (facial) that causes the inability to close the eyes, wrinkle the forehead, or raise the forehead, along with paralysis of the lower part of the face.)

Question 86

The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point?
• “Testing for this problem will involve having blood tests only.”
• “You will be able to observe symptoms of this problem early on.”
• “Pain is the only sensation associated with this problem.”
• “Effective blood glucose regulation can prevent this problem.”

Answer 86

“Effective blood glucose regulation can prevent this problem.”

(Maintaining optimal glycemic control can prevent or delay the onset of diabetic neuropathy.)

Question 87

The husband of a 65-year-old female tells the nurse, “My wife is having trouble navigating the steps in our home and needs my help to step down off a curb.” What part of the nervous system should the nurse assess for a potential source of the problem?
•	 Cerebellum
•	 Temporal lobe
•	 Deep tendon reflexes
•	 Cranial nerves

Answer 87

Cerebellum

(The cerebellum’s primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone.)

Question 88

After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further.
• True
• False

Answer 88

False

Question 89

When conducting a Romberg test, why does the nurse ask the client to stand feet together with eyes open and then closed?

Answer 89

Vision can compensate for loss of position sense.

Question 90

A nurse is working with a client who is victim of a shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the “fight-or-flight” response in this client and understands that this represents an activation of which of the following?
•	 Sympathetic nervous system
•	 Central nervous system
•	 Parasympathetic nervous system
•	 Somatic nervous system

Answer 90

Sympathetic nervous system

(The sympathetic nervous system (“fight-or-flight” system) is activated during stress and elicits responses such as decreased gastric secretions, bronchiole dilatation, increased pulse rate, and pupil dilatation.)

Question 91

A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen “staring off into space” and not paying attention. If this is a seizure, it most likely represents which type?
•	 Absence
•	 Myoclonus
•	 Pseudo seizure
•	 Tonic-clonic

Answer 91

Absence

(This is a common description and scenario for absence seizures, which are generally brief (fewer than 10 seconds, “petit mal”))