Chapter 08: Health Assessment

Question 1

The nurse admits the patient with mild chest pain from the emergency department. Which
should the nurse implement first to gain patient cooperation during a physical assessment?
a. Explain the procedure and its purpose.
b. Perform assessment in stages over the day.
c. Complete assessment within 3–5 minutes.
d. Assess painful areas before nontender areas.

Answer 1

a. Explain the procedure and its purpose.

Question 2

The nurse assesses a patient with light skin and observes normally shaped nail beds exhibiting
pallor and a slight bluish color. Which would the nurse implement first?
a. Provide a warm heating pad.
b. Collaborate with the health care provider.
c. Assess the patient’s oxygen saturation.
d. Check for restricted venous return.

Answer 2

c. Assess the patient’s oxygen saturation

Question 3

The nurse is performing a neurological assessment. Which patient behaviors demonstrate a
level of consciousness within normal limits?
a. States name, age, and date but not location.
b. Is lethargic; responds logically to questions.
c. Responds verbally, but words are unintelligible.
d. Responds to questions spontaneously; is alert and oriented.

Answer 3

d. Responds to questions spontaneously; is alert and oriented.

Question 4

How often should the nurse perform a general assessment of the patient?

a. At least every 4 hours
b. As often as it is needed
c. When the patient requests it
d. At the rate set by agency policy

Answer 4

b. As often as it is needed

Question 5

The nurse is assessing a patient with a cast extending from just below the left knee to the toes.
Which assessment contains a desirable patient outcome?
a. The toes are pink bilaterally.
b. The cast is warm at the ankle.
c. Paresthesia is present in the left foot.
d. The cast is snug at the knee

Answer 5

a. The toes are pink bilaterally.

Question 6

The patient has an irregular, elevated, localized area of edema on the left forearm. Which term 
should the nurse use when documenting?
a. Tumor
b. Wheal
c. Macule

d. Vesicle

Answer 6

b. Wheal

Question 7

The nurse is concerned with possible impaired peripheral perfusion after performing a
patient’s assessment. Which assessment finding about the patient’s lower extremities supports
the nurse’s suspicion?
a. The ankle bones are prominent.
b. The skin is warm and pink bilaterally.
c. The legs ache when in a dependent position.
d. The peripheral pulses are absent on both legs.

Answer 7

d. The peripheral pulses are absent on both legs.

Question 8

The nurse is listening to the patient’s lungs. Which information should the nurse use to
document normal patient lung sounds?
a. Rales in the right lower lobe
b. No adventitious breath sounds
c. Pleural friction rub in the left lung
d. Inspiratory wheezing in the upper lobes

Answer 8

b. No adventitious breath sounds

Question 9

A patient has the following intake: a cup of oatmeal, a half cup of ice, 3 ounces of apple juice,
and 6 ounces of coffee. What is the total intake the nurse should document on the intake
portion?
a. 210 mL
b. 390 mL
c. 600 mL
d. 630 mL

Answer 9

b. 390 mL

Question 10

Which aspect of obtaining health information can the nurse delegate to nursing assistive
personnel (NAP)?
a. Auscultate apical pulse of a patient with acute angina.
b. Take vital signs of a patient who might be discharged.
c. Complete lung assessment of a patient with pneumonia.
d. Clarify effects of antihypertensive therapy for a patient.

Answer 10

b. Take vital signs of a patient who might be discharged.

Question 11

The nurse is teaching a nursing student the correct technique for assessing an apical pulse.
Which method when used by the student demonstrates adequate knowledge?
a. Percusses the left ventricular wall.
b. Palpates along the left sternal border.
c. Directs the patient to lie in a supine position.
d. Listens at the fifth intercostal space at the point of maximal impulse (PMI).

Answer 11

d. Listens at the fifth intercostal space at the point of maximal impulse (PMI).

Question 12

The nurse is preparing to assess the patient’s abdomen. Nursing care is appropriate if which
maneuver is seen?
a. The abdomen is auscultated after percussion.
b. The nurse instructs the patient to extend the legs.
c. The nurse inspects the abdomen before auscultation.
d. The assessment begins with palpation, followed by auscultation

Answer 12

c. The nurse inspects the abdomen before auscultation.

Question 13

An older adult is being assessed by the nurse. Which finding does the nurse consider
abnormal when assessing the patient’s risk for fall?
a. Use of an assistive device
b. Wearing glasses
c. Get-up-and-go test completed in 35 seconds
d. Romberg’s test position held for 25 second

Answer 13

c. Get-up-and-go test completed in 35 seconds

Question 14

The nurse assesses a patient with arterial occlusive disease in the lower extremities. Which
activity by the nurse is most appropriate?
a. Use a Doppler device to locate pulses.
b. Massage the feet and ankles twice daily.
c. Elevate the legs slightly when in the chair.
d. Measure the circumference of the thighs daily.

Answer 14

a. Use a Doppler device to locate pulses

Question 15

A patient with back pain asks why the nurse needs so many details about health history. What
is the most effective response by the nurse?
a. “You seem reluctant to provide information.”
b. “We need complete data to plan nursing care.”
c. “It will take a short time to answer all questions.”
d. “We need to determine contributors to your pain.”

Answer 15

b. “We need complete data to plan nursing care.”

Question 16

The nurse is assessing an older patient and finds the heart rate to be 52 beats per minute and
irregular. Suddenly the patient complains of dizziness and “feeling faint.” Which action does
the nurse take next?
a. Ask the patient about valve replacement surgery.
b. Apply 3 L of oxygen via nasal cannula.
c. Assess the patient’s blood pressure.
d. Explain that this is a normal finding in older adults.

Answer 16

c. Assess the patient’s blood pressure.

Question 17

The nurse assesses the patient admitted with constipation. Which assessment finding warrants 
further investigation?
a. No aortic bruit
b. Firm liver edge
c. Bowel sounds audible
d. Abdomen distended and taut

Answer 17

d. Abdomen distended and taut

Question 18

The nurse observes yellow sclerae while assessing the patient’s eyes. What does the nurse 
look for to validate this finding?
a. A history of pallor
b. Jaundice
c. Cyanosis
d. Ecchymosis

Answer 18

b. Jaundice

Question 19

The nurse assesses the patient with altered musculoskeletal function. Which is the best reason
supporting the nurse’s motive for asking detailed questions?
a. Explore how the patient’s family reacts to the disability.
b. Evaluate patient concerns about the problem at this time.
c. Determine how the alteration affects the patient’s lifestyle.
d. Validate the amount of physical rehabilitation completed.

Answer 19

c. Determine how the alteration affects the patient’s lifestyle.

Question 20

The nurse assesses the patient’s lungs to find high-pitched musical sounds on inspiration and

expiration. Which description does the nurse use to document the findings?
a. Rhonchi
b. Wheezes
c. Crackles
d. Friction rub

Answer 20

b. Wheezes

Question 21

The nurse is performing a cardiovascular assessment at the fifth intercostal space at the
midclavicular line. What would the nurse be attempting to check?
a. S3
b. Point of maximal impulse (PMI)
c. Murmur
d. Visible pulsations

Answer 21

b. Point of maximal impulse (PMI)

Question 22

The nurse documents the patient’s swollen lower extremities and measures the depth of a
4-mm indentation made 1 minute ago. Which is the best description for the nurse to use to
describe the patient’s lower extremities?
a. 2+ pitting edema
b. Mild pitting edema
c. 2+ nonpitting edema
d. Severe nonpitting edema

Answer 22

a. 2+ pitting edema

Question 23

The nurse assesses the pupils of an older patient. What unexpected finding might the nurse 
identify about the patient’s pupils?
a. They are 3 mm in size.
b. Both of them are round.
c. Absence of convergence.
d. They respond to light spontaneously.

Answer 23

c. Absence of convergence.

Question 24

The nurse assesses the adult patient’s spine. Which expected finding does the nurse identify
about the patient’s alignment and posture?
a. Upper spine bent slightly
b. Spine in straight alignment
c. Slumping to nondominant side
d. Dominant side of patient favored

Answer 24

b. Spine in straight alignment

Question 25

The nurse assesses a possible melanoma on the patient’s skin. Which characteristic does the
lesion have that is consistent with a melanoma?
a. Regular borders
b. Larger than 6 mm
c. Symmetrical borders
d. Reddened coloration

Answer 25

b. Larger than 6 mm

Question 26

The patient has iron deficiency anemia. What sign causes the nurse to intervene as a priority?

a. Pallor
b. Jaundice
c. Cyanosis
d. Erythema

Answer 26

c. Cyanosis

Question 27

The nurse is assessing the temperature of the lower legs. Which method should the nurse use
to best assess the patient’s skin temperature subjectively?
a. Oral thermometer
b. Dorsum of the hand
c. Tympanic thermometer
d. Thumb and index finger

Answer 27

b. Dorsum of the hand

Question 28

The school nurse alerts parents to observe for chickenpox. Which clinical indicator does the
nurse instruct the parents to observe for chickenpox?
a. Wheals
b. Nodules
c. Macules
d. Vesicles

Answer 28

d. Vesicles

Question 29

The patient is being assessed for a possible respiratory problem. In which position should the
patient be placed to facilitate chest expansion during a thoracic assessment?
a. Prone
b. Side lying
c. High-Fowler’s
d. Dorsal recumbent

Answer 29

c. High-Fowler’s

Question 30

The nurse is preparing to begin the thoracic assessment of a patient. What is the initial step of 
the thoracic assessment?
a. Percussion of the lateral thorax
b. Palpation of the anterior thorax
c. Measurement of the respiratory rate
d. Inspection of the posterior thorax

Answer 30

d. Inspection of the posterior thorax

Question 31

The nurse begins to assess the patient’s respiratory system. Which assessment by the nurse
best determines the patient’s diaphragmatic excursion?
a. Observation of respiratory effort
b. Percussion over air-filled regions
c. Auscultation of thorax symmetrically
d. Palpation of chest inspiratory movement

Answer 31

d. Palpation of chest inspiratory movement

Question 32

The nurse is preparing to auscultate the pulmonic area. At which site should the nurse place
the stethoscope?
a. At the costovertebral angle
b. Over the costochondral junction
c. At Erb’s point
d. On the left side at the second intercostal space

Answer 32

d. On the left side at the second intercostal space

Question 33

The nurse is performing an abdominal assessment. Which action indicates proper technique?

a. Assesses the painful areas first.
b. Auscultates each quadrant for 5 minutes.
c. Palpates lightly to locate painful and tender areas.
d. Positions the patient with the arms behind the head.

Answer 33

c. Palpates lightly to locate painful and tender areas.

Question 34

The nurse admitted a patient with clear lungs and 2 days later has rhonchi in the left lung.
Which should the nurse implement next?
a. Place the patient in high-Fowler’s position.
b. Obtain a stat portable chest x-ray film.
c. Notify the health care provider immediately.
d. Complete a full respiratory assessment.

Answer 34

d. Complete a full respiratory assessment.

Question 35

The nurse is instructing a patient how to breathe during auscultation of the lungs. Instruction
by the nurse has been effective if the patient breathes in which manner?
a. Takes rapid shallow breaths.
b. Breathes with the mouth open.
c. Coughs and then takes a deep breath.
d. Takes a deep breath and holds it.

Answer 35

b. Breathes with the mouth open.

Question 36

The nurse assesses an adult patient with a cardiopulmonary illness and hears a grating sound
over the lower lateral lung during inspiration that does not clear with coughing. What would
the nurse most likely document as a result of the assessment findings?
a. Rhonchi
b. Pleural friction rub
c. Wheezes
d. Crackles

Answer 36

b. Pleural friction rub

Question 37

The nurse assesses peripheral perfusion. Which does the nurse find in a patient with arterial 
insufficiency?
a. Edema
b. Warm skin
c. Palpable pulses
d. Pain with exercise

Answer 37

d. Pain with exercise

Question 38

The nurse is performing a neuromuscular assessment. Which method should the nurse use to
evaluate muscle strength?
a. Measure the muscle size.
b. Perform range of motion.
c. Apply pressure against resistance.
d. Observe the patient’s gait and transfers.

Answer 38

c. Apply pressure against resistance.

Question 39

The nurse is performing an abdominal assessment. Which action indicates proper technique?

a. Assesses the painful areas first.
b. Auscultates each quadrant for 5 minutes.
c. Palpates lightly to locate painful and tender areas.
d. Positions the patient with the arms behind the head

Answer 39

b. Auscultates each quadrant for 5 minutes.