Health assessment and physical exam Flashcards
A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which statement made by the new graduate nurse requires the preceptor to
intervene?
a. “I will use the information from my assessment to figure out if your antihypertensive
medication is working effectively.”
b. “Nursing assessment data are used only to provide information about the effectiveness
of your medical care.”
c. “Nurses use data from their patient’s physical assessment to determine a patient’s
educational needs.”
d. “Information gained from physical assessment helps nurses better understand their patients’
emotional needs.”
b. “Nursing assessment data are used only to provide information about the effectiveness
of your medical care.”
Having misplaced a stethoscope, a nurse borrows a colleague’s stethoscope. The nurse next enters the patient’s room and identifies self, washes hands with soap, and states the purpose of
the visit. The nurse performs proper identification of the patient before auscultating the patient’s lungs. Which critical health assessment step should the nurse have performed?
a. Running warm water over stethoscope
b. Draping stethoscope around the neck
c. Rubbing stethoscope with betadine
d. Cleaning stethoscope with alcohol
d. Cleaning stethoscope with alcohol
A nurse is preparing to perform a complete physical examination on a weak, older-adult
patient with bilateral basilar pneumonia. Which position will the nurse use?
a. Prone
b. Sims’
c. Supine
d. Lateral recumbent
c. Supine
A nurse is conducting Weber’s test. Which action will the nurse take?
a. Place a vibrating tuning fork in the middle of patient’s forehead.
b. Place a vibrating tuning fork on the patient’s mastoid process.
c. Compare the number of seconds heard by bone versus air conduction.
d. Compare the patient’s degree of joint movement to the normal level.
a. Place a vibrating tuning fork in the middle of patient’s forehead.
A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Which laboratory test will the nurse expect to be ordered, based upon the physical findings?
a. Oxygen saturation
b. Liver function test
c. Carbon monoxide
d. Thyroid-stimulating hormone test
d. Thyroid-stimulating hormone test
A febrile preschool-aged child presents to the after-hours clinic. Varicella (chickenpox) is
diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions
filled with serous fluid. Which type of skin lesion will the nurse report?
a. Vesicles
b. Wheals
c. Papules
d. Pustules
a. Vesicles
A school nurse recognizes a belt buckle–shaped ecchymosis on a 7-year-old student. When
privately asked about how the injury occurred, the student described falling on the playground.
Which action will the nurse take next?
a. Talk to the principal about how to proceed.
b. Disregard the finding based upon child’s response.
c. Interview the patient in the presence of the teacher.
d. Contact social services and report suspected abuse.
d. Contact social services and report suspected abuse.
A nurse identifies lice during a child’s scalp assessment. The nurse teaches the parents about
hair care. Which information from the parents indicates the nurse needs to follow up?
a. We will use lindane-based shampoos.
b. We will use the sink to wash hair.
c. We will use a fine-toothed comb.
d. We will use a vinegar hair rinse.
a. We will use lindane-based shampoos.
A parent calls the school nurse with questions regarding the recent school vision screening.
Snellen chart examination revealed 20/60 for both eyes. Which response by the nurse is the best regarding the eye examination results?
a. Your child needs to see an ophthalmologist.
b. Your child is suffering from strabismus.
c. Your child may have presbyopia.
d. Your child has cataracts.
a. Your child needs to see an ophthalmologist.
During a routine pediatric history and physical, the parents report that their child was a very small, premature infant that had to stay in the neonatal intensive care unit longer than usual.
They state that the infant was yellow when born and developed an infection that required “every antibiotic under the sun” to reach a cure. Which exam is a priority for the nurse to conduct on the child?
a. Cardiac
b. Respiratory
c. Ophthalmic
d. Hearing acuity
D. Hearing acuity
During a sexually transmitted illness presentation to high-school students, the nurse recommends the human papillomavirus (HPV) vaccine series. Which condition is the nurse trying to prevent?
a. Breast cancer
b. Ovarian cancer
c. Cervical cancer
d. Testicular cancer
c. Cervical cancer
A male student comes to the college health clinic. He hesitantly describes that he found
something wrong with his testis when taking a shower. Which assessment finding will alert the nurse to possible testicular cancer?
a. Hard, pea-sized testicular lump
b. Rubbery texture of testes
c. Painful enlarged testis
d. Prolonged diuretic use
a. Hard, pea-sized testicular lump
The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. Which proper sequence will the nurse follow to perform the initial assessment?
a. Light palpation, deep palpation, and inspection
b. Inspection, light palpation, and deep palpation
c. Auscultation and light palpation
d. Inspection and light palpation
Inspection and light palpation
The nurse is examining a female with vaginal discharge. Which position will the nurse place the patient for proper examination? a. Sitting b. Lithotomy c. Knee-chest d. Dorsal recumbent
Lithotomy
On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. Which condition will the nurse assess for in this patient?
a. Anorexia
b. Weight loss
c. Fluid retention
d. Increased nutritional intake
Fluid retention
The patient is a 45-year-old African-American male who has come in for a routine annual
physical. Which type of preventive screening does the nurse discuss with the patient?
a. Digital rectal examination of the prostate
b. Complete eye examination every year
c. CA 125 blood test once a year
d. Colonoscopy every 3 years
Digital rectal examination of the prostate
An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old American woman of Chinese descent. Which action will the nurse do first?
a. Place the patient in the lithotomy position.
b. Drape the patient to enhance patient comfort.
c. Assess the patient’s feelings about the examination.
d. Ask the patient if she would like her mother to be present in the room.
Assess the patient’s feelings about the examination.
An older-adult patient is being seen for chronic entropion. Which condition will the nurse assess for in this patient? a. Ptosis b. Infection c. Borborygmi d. Exophthalmos
Infection
During a school physical examination, the nurse reviews the patient’s current medical
history. The nurse discovers the patient has allergies. Which assessment finding is consistent with allergies?
a. Clubbing
b. Yellow discharge
c. Pale nasal mucosa
d. Puffiness of nasal mucosa
Pale nasal mucosa
Upon assessment, the patient is breathing normally and has normal vesicular lung sounds. Which expected inspiratory-to-expiratory breath sounds will the nurse hear?
a. The expiration phase is longer than the inspiration phase.
b. The inspiratory phase lasts exactly as long as the expiratory phase.
c. The expiration phase is 2 times longer than the inspiration phase.
d. The inspiratory phase is 3 times longer than the expiratory phase.
The inspiratory phase is 3 times longer than the expiratory phase.
A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which action will the nurse take when performing an abdominal assessment?
a. Assess the area that is most tender first.
b. Ask the patient about the color of her stools.
c. Recommend that the patient take more laxatives.
d. Avoid sexual references such as possible pregnancy.
Ask the patient about the color of her stools.
During a genitourinary examination of a 30-year-old male patient, the nurse identifies a small amount of a white, thick substance on the patient’s uncircumcised glans penis. What is the nurse’s next step?
a. Record this as a normal finding.
b. Avoid embarrassing questions about sexual activity.
c. Notify the provider about a suspected sexually transmitted infection.
d. Tell the patient to avoid doing self-examinations until symptoms clear.
Record this as a normal finding.
The nurse is preparing for a rectal examination of a nonambulatory male patient. In which
position will the nurse place the patient?
a. Sims’
b. Knee-chest
c. Dorsal recumbent
d. Forward bending with flexed hips
Sims’
A teen patient is tearful and reports locating lumps in her breasts. Other history obtained is that she is currently menstruating. Physical examination reveals soft and movable cysts in both breasts that are painful to palpation. The nurse also notes that the patient’s nipples are erect, but the areola is wrinkled. Which action will the nurse take after talking with the health care provider?
a. Reassure patient that her symptoms are normal.
b. Discuss the possibility of fibrocystic disease as the probable cause.
c. Consult a breast surgeon because of the abnormal nipples and areola.
d. Tell the patient that the symptoms may get worse when her period ends.
Discuss the possibility of fibrocystic disease as the probable cause.
A nurse is performing a mental status examination and asks an adult patient what the statement “Don’t cry over spilled milk” means. Which area is the nurse assessing?
a. Long-term memory
b. Abstract thinking
c. Recent memory
d. Knowledge
Abstract thinking
During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. Which assessment finding will the nurse report to the health care provider?
a. Bruit
b. Thrill
c. Phlebitis
d. Right-sided heart failure
Bruit
The nurse considers several new female patients to receive additional teaching on the need for more frequent Pap test and gynecological examinations. Which assessment findings reveal the patient at highest risk for cervical cancer and having the greatest need for patient education?
a. 13 years old, nonsmoker, not sexually active
b. 15 years old, social smoker, celibate
c. 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners
d. 50 years old, stopped smoking 30 years ago, has history of multiple pregnancies
22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners.
The paramedics transport an adult involved in a motor vehicle accident to the emergency department. On physical examination, the patient’s level of consciousness is reported as opening
eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli. Which value will the nurse report for the patient’s Glasgow Coma Scale score?
a. 5
b. 7
c. 9
d. 11
9
While assessing the skin of an 82-year-old patient, a nurse discovers nonpainful, ruby red papules on the patient’s trunk. What is the nurse’s next action?
a. Explain that the patient has basal cell carcinoma and should watch for spread.
b. Document cherry angiomas as a normal older adult skin finding.
c. Tell the patient that this is a benign squamous cell carcinoma.
d. Record the presence of petechiae.
Document cherry angiomas as a normal older adult skin finding.
A nurse is caring for a group of patients. Which patient will the nurse see first?
a. An adult with an S4 heart sound
b. A young adult with an S3 heart sound
c. An adult with vesicular lung sounds in the lung periphery
d. A young adult with bronchovesicular breath sounds between the scapula posteriorly
An adult with an S4 heart sound
A nurse is auscultating different areas on an adult patient. Which technique should the nurse use during an assessment?
a. Uses the bell to listen for lung sounds
b. Uses the diaphragm to listen for bruits
c. Uses the diaphragm to listen for bowel sounds
d. Uses the bell to listen for high-pitched murmurs
Uses the diaphragm to listen for bowel sounds
The nurse is assessing an adult patient’s patellar reflex. Which finding will the nurse record as normal?
a. 1+
b. 2+
c. 3+
d. 4+
2+
A patient in the emergency department is reporting left lower abdominal pain. Which proper order will the nurse follow to perform the comprehensive abdominal examination?
a. Percussion, palpation, auscultation
b. Percussion, auscultation, palpation
c. Inspection, palpation, auscultation
d. Inspection, auscultation, palpation
Inspection, auscultation, palpation
The nurse completed assessments on several patients. Which assessment finding will the nurse record as normal?
a. Pulse strength 3
b. 1+ pitting edema
c. Constricting pupils when directly illuminated
d. Hyperactive bowel sounds in all four quadrants
Constricting pupils when directly illuminated
The patient presents to the clinic with dysuria and hematuria. How does the nurse proceed to assess for kidney inflammation?
a. Uses deep palpation posteriorly.
b. Lightly palpates each abdominal quadrant.
c. Percusses posteriorly the costovertebral angle at the scapular line.
d. Inspects abdomen for abnormal movement or shadows using indirect lighting.
Percusses posteriorly the costovertebral angle at the scapular line.
The nurse is assessing skin turgor. Which technique will the nurse use?
a. Press lightly on the forearm.
b. Press lightly on the fingertips.
c. Grasp a fold of skin on the sternal area.
d. Grasp a fold of skin on the back of the hand.
Grasp a fold of skin on the sternal area.
An older-adult patient is taking aminoglycoside for a severe infection. Which assessment is the priority? a. Eyes b. Ears c. Skin d. Reflexes
Ears
The patient has had a stroke that has affected the ability to speak. The patient becomes
extremely frustrated when trying to speak. The patient responds correctly to questions and
instructions but cannot form words coherently. Which type of aphasia is the patient
experiencing?
a. Sensory
b. Receptive
c. Expressive
d. Combination
Expressive
The nurse is assessing the tympanic membranes of an infant. Which action by the nurse demonstrates proper technique?
a. Pulls the auricle upward and backward.
b. Holds handle of the otoscope between the thumb and little finger.
c. Uses an inverted otoscope grip while pulling the auricle downward and back.
d. Places the handle of the otoscope between the thumb and index finger while pulling the auricle upward.
Uses an inverted otoscope grip while pulling the auricle downward and back.
A nurse is assessing a patient’s cranial nerve IX. Which items does the nurse gather before
conducting the assessment? (Select all that apply.)
a. Vial of sugar
b. Snellen chart
c. Tongue blade
d. Ophthalmoscope
e. Lemon applicator
- Vial of sugar
- Tongue blade
- Lemon applicator
A nurse is assessing several patients. Which assessment findings will cause the nurse to follow up? (Select all that apply.)
a. orthopnea
b. Nonpalpable lymph nodes
c. Pleural friction rub present
d. Crackles in lower lung lobes
e. Grade 5 muscle function level
f. A 160-degree angle between nail plate and nail
- Orthopnea
- Pleural friction rub present
- Crackles in lower lung lobes
A nurse is preparing to perform a lung assessment on a patient and discovers through the nursing history the patient smokes. The nurse figures the pack-years for this patient who has
smoked two and a half (2 1/2) packs a day for 20 years. Which value will the nurse record in the patient’s medical record? Record answer as a whole number. _________ pack-years
50
Lower extremity swollen and warm with normal pulse:
Venous problems
Neck vein visible when sitting:
Jugular vein distention
Swayback:
Lordosis
Lower extremity pale and cool with decreased pulse
Arterial problems
Ringing in ears:
Tinnitus
Black, tarry stools
Melena
Rinne test:
Comparison of air and bone conduction by placing a vibrating tuning fork on pt’s mastoid process and comparing lengths
Bell of stethoscope used for:
Low-pitched, vascular
Diaphragm of stethoscope used for:
High-pitched, bowel and lung
Light palpation:
Identify tenderness
Deep palpation:
Condition of organs
How to measure depth of edema:
1+ - 2mm
2+ - 4mm
3+ - 6mm
4+ - 8mm
Crackles:
- Heard over R or L lobes
- High-pitched
- Not cleared with cough
Rhonchi:
- Heard over trachea/bronchi
- Low-pitched
- Can be cleared with cough
Wheezes:
- Heard over all lung fields
- High-pitched
- Whistling/musical sound
Pleural friction rub:
- Dry/rubbing
- Not cleared with cough
1st intercostal space:
Aortic area
2nd intercostal space:
Pulmonic area
4th-5th intercostal space:
Tricuspid area
Goniometer:
Measures degree of motion
Expressive aphasia:
Understands written and verbal speech but can’t write/speak
Receptive aphasia:
Can’t understand written/verbal speech
