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
