Chapter 22: Assessing Health Status My Nursing Test Banks

Chapter 22: Assessing Health Status

Test Bank

MULTIPLE CHOICE

1. During a health interview, an elderly patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

a.

repeat the questions at the end of the visit to cross-check for accuracy of data.

b.

reassure the patient that forgetfulness is a normal part of the aging process.

c.

gather information from a family member accompanying the patient.

d.

omit the interview and proceed to a physical examination.

ANS: C

If the elderly person has difficulty with memory, data may be gathered from a family member or significant other.

DIF: Cognitive Level: Analysis REF: p. 368, Elder Care

OBJ: Theory #2 TOP: Data Collection

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

2. It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

a.

admission to the unit.

b.

discharge.

c.

the beginning of each shift.

d.

the patients wakening in the morning.

ANS: C

A quick focused assessment should be performed on each patient at the beginning of each shift to monitor for subtle changes in condition. This assessment is not the full assessment done on admission.

DIF: Cognitive Level: Comprehension REF: p. 367 OBJ: Clinical Practice #2

TOP: Quick Focused Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

3. The nurse lightly palpates the abdomen of a patient during a physical examination. On palpation to the right side of the abdomen, the patient cries out and draws the knees to the chest. The nurse should:

a.

discontinue the examination and report findings to the physician.

b.

palpate the abdominal skin 1.5 to 2 inches to determine the cause of pain.

c.

continue the examination and have the patient take deep breaths.

d.

proceed to percuss the abdomen with a quick snap of the wrist.

ANS: A

When palpating, the nurse should observe the patients face for signs of discomfort and discontinue palpations if they appear to cause pain.

DIF: Cognitive Level: Analysis REF: p. 370 OBJ: Theory #3

TOP: Physical Examination Techniques KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

4. When performing deep palpation, the nurse should use:

a.

one hand and exert pressure to depress tissue about one half to three fourths of an inch.

b.

either one or two hands to depress the tissue about 1 inch.

c.

either one or two hands to depress the tissue about 1.5 to 2 inches.

d.

two hands and exert pressure to depress the tissue about 3 to 4 inches.

ANS: C

Deep palpation uses either hand to depress the tissue 1.5 to 2 inches.

DIF: Cognitive Level: Comprehension REF: p. 370 OBJ: Theory #3

TOP: Deep Palpation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

5. To auscultate the breath sounds of a patient correctly, the nurse should:

a.

inspect the chest wall for characteristics of movements and respirations.

b.

use a stethoscope and properly position the earpieces and diaphragm.

c.

percuss the chest by quickly tapping on the chest wall surface to produce sounds.

d.

touch the chest wall and note the texture, temperature, and moisture of the skin.

ANS: B

Auscultation requires properly placing the earpieces in the ears pointing forward toward the nose and using the diaphragm to auscultate for breath sounds.

DIF: Cognitive Level: Knowledge REF: pp. 370-371 OBJ: Clinical Practice #2

TOP: Physical Assessment KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

6. The nurse weighing an infant in an outpatient clinic should:

a.

place a towel on the scale prior to weighing the baby.

b.

place the baby in a prone position on the scale to reduce the infants movement.

c.

keep one hand hovering over the infant during the weighing procedure.

d.

rest a hand lightly on the infants abdomen during weighing to prevent a fall.

ANS: C

The nurse should keep a hand hovering over the infant during the weighing to prevent a fall. Infants are never left unattended on a scale.

DIF: Cognitive Level: Application REF: p. 272 OBJ: Theory #3

TOP: Basic Physical Assessment: Safety | Weight

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

7. An 8-year-old patient is due for height measurement during a routine examination. For an accurate measurement to be obtained, the child should be asked to stand with:

a.

back toward the rod and the feet 6 inches apart.

b.

back toward the rod and the feet centered together.

c.

front toward the rod and the feet 8 inches apart.

d.

front toward the rod and the feet 4 inches apart.

ANS: B

The patient stands with back toward and the feet together and centered under the height rod attached to a standing scale.

DIF: Cognitive Level: Comprehension REF: p. 372 OBJ: Clinical Practice #2

TOP: Basic Physical Assessment: Height

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

8. The nurse taking a blood pressure should:

a.

place the arm so that the brachial artery is at waist level.

b.

position the patient so that the arm is level with the shoulder.

c.

request that the patient put feet flat on the floor.

d.

chat with the patient to reduce any anxiety in the patient.

ANS: C

For best accuracy, the patient should have both feet flat on the floor and the brachial artery at the level of the right atrium.

DIF: Cognitive Level: Application REF: p. 374, Clinical Cues

OBJ: Theory #3 TOP: Vital Signs: Blood Pressure

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

9. When the heart is assessed for the point of maximal impulse (PMI), the stethoscope should be placed on the:

a.

fifth intercostal space, left midclavicular line.

b.

fifth intercostal space, left anterior axillary line.

c.

second intercostal space, right midclavicular line.

d.

fourth intercostal space, left lateral sternal border.

ANS: A

The PMI of the heart is located close to the fifth intercostal space at the left midclavicular line.

DIF: Cognitive Level: Knowledge REF: p. 375 OBJ: Theory #3

TOP: Physical Examination Techniques KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

10. A nurse caring for a patient on bed rest with a history of respiratory health problems should:

a.

monitor for skin turgor every shift.

b.

monitor peripheral pulses once a shift.

c.

auscultate lung sounds at the beginning of a shift.

d.

auscultate for bowel sounds once a shift.

ANS: C

Auscultation of lungs is performed on initial assessment for persons with respiratory problems and once a shift for patients on bed rest.

DIF: Cognitive Level: Application REF: p. 376 OBJ: Theory #3

TOP: Physical Examination Techniques KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

11. The nurse assessing a patients capillary refill finds that it took 5 seconds for the color to return. The most appropriate intervention to do following this assessment is to:

a.

assess the radial pulse and the blood pressure.

b.

document the results as normal.

c.

repeat the assessment.

d.

notify the charge nurse.

ANS: C

If the color returns slowly, check the capillary refill again, because normal refill time is less than 3 seconds.

DIF: Cognitive Level: Analysis REF: p. 378 OBJ: Theory #3

TOP: Capillary Refill KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

12. The nurse is aware that the best way to assess dependent pitting edema in a patient with congestive heart failure is to:

a.

measure the circumference of the ankles daily.

b.

inquire whether the patients shoes fit tightly.

c.

auscultate lung sounds every shift.

d.

press fingers into the tissue over the tibia, just above the ankle.

ANS: D

When the nurse presses his fingers into the tissue over the tibia just above the ankle, an indentation mark appears as evidence of pitting edema.

DIF: Cognitive Level: Comprehension REF: p. 378 OBJ: Theory #3

TOP: Pitting Edema KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

13. A nurse records absence of bowel sounds after assessing the abdomen in:

a.

the two lower quadrants for 2 minutes each.

b.

the two upper quadrants for 5 minutes.

c.

all quadrants for 3 minutes each.

d.

each quadrant for 1 minute.

ANS: C

Auscultate for bowel sounds with the patient in a supine position. An absence of bowel sounds should be documented after there are no bowel sounds in each quadrant for 2 to 5 minutes.

DIF: Cognitive Level: Comprehension REF: p. 378 OBJ: Theory #3

TOP: Absence of Bowel Sound KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

14. The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of:

a.

7.

b.

10.

c.

12.

d.

15.

ANS: D

The Glasgow Coma Scale is used for the evaluation of neurologically impaired patients: spontaneous eye opening = 4, obeying commands = 6, orientation = 5. This is the highest possible score of 15.

DIF: Cognitive Level: Analysis REF: p. 379, Table 22-4

OBJ: Clinical Practice #4 TOP: Glasgow Coma Scale

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

15. Prior to preparing a female patient for a pelvic examination, the nurse should:

a.

encourage her to void in the bathroom.

b.

provide a pillow for the head and the hips.

c.

hand the patient a sheet and allow her to drape herself.

d.

cleanse the external genitalia with soap and water.

ANS: A

Before a pelvic examination, the bladder should be emptied for a more effective examination.

DIF: Cognitive Level: Application REF: p. 381 OBJ: Theory #3

TOP: Special Focus Examinations KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

16. To perform the Weber test, the tuning fork is struck and placed:

a.

at the nape of the neck.

b.

in the middle of the bridge of the nose.

c.

behind the right and then the left ear.

d.

in the middle of the forehead or skull.

ANS: D

The Weber test is performed by striking the tuning fork and placing it in the middle of the patients forehead or skull.

DIF: Cognitive Level: Comprehension REF: p. 386 OBJ: Theory #3

TOP: Auditory Examination KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

17. When examining a patients pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:

a.

consensual response.

b.

brisk response.

c.

accommodation.

d.

dilation response.

ANS: A

Consensual response is when both pupils constrict when either eye is stimulated by light.

DIF: Cognitive Level: Comprehension REF: p. 387 OBJ: Clinical Practice #4

TOP: Pupillary Response KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

18. To correctly determine the strength of a patients lower extremities during a neurologic examination, the nurse asks the patient to:

a.

wiggle the toes of both feet at the same time.

b.

push against his hand with the sole of one foot and then the other.

c.

pull both feet up at the same time to stretch the Achilles tendons.

d.

stand up independently.

ANS: B

To test extremity muscle strength, the nurse should have the patient push against his hand with the sole of one foot and then with the other.

DIF: Cognitive Level: Comprehension REF: p. 387, Skill 22-2

OBJ: Clinical Practice #4 TOP: Review of Body Systems: Neurologic

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

19. The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurses best reply is:

a.

You stand 50 feet away from the chart while I test each of your eyes.

b.

I will be testing your vision with your reading glasses on.

c.

You stand 20 feet away from the chart while I test each of your eyes.

d.

The number beside the largest print read is your visual acuity score.

ANS: C

To perform a visual acuity test using a Snellen eye chart, you should position the patient 20 feet from the chart for the test to be accurate.

DIF: Cognitive Level: Comprehension REF: p. 374, Steps 22-2

OBJ: Clinical Practice #3 TOP: Visual Testing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: basic care and comfort

20. The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

a.

bell of the stethoscope directly on the patients skin.

b.

bell of the stethoscope on top of the patients gown.

c.

diaphragm of the stethoscope directly on the patients skin.

d.

diaphragm of the stethoscope on top of the patients gown.

ANS: A

Abnormal heart sounds are best heard when the bell of the stethoscope, which picks up lower pitched sounds, is placed against the patients skin.

DIF: Cognitive Level: Comprehension REF: p. 376, Steps 22-3

OBJ: Clinical Practice #4 TOP: Physical Examination Techniques: Heart

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

21. Before starting the initial morning care or the physical assessment of the patient, the first intervention the nurse would perform would be:

a.

putting down the side rails.

b.

washing his or her hands.

c.

placing the bed at working height.

d.

turning on the overhead light.

ANS: B

The nurse should wash his or her hands before starting a procedure to prevent the spread of microorganisms.

DIF: Cognitive Level: Application REF: p. 376, Steps 22-3

OBJ: Clinical Practice #2 TOP: Physical Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment

22. A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

a.

monitor intake and output.

b.

auscultate lung and abdominal sounds.

c.

check for verbal and motor response.

d.

monitor daily weight.

ANS: C

A neurologic examination that includes the Glasgow Coma Scale is performed for any patient who has sustained a head injury.

DIF: Cognitive Level: Application REF: pp. 388-389, Table 22-4

OBJ: Clinical Practice #4 TOP: Physical Examination: Neurologic

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

23. A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?

a.

When I shine a light into the patients eyes, the pupils should constrict.

b.

When I shine a light into the patients eyes, the pupils should dilate.

c.

It is normal for the pupils to react sluggishly to light.

d.

Pupil checks should be performed with the room lights on.

ANS: A

The pupils should constrict briskly when a light is shone.

DIF: Cognitive Level: Comprehension REF: p. 387, Skill 22-2

OBJ: Clinical Practice #4 TOP: Health Teaching

KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: basic care and comfort

24. An elderly American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a:

a.

psychological history.

b.

financial history.

c.

cultural assessment.

d.

literacy assessment.

ANS: C

Cultural assessment should be done to determine cultural preferences and health beliefs to better understand how illness is affecting a patients life.

DIF: Cognitive Level: Application REF: p. 368, Elder Care

OBJ: Clinical Practice #1 TOP: Culture

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: coping and adaptation

25. A female patient of Asian descent was admitted to the medicalsurgical unit with possible lung cancer. A male nurse is preparing to perform a physical assessment. It is best for the male nurse to:

a.

ask the family members to leave the room to ensure patient privacy.

b.

perform the procedure accurately and quickly to lessen patient anxiety.

c.

examine only the affected body systems to decrease patient discomfort.

d.

ask the patient for permission to perform the assessment before starting.

ANS: D

Many cultures do not permit the touching of a female by a male outside of the family; the male nurse should ask for permission before touching her.

DIF: Cognitive Level: Application REF: p. 380, Cultural

OBJ: Clinical Practice #1 TOP: Culture

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: psychosocial adaptation

COMPLETION

26. Prior to assessing a patients blood pressure in both arms, the nurse will instruct the patient to lie down for at least ________ minutes.

ANS:

5

five

When blood pressure is measured in both arms, the nurse should instruct the patient to sit or lie down for at least 5 minutes.

DIF: Cognitive Level: Application REF: p. 374 OBJ: Theory #1

TOP: Blood Pressure KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

27. The nurse who is assessing a patient for heart sounds anticipates that the S2 sound (the dub sound) can be heard best at the ________ area.

ANS:

aorta

The S2 sound, or the dub sound, is heard most clearly over the aortic area.

DIF: Cognitive Level: Application REF: p. 375 OBJ: Theory #3

TOP: Heart Sounds KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

28. The nurse is assessing a patients heart sounds and hears a swish that is recorded as a ___________.

ANS:

murmur

Heart murmurs are heard in addition to the S1 and S2.

DIF: Cognitive Level: Comprehension REF: p. 375 OBJ: Theory #3

TOP: Murmurs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

29. The nurse is assessing a patients lung sounds and hears a wheeze in the lower left lobe. This wheeze is categorized as a(n) ____________ sound.

ANS:

adventitious

Adventitious sounds are abnormal breath sounds that should be documented and reported.

DIF: Cognitive Level: Knowledge REF: p. 376 OBJ: Theory #3

TOP: Adventitious Sounds KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

30. The nurse notes that a patient has an exaggerated lumbar curve. This is indicative of __________.

ANS:

lordosis

Lordosis is characterized by an exaggerated lumbar curve.

DIF: Cognitive Level: Comprehension REF: p. 375 OBJ: Theory #2

TOP: Lordosis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

31. The nurse is aware that the most accurate quick method to check hydration status in the elderly is to evaluate the moisture of the ______.

ANS:

mucous membranes

The loss of skin elasticity makes the evaluation of skin turgor ineffective in the elderly. An assessment of the moisture of the mucous membranes is a more reliable evaluation.

DIF: Cognitive Level: Application REF: p. 378, Elder care

OBJ: Theory #2 TOP: Hydration Status in the Elderly

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

32. The nurse takes special care in the draping of a patient in the lithotomy position in order to diminish _______________.

ANS:

exposure

embarrassment

A patient who feels exposed and embarrassed will be tense and less able to cooperate.

DIF: Cognitive Level: Comprehension REF: p. 381 OBJ: Clinical Practice #7

TOP: Draping KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

33. When the nurse asks the neurologically impaired patient to follow the motion of the nurses fingers, the patients eyes track the fingers with jerky movements, which should be documented as ________________.

ANS:

nystagmus

Nystagmus is the term used to describe jerky movements of the eye as it follows or tracks an object such as the examiners fingers.

DIF: Cognitive Level: Application REF: p. 387, Skill 22-2

OBJ: Theory #3 TOP: Nystagmus KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

MULTIPLE RESPONSE

34. When teaching a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)

a.

Difficulty in swallowing

b.

Persistent cough

c.

Hyperactive bowel sounds

d.

Vesicular breath sounds

e.

Changes in pulse rate

f.

Obvious change in a mole

ANS: A, B, C, F

The warning signs of cancer are changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or a lump in a breast, indigestion or difficulty swallowing, a nagging cough, and changes in a wart or mole.

DIF: Cognitive Level: Comprehension REF: p. 380, Patient Teaching

OBJ: Clinical Practice #5 TOP: Health Education

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

35. The nurse uses the technique of inspection to initially assess: (Select all that apply.)

a.

skin tone.

b.

skin turgor.

c.

body contours.

d.

color.

e.

characteristics of movement.

ANS: A, C, D, E

Inspection can initially assess skin tone, body contours, color, characteristics of movement, skin lesions, and obvious weakness.

DIF: Cognitive Level: Comprehension REF: p. 370 OBJ: Theory #1

TOP: Inspection KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

36. Percussion is a technique by which the nurse can assess sounds relative to the underlying structures that indicate the presence of: (Select all that apply.)

a.

air.

b.

infection.

c.

fluid.

d.

the inflammatory process.

e.

a solid organ.

ANS: A, C, E

Percussion is a technique that causes difference resonance of the underlying structures. Percussion can detect the presence of air or fluid or the location of a solid organ.

DIF: Cognitive Level: Comprehension REF: p. 370 OBJ: Theory #1

TOP: Percussion KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

37. Periodic tests recommended for men are: (Select all that apply.)

a.

monthly testicular self-examination (TSE) after age 14.

b.

blood glucose every 2 years if above 150/mg/dl.

c.

annual prostate-specific antigen (PSA) after age 50.

d.

annual digital rectal examination (DRE) after age 45.

e.

cholesterol every 2 years if below 200 mg/dl.

ANS: A, C, E

TSEs should be done monthly after the age of 14, PSAs should be done annually after the age of 50, and cholesterol should be checked every 1 to 3 years if below 200 mg/dl.

DIF: Cognitive Level: Knowledge REF: p. 386, Health Promotion

OBJ: Clinical Practice #6 TOP: Periodic Exams

KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

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