HEALTH ASSESSMENT FINAL
1) The nurse is examining a patient’s lower leg and notices a draining ulceration. Which of these actions is most
... [Show More] appropriate in this situation?
a) Wash hands and contact the physician.
b) Continue to examine the ulceration and then wash hands.
c) Wash hands, put on gloves, and continue with the examination of the ulceration.
d) Wash hands, proceed with rest of the physical examination, and then continue with the examination of the leg ulceration.
2) During the examination, it is often appropriate to offer some brief teaching about the patient’s body or the examiner’s findings. Which of these statements by the nurse is most appropriate?
a) “Your atrial dysrhythmias are under control.”
b) “You have pitting edema and mild varicosities.”
c) “Your pulse is 80 beats per minute. This is within the normal range.”
d) “I’m using my stethoscope to listen for any crackles, wheezes, or rubs.”
3) The nurse keeps in mind that the most important reason to share information and offer brief teaching while performing the physical examination is to help:
a) The examiner feel more comfortable and gain control of the situation
b) Build rapport and increase the patient’s confidence in the examiner
c) The patient understand his or her disease process and treatment modalities
d) The patient identify questions about his or her disease and potential areas of patient education
4) The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?
a) When the infant is sleeping
b) At the end of the examination
c) Before auscultation of the thorax
d) Halfway through the examination
5) When preparing to perform a physical examination on an infant, the nurse should:
a) Have the parent remove all clothing except the diaper on a boy
b) Instruct the parent to feed the infant immediately before the examination
c) Encourage the infant to suck on a pacifier during the abdominal examination
d) Ask the parent to briefly leave the room when assessing the infant’s vital signs
6) A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination?
a) Auscultate the lungs and heart while the infant is still sleeping.
b) Examine the infant’s hips because this procedure is uncomfortable.
c) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
d) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
7) A 2-year-old child has been brought to the clinic for a well-child check-up. The best way for the nurse to begin the assessment is reflected by which statement?
a) Ask the parent to place the child on the examining table.
b) Have the parent remove all of the child’s clothing before the examination.
c) Allow the child to keep a security object such as a toy or blanket during the examination.
d) Initially focus interactions on the child, essentially “ignoring” the parent, until the child’s trust has been obtained.
8) The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?” Which critique of the nurse’s technique is most accurate?
a) Asking questions enhances the child’s autonomy.
b) Asking the child for permission helps to develop a sense of trust.
c) This is an appropriate statement because children at this age like to have choices.
d) Children at this age like to say “No.” The examiner should not offer a choice when there is none
9) During an interview, the nurse states, “You mentioned shortness of breath. Tell me more about that.” Which verbal skill is used with this statement?
a) Reflection
b) Facilitation
c) Direct question
d) Open-ended question
10) A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?
a) “Mr. Y., at your age, surely you have been hospitalized before!”
b) “Mr. Y., I just need permission to get your medical records from County Medical.”
c) “Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?”
d) “Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?”
11) An Asian-American woman is experiencing diarrhea, which is felt to be “cold” or “yin.” The nurse expects that the woman is likely to try to treat it with:
a) Foods that are “hot” or “yang”
b) Readings and Eastern medicine meditations
c) High doses of medicines thought to be “cold”
d) No treatment at all because diarrhea is an expected part of life
12) Illness is seen as a part of life’s rhythmic course and as an outward sign of disharmony
within. This statement most accurately reflects the views about illness from the
a) Naturalistic
b) Biomedical
c) Reductionist
d) Magicoreligious
13) An imaginary line connecting the highest point on each iliac crest would cross the vertebra.
a) First sacral
b) Fourth lumbar
c) Seventh cervical
d) Twelfth thoracic
theory.
14) The nurse is explaining to a patient that there are “shock absorbers” in his back to cushion the spine and to help it move. The nurse is referring to his:
a) Vertebral column
b) Nucleus pulposus
c) Vertebral foramen
d) Intervertebral disks
15) During an interview the patient states, “I can feel this bump on the top of both of my shoulders—it doesn’t hurt but I am curious about what it might be.” The nurse should tell the patient:
a) “That is your subacromial bursa.”
b) “That is your acromion process.”
c) “That is your glenohumeral joint.”
d) “That is the greater tubercle of your humerus.”
16) The nurse is checking the range of motion in a patient’s knee and knows that the knee is capable of which movement(s)?
a) Flexion and extension
b) Supination and pronation
c) Circumduction
d) Inversion and eversion
17) A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the joint.
a) Interphalangeal
b) Tarsometatarsal
c) Metacarpophalangeal
d) Tibiotalar
18) The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?
a) Dullness
b) Tympany
c) Resonance
d) Hyperresonance
19) Which structure is located in the left lower quadrant of the abdomen?
a) Liver
b) Duodenum
c) Gallbladder
d) Sigmoid colon
20) A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has:
a) Aphasia
b) Dysphasia
c) Dysphagia
d) Anorexia
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