NR304 / NR-304: Health Assessment II FINAL EXAM REVIEW Chamberlain College Of Nursing

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NR-304 Health Assessment II NR-304 Final Exam Review 1. What is the purpose of the health history? - Provide the database of subjective data about Pt's health 2. What are the specific ca... tegories contained in the health history? - 3. After completing an initial assessment on a client, the nurse has charted: Vital signs: t-100.1 oral, Apical HR 98 irregular, RR 24 shallow, B/P 128/90, Pulse ox 90% on RA What type of data is this? What are you worried about? - 4. During assessment of the lower extremities of a male client the nurse is unable to palpate the dorsalis pedis pulse. What action should the nurse take first? a) Notify the Physician b) Return in a few hours and reassess c) Ask the client if this is "normal" for him d) Reposition the fingers and assess again 5. An example of objective data obtained during the physical assessment includes: Select all that apply a) Sore throat b) Audible wheeze c) Headache d) Tinnitus e) Pressure ulcer rt. ankle 6. Name the four components of general survey. PBMB - Physical appearance - Body structure - Mobility - Behavior 7. A mother is at the clinic with her 2-year-old son and states “he won’t go to sleep at night and during the day he has several fits. I get so upset when this happens.” The nurse’s best verbal response should be: a) “Go on, I’m listening b) “Tell me what you mean by fits.” c) “Yes, it can be upsetting when a child has a fit.” d) “Don’t be upset when he has a fit, all 2-year-olds have fits.” RATIONALE: 8. Which of the following statements illustrates the use of open-ended questions? Select all that apply a) Elicits cold facts b) Builds & enhances rapport c) Leaves interactions neutral d) Calls for short one-to two-word answers e) Used when narrative information is needed 9. A client's reason for seeking care is "shortness of breath". When obtaining a health history, which of these questions, by the nurse, would obtain the most helpful information? a) Will you please describe the activities that cause you to be short of breath? b) Have you been short of breath for long? c) Hon, are you short of breath now? d) Do you have interstitial pneumonia? 10. During an exam the nurse notices the client has round, flat red lesions on the skin of the forearm. The nurse suspects: a) Petechiae b) Pruritis c) Herpes zoster d) Psoriasis RATIONALE: 11. Vesicular - 12. Presbyopia 13. Tuning fork is used in which tests? - 14. A 65-year-old man with emphysema has come to the clinic for a follow-up appt. On assessment of the skin, the nurse might expect to assess the following: a) Jaundice b) Senile angiomas c) Herpes zoster d) Clubbing of the nails RATIONALE: 15. ABCDE of melanoma - 16. A mother presents with her son, who has been in a new day care facility. On examination the nurse assesses moist, thin vesicles with an erythematous base around the nose and mouth. The nurse suspects: a) Eczema b) Impetigo c) Herpes zoster d) Dermatitis 17. A healthcare provider has diagnosed a client with purpura. The nurse knows this is: a) Blue dilation of blood vessels in a star-shaped linear pattern on the legs b) Fiery red star-shaped markings on the cheek with a solid center c) Confluent and extensive patches of petechiae d) Tiny little areas of hemorrhage less than 2 mm, round and discrete 18. Tiny punctuate hemorrhages - 19. A large patch of capillary bleeding into tissues - 20. A hypertrophic scar - 21. Elevated cavity containing free fluid up to 1cm - 22. Variations of hyperpigmentation - 23. solid, elevated, hard or soft, larger than 1 cm - 24. What are the 5 listening points of the heart? - 25. A nurse is assessing a client admitted with congestive heart failure (CHF) for edema. The nurse assesses the following in dependent parts of the body - when applying pressure there is a dent in the skin that lasts a very long time. The nurse should document this as: a) 1+ - (2mm depth) b) 2+ - (4mm depth) c) 3+ - (6mm depth) d) 4+ - (8mm depth) 26. The nurse is performing a skin assessment on a client & assesses the skin for turgor. The nurse grasps a fold of skin in which body area to best assess? a) Back of the hand b) Sternal area c) Top of foot d) Sacral area 27. The nurse notes documentation that a client's peripheral pulses are 2+. The nurse determines that the pulses are: a) Bounding b) Absent c) Normal d) Weak 28. When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: a) Height & weight b) Leg circumference c) Biceps skinfold thickness d) Hip & waist measurement 29. BMI formula - 30. A client with a long history of COPD is being assessed. The nurse would be likely to inspect (Select all that apply): a) Asymmetric respiratory expansion b) Decreased tactile fremitus c) Hypertrophied neck muscles d) Anterior/posterior-to transverse diameter of 1:1 e) Tripod positioning 31. Where will the nurse place the stethoscope to auscultate the apices of the lungs? - 32. An adult client with a history of allergies comes to the clinic with c/o wheezing and dyspnea. The assessment reveals nasal flaring, use of accessory muscles and tachypnea. This description is consistent with? a) Atelectasis b) Lobar pneumonia c) Asthma d) CHF 33. During palpation of the anterior chest wall, the nurse palpates a coarse crackling sensation over the skin surface. The nurse suspects: a) Tactile fremitus b) Friction rub c) Crepitus d) Adventitious sounds 34. A nurse is performing a lung assessment on a client diagnosed w/ RLL pneumonia. The client is asked to say "eee" and through the stethoscope the nurse hears an "aaa" sound over the RLL. What term should be used to document the finding? a) Tactile fremitus b) Egophony c) Bronchophony d) Whispered pectoriloquy RATIONALE: 35. What is orthopnea? How is it measured? - 36. During percussion, the nurse knows that a resonant percussion tone over a lung lobe most likely results from: a) Shallow breathing b) Normal lung tissue c) Decreased adipose tissue d) Increased density of lung tissue 37. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a) Third intercostal space b) Over the lobe’s posterior c) Between the scapulae d) Fifth intercostal space 38. When auscultating the heart over the 2nd intercostal space to the left of the sternal border, the nurse is listening to what area? a) Erbs b) Pulmonic c) Aortic d) Tricuspid 39. In assessing the carotid arteries of an older client with cardiovascular disease the nurse should: a) Palpate the artery in the upper neck at the angle of the jaw b) Palpate the arteries simultaneously c) Instruct the pt. to take slow deep breaths during auscultation d) Listen w/the bell of the stethoscope to assess for bruit 40. Can crackles clear with coughing? - 41. Why is it important for clients to use Incentive Spirometry? - 42. A 67-year-old client states he recently began to have pain in his left calf when climbing 10 stairs to his apartment. The pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. This client is most likely experiencing: a) Thrombophlebitis b) Arterial obstruction (claudication) c) Paresthesia d) Venous insufficiency RATIONALE: 43. On inspection of a client's leg the nurse notes an ulcer on the lateral ankle with drainage. The nurse knows this could be: a) A varicosity b) A venous stasis ulcer c) An arterial ulcer d) Pitting edema 44. Connect the concept of immobility and venous stasis - 45. Hypothyroidism can have the following signs and symptoms: Select all that apply a) Dry skin b) Dry hair c) Tachycardia d) Exophthalmos e) Bradycardia 46. During the history, a client tells the nurse that "I have the sensation of a ringing and buzzing in my ear that is driving me crazy". The nurse suspects: a) Vertigo b) Syncope c) Otitis media d) Tinnitus 47. The nurse performs the confrontation test, the nurse has assessed: a) EOM's b) PERRLA c) Near vision d) Peripheral vision 48. define PERRLA 49. A client states he is frequently constipated and when he has a bowel movement, he notes rectal bleeding and pain. The client asks the nurse, "Do I have hemorrhoids or is there something else wrong with me?" The nurse assesses the perianal area and suspects: a) A rectal prolapse b) A pilonidal cyst c) Hemorrhoids d) A rectal abscess 50. A client recovering from an open reduction of the humerus states, "I haven't been able to extend the fingers on my hand since this morning." What action should the RN take next? a) Massage the fingers b) Administer prescribed analgesics c) Elevate the arm to prevent edema d) Assess CMS with the 5 P's 51. A client in the ICU develops pre-renal failure following surgery. Which of the following causes should the RN suspect? a) Vascular Disease b) Urethral obstruction c) Hypovolemia d) Glomerulonephritis 52. The nurse has just recorded, guarding of the abdomen, positive Blumberg & Psoas signs in a client. The nurse suspects: a) Perforated spleen b) Enlarged gallbladder c) Hepatitis d) Appendicitis 53. During an exam, the nurse notes that a client's legs turn white when they are raised above the pts. head. The nurse should suspect: a) Lymphedema b) Raynaud's disease c) Chronic venous insufficiency d) Chronic arterial insufficiency RATIONALE: 54. The nurse assesses a positive Murphy's sign in the client brought to the unit from the ED. The nurse continues with the assessment and begins the POC, which would most likely include: a) A report to the healthcare provider regarding the diagnosis of appendicitis b) Expecting that this client will be placed on a general diet c) Expecting that this client will be NPO for upcoming surgery to remove the gallbladder (cholecystectomy) d) Measuring of the abdominal girth for ascites 55. The Advanced Practice Nurse (APN) is performing a clinical breast exam (CBE) on a female client. Which of the following will the nurse include? a) Do not include palpation of the axilla in the exam b) Palpate the 4 quadrants in a systematic manner c) Palpate only if there is pain d) Educate the client to only perform breast-self exam after age 35 RATIONALE: 56. Assessing a client for increased intracranial pressure would include which of the the following: a) Change in LOC b) Pupillary changes c) Headache d) Papilledema e) All of the above RATIONALE: - 57. On inspection of a client's foot, the nurse notes a 3 cm round ulcer on the Lt. great toe with a pale base, well-defined edges and no drainage. The nurse knows this could be a/an: a) Varicosity b) Venous stasis ulcer c) Arterial ulcer d) Pitting edema RATIONALE: 58. The nurse is caring for a client s/p hip arthroplasty. Which of the following interventions should the nurse include in the client's plan of care (POC)? a) Flex the operative hip 90 degrees b) Abduct the operative hip c) Adduct the operative hip d) Turn 45 degrees to the operative side RATIONALE: 59. Which of the following are age-related changes found in the musculoskeletal system of the older adult? a) Decreased height b) Progressive decrease in reaction time c) Slight flexion of the hips and knees d) Decreased ROM and flexibility e) Kyphosis f) Altered gait g) Changes in the normal angle of the hip, decreased abduction h) All of the above 60. Dysphonia - 61. Dysarthria - 62. Broca - 63. Wernicke - 64. Which of the following is a normal finding in the abdominal assessment? a) The presence of a bruit b) A tympanic percussion tone c) A palpable spleen d) A resonant percussion tone RATIONALE: 65. A client is complaining of new-onset calf & foot pain. The nurse notes that the leg below the knee is cool & pale. The dorsalis pedis & posterior-tibial pulses are assessed as "0" w/ palpation and "0" following validation with a Doppler. The priority nursing intervention is: a) Place a cradle over the bed to prevent pressure from bedding b) Elevate the leg c) Massage the leg d) Notify the healthcare provider immediately RATIONALE: 66. What is the proper sequence of the abdominal assessment . . . and why?? - 67. The RN is performing a Romberg test to assess cerebellar function. A negative Romberg is: a) Maintaining balance with feet together & eyes closed for 20-30 seconds without support b) Maintaining balance when sitting with eyes closed c) Maintaining balance with feet separated & eyes closed while standing d) Maintaining balance if sitting with eyes open RATIONALE: 68. The RN is conducting a cranial nerve assessment on a client. The patient is unable to hear the vibration of the tuning fork when the Weber test is performed. The nurse documents a deficit of which cranial nerve? a) II b) III c) VI d) VIII RATIONALE: 69. When assessing a female client's LOC & orientation, the RN notes that she is alert, knows her name, where she is and the time of day. The client is able to explain why she is in the hospital. How should the RN document these assessment findings? a) A&O X3 b) Altered LOC c) A&O X4 d) A&O X2 RATIONALE: 70. Why is the Glasgow Coma Scale done? Scale to give an accurate Level of Consciousness - 71. "Less than 8, Intubate" is associated with.... - 72. What are the areas covered in the Glasgow coma scale? - 73. What should the nurse include when educating a male client about testicular self-exam (TSE)? a) Perform TSE prior to taking a shower b) If you note an enlarged testicle or lump, notify your healthcare provider c) The testicle should feel lumpy d) Perform TSE weekly RATIONALE: 74. Would an abdominal aortic aneurysm produce a bruit? Why? - 75. Where on the abdomen should the nurse auscultate for an abdominal aortic bruit? - 76. Which of the following may be auscultated during the abdominal assessment? Select all that apply a) Vascular Sounds b) Pulsations below the xiphoid c) Referred pain d) Bowel Sounds 77. When auscultating bowel sounds, the nurse knows: a) It is normal to inspect pulsations in thin clients b) Palpation should precede auscultation c) The bell of the stethoscope should be used d) Bowel sounds are not constant & it may take several minutes RATIONALE: 78. Impairment of cranial nerve VII results in: a) Facial asymmetry b) Absence of the ability to smell c) Absence of eye movement d) Inability to chew RATIONALE: 79. A client is admitted following surgical repair of fracture of the tibia. Which assessment should the nurse report to the healthcare provider? a) Pain that is relieved with medication b) Warm toes c) Palpable pedal pulse d) Paresthesia of the toes 80. What are the 6 P's? - 81. What is the test where the Pt is asked to keep the back of the hands together for 1 full min? What other test is used for carpal tunnel? - 82. A nurse notes documentation in a client's record that the client is experiencing anuria. The nurse determines the client: a) Is unable to produce urine b) Has a diminished capacity to form urine c) Has microscopic red blood cells in the urine d) Has episodes of oliguria RATIONALE: 83. During the initial interview a female client reports a lesion on the perineum. Inspection reveals a small painful blister. The RN is aware that the most likely source of the lesion is: a) Syphilis b) Herpes simplex c) Gonorrhea d) HPV 84. What parts of the neuro assessment includes the following? •Light touch, sharp and dull •Vibration •Position •Stereognosis & graphesthesia •2 pt. discrimination 85. What are the 5 parts of the Neuro assessment? - 86. Explain the Allen test - 87. arterial vs venous ulcers - [Show More]

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