Health Assessment Solved Past paper 2019

Q1) define interview and explain the principles of interviewing

Interview Definition:

The interview is a process of communication or interaction in which the subject or interviewee gives the needed information verbally in a face to face situation.

Principles Of Interviewing:

  1. Interviewing is a special kind of conversation
  2. Has a definite purpose
  3. More structured
  4. Strong element of control
  5. Two parties only: interviewer and respondent
  6. Different amounts of speaking (30/70)
  7. A significant aspect of daily business

Q2) describe the component of health history that should be produced during the assessment of skin, head and neck

Subjective Data:

  1. Any previous skin disease or problem (infection, rashes, lesions, itching).
  2. How was it treated?
  3. Skin allergic problem
  4. precipitating factors (stress, weather, drugs)
  5. Any birth marks or tattoos.
  6. Change in skin color, pigmentation and lesions
  7. Any recent hair loss
  8. Amount of sun exposure

Examination of Skin:

1. Color
2.Temperature
3.Texture
4.Mobility
5.Turgor
6.Moisture
7.Sensation
8.Integrity

Lesions

  1. lLocation/ distribution
  2. lMorphology
  3. –Primary
  4. –Secondary
  5. –Vascular
  6. –Cancerous

Q3) classify the structure landmarks of the nose mouth and pharynx

Nose

  1. The nose is the first segment of the respiratory system.
  2. It is the sensory organ of smell
  3. External nose (It shaped like a triangle with one side attached to the face on its leading edge.
  4. The superior part is the bridge and the free corner is the tip.
  5. The oval openings at the base of the triangle are the nares just inside, each nares widen into the vestibule.
  6. The upper third of the external nose is made of bone, the rest is cartilage. The parts of the nose are:
  7. Nasal cavity
  8. Septum
    iii.        Turbinate
    Paranasal sinuses
    Frontal
    Maxillary
    vii.       Ethmoid
    VIII. Sphenoid

Mouth

  1. Mouth is the first segments of the digestive system and the airway of the respiratory system.
  2. The oral cavity is the short passage boarded by the lips, palate, checks, and tongue.
  3. It continues the teeth, gums, tongue and salivary glands.
  4. The arching roof of the mouth is the palate, it is divided into two parts.
  5. The interior, hard palate; Posterior to this is the soft palate.
  6. The uvula is the free projection hanging down from the middle of the soft palate.
  7. The cheeks are the side walls of the oral cavity.
  8. Floor of the mouth is tongue and horse shoe shaped mandible bone.
  9. Parotid
  10. Submandibular gland
  11. Sublingual fold, duct and gland
  12. Teeth

Pharynx:

  1. Oropharynx
  2. Tonsils
  3. Nasopharynx

Q4) describe the specific assessment to be made during the physical examination of abdomen

Assessment

1. Inspect
a. Shape and contour
i. Look across abdomen left to right
ii. Can use pen light to look for visible bulging or masses
iii. Look for distention
b. Umbilicus – discoloration, inflammation, or hernia
c. Skin texture and color
d. Lesions or scars
i. Note details – length, color, drainage, etc.
e. Visible pulsations
f. Respiratory movements (belly breather)
2. Auscultate
a. Start in RLQ → RUQ → LUQ → LLQ
i. This follows the large intestine
b. Use diaphragm of stethoscope to listen for 1 full minute per quadrant
i. Active – Should hear 5-30 clicks per minute
ii. Hypoactive
iii. Hyperactive
iv. Absent – must listen for 5 minutes per quadrant to confirm this
c. Use bell of stethoscope to listen for bruits
i. Aorta – over the epigastrium
ii. Iliac and femoral arteries – Inguinal are
iii. Renal arteries – A few cm above and to the side of the umbilicus
1. Press firmly
iv. The presence of a bruit could indicate narrowing of the arteries – if this is a new finding, report to provider
3. Percuss
a. Percuss x 4 quadrants, starting in RLQ as with auscultation
b. Expect to hear tympany
c. Dullness could indicate a mass, fluid-filled bladder, blood in the belly, or significant adipose tissue
i. Exception – dullness over the liver is expected
d. CVA tenderness
i. Place nondominant hand flat over the costovertebral angle (flank).
ii. Strike your hand with the ulnar surface of your dominant hand
iii. Should be nontender
iv. Repeat bilaterally
4. Palpate
a. Light palpation – small circles in all 4 quadrants
i. Can do 4 small areas in each quadrant to be thorough
b. Deep palpation – deeper circles in all areas
c. Palpating for masses – make note of size, location, consistency, tenderness, and mobility
d. Make note of any guarding or tenderness
e. Assess for rebound tenderness
i. Press down slowly and deeply
ii. Release quickly
iii. Ask patient which hurt most (down or up)
iv. Rebound tenderness over RLQ could indicate appendicitis
f. If distended, perform Fluid-Wave test to look for ascites:
i. Place patient’s hand over umbilicus
ii. Place your hand on right flank, then tap or push on the left flank with your other hand
iii. If you feel the tap/push on the opposite hand, that’s a Positive Fluid-Wave test
1. Indicates Ascites
iv. You may also see the patient’s hand ‘wave’ with the fluid

Q5) define breast examination and discuss the steps of self-breast examination

 Definition

A physical exam of the breast performed by a health care provider to check for lumps or other changes. Also called CBE.

steps of self-breast examination

 Step 1: stand up before the mirror and Start by looking for differences between your breasts

  1. Good breast self-exams should be concerned with both the look and feel of breasts. The look element should be performed while either standing or sitting in front of a mirror, with your clothes removed. Examine both breasts and look for:
  2. Visible lumps
  3. Any unusual differences between the two breasts

iii.  Dimpling or indentations in the breast tissue

  1. Redness, scaliness, or other changes to the skin or nipples that appear abnormal
  2. Changes to your nipples, for example a nipple that is newly inverted or pulling in

Step 2: Put your hands on your hips, pull your elbows forward

  1. Look for the same changes in the breasts from Step 1 — such as redness, lumps and indentations — this time with your hands resting on your hips

while squeezing your elbows forward since this might bring out lumps that might not appear otherwise. Keep your hands on your hips and slowly swivel from side to side to catch possible abnormalities from more angles.

  1. Next, lift your arms above your head to see if there’s any puckering or dimpling of the skin when you elevate them. “When you raise your arms, the mass, if there is one, stays there and the skin pulls in,” says Kruper.

Step 3: Use 3 fingers when examining your breasts

  1. The feel part of the breast self-exam should be done while lying down, with a pillow propping up your head and your arm resting behind it. With the opposite hand, take the first three fingers — index, middle and ring fingers — and use them to press down around the breast and surrounding area using circular motions. Using three fingers, rather than just one, keeps you from mistaking normal breast tissue for lumps. Increase the pressure you use with each pass around the breasts to ensure you are not just feeling superficial tissue.

Step 4: Examine the areas surrounding the breast

  1. After examining your breasts, it is important to perform a check of the areas around them. Continue to use circular motions and increasing pressure as you move from the collarbone to the sternum and down below the breast. From the lower part of the breast, travel up to the area under your arm to look for any swelling in the lymph nodes. “What you’re looking for is something that stands out — something that feels like a pea, or a marble or a walnut,” says Kruper. “Something that definitely feels different than the surrounding breast tissue.”

Step 5: Perform the test at the same time each month

A, Be sure to do the breast self-examination the same time every month. If you are still menstruating, Kruper recommends you do the exam about seven to 10 days after your menstrual cycle, since at that time there will likely be fewer cycle-related changes in the breast tissue. Women who are postmenopausal can do the exam at any time of the month, as long it is around the same time each month.

B, Keep in mind that there is some debate about whether women should perform routine breast self-exams to find potentially cancerous lumps.

According to current research, some of the issues depend on the possibility of false positives and the possibility that the screenings might not really increase a woman’s probability of survival.

Q6) classify the equipment needed to perform a physical examination

 The equipment needed to perform a physical examination

  1. Within reach and ready
  2. Arranged as per need
  3. Required equipment
  4. Extra supplies/equipment
  5. Clean or sterile equipment
  6. Warm metallic piece

The following are the more common but essential medical tools that are used during physical health exam.

  1. Medical Weighing Scale
  2. Sphygmomanometer
  3. Stethoscope
  4. Thermometer
  5. Ophthalmoscope
  6. OTOSCOPE
  7. TUNING FORK
  8. NASAL SPECULUM
  9. PERCUSSION HAMMER
  10. VAGINAL SPECULUM
  11. PROTOSCOPE
  12. GLOVES

Q7) define health assessment and identify types of health assessment

Definition

A health assessment is a plan of treatment that outlines a person’s unique requirements and how those needs will be met. A is provided by the hospital system or a skilled nursing facility. Health assessment is the evaluation of one’s health status through a physical exam and a health history. It is done to detect diseases in people who appear to be healthy.
There are four types of Health Assessment

1)   Comprehensive Initial Assessment:

  1. The initial assessment, also known as triage assessment.
  2. Performed shortly after admittance to hospital
  3. Performed by the nurse to collect data on all aspects of patient’s health
  4. It helps to determine the nature of the problem and prepares the way for the ensuing assessment stages.
  5. The initial assessment is used more than the other assessments used by nurses.
  6. Components may include obtaining a patient’s medical history or putting him/her through a physical exam, or preparing a psychosocial assessment for a mental health patient.
  7. Other components may include obtaining a patient’s vital signs and taking subjective statements from the patient, as well as double-checking the subjective symptoms with the objective signs of the condition.

2)   Focused Assessment:

  1. The focused assessment is the stage in which the problem is exposed and treated.
  2. Due to the importance of vital signs and their ever-changing nature, they are continuously monitored during all parts of the assessment.
  3. May be performed during initial assessment or as routine ongoing data collection
  4. Performed to gather data about a specific problem already identified, or to identify new or overlooked problems
  5. Performed by the nurse to collect data about the specific problem
  6. Depending on the problem, initial treatment for pain and long-term treatment for the root cause of the trouble is administered and monitored.
  7. Part of the goal of the focused assessment is to diagnose and treat the patient in order to stabilize her condition.
  8. Focused assessments may also include X Rays or other types of tests.

3)   Time-Lapsed Assessment:

  1. Once treatment has been implemented, a time-lapsed assessment must be conducted to ensure that the patient is recovering from his problem and his condition has stabilized.
  2. Depending on the nature of the problem, the time-lapsed assessment may span the length of one or two hours or a couple of months.
  3. Performed to compare a patient’s current status to baseline data obtained earlier
  4. Performed to reassess health status and make necessary revisions in plan of care
  5. Performed by the nurse to collect data about current health status of patient
  6. During the time-lapsed assessment, the current status of the patient is compared to the previous baseline during and prior to treatment.
  7. Similar to the focused assessment, the time lapsed assessment may also include lab work, X-rays or other diagnostic medical testing.

4)   Emergency Assessments:

  1. During emergency procedures, a nurse is focused on rapidly identifying the root causes of concern for the patient and assessing the airway, breathing and circulation (ABCs) of the patient.
  2. Once the ABCs are stabilized, the emergency assessment may turn into an initial or focused assessment, depending on the situation.
  3. If the nurse is not in a health care setting, emergency assessments must also include an assessment for scene safety so that no other individuals, including the nurse himself/herself are hurt during the rescue and emergency response process.
  4. Performed by the nurse to gather data about the life-threatening problem

 

Health Assessment Paper- MCQs/BCQs

1) When doing an assessment on a client’s eyes the very first thing that a nurse should look at is?
A. Eye internal structures
B. Eye external structures
C. The pupils reactivity to light
D. Color of the irises of the eye
2) While the nurse is inspecting the throat of a client with a tongue blade, the client begins to gag. What does this response indicate to the nurse?
A. The client is nauseated.
B. The client has nerve damage to his tongue.
C. The client has a functioning response.
D. The client has a malfunctioning response
3) During the health history, a client begins to talk about her dog and the trouble she is having housebreaking the new pet. To help the client return to the health interview, the nurse could use the communication skill:
A. Listening
B. Reflecting
C. Questioning
D. Focusing
4) After inspecting a client’s abdomen, which assessment technique should the nurse use next?
A. Light Palpation
B. Percussion
C. Auscultation
D. Deep Palpation
5) Nurse Tara asks her client Farhan to clench his jaw as she continues to palpate his head. When she asks him to do this what is Nurse Tara most likely trying to palpate?
A. Faran’s submandibular joint
B. Farhan’s submental joint
C. Farhan’s temporomandibular joint
D. Faran’s temporal artery
6) The nurse is planning to palpate a client’s bladder. Which area of the abdomen should this palpation be done?
A. Hypogastric region
B. Right hypochondriac region
C. Right Lower Quadrant
D. Left lumbar region
7) A 70-year-old male client comes into the clinic with weight loss and difficulty swallowing. Which of the following should the nurse document for this client?
A. Odynophagia
B. Bulimia
C. Dysphagia
D. Aphasia
8) A 15-year-old high school student came to the clinic with a 1-day history of nausea and anorexia. He describes the pain as generalized yesterday, but today it has localized to the right lower quadrant. You palpate the left lower quadrant and the patient experiences pain in the right lower quadrant. What is the name of this sign?
A. Murphy’s sign
B. Psoas sign
C. Grey Turner’s sign
D. Rovsing’s sign
9) During eye assessment when you asked the patient to follow your finger or pencil as you move it in toward the bridge of the nose. Which of the following test you are performing?
A. Visual acuity
B. Visual Fields by Confrontation
C. Test for convergence
D. Visual fields
10) A nurse doing her assessment proceeds to palpate a client’s frontal and maxillary sinuses. What should she make sure she checks for?
A. Tactile signs of carcinoma
B. Swelling
C. Lesions
D. Tenderness
11) A nurse would use either a Snelling chart or the finger wiggle test to assess a client’s what?
A. Hearing
B. Vision
C. Consensual light reflex
D. Bone conduction
12) During assessment of pharynx you as the client to say “Ah” and uvula and soft palate rise centrally. It determines the function of which cranial nerve:
A. Spinal accessory
B. Vagus
C. Trochlear
D. Trigeminal
13) During the assessment of a client, the nurse gently touches the tip of a sterile cotton swab in the client’s eye. Which of the following would be considered an expected response for the client to make?
A. Begin sneezing.
B. Blink.
C. Scream in pain.
D. Swat the nurse’s hand away.
14) If assessing a client for kidney tenderness, where would you begin?
A. External Oblique Angle
B. Left Upper Quadrant
C. Right Upper Quadrant
D. Costovertebral Angle
15) The three things a nurse needs to check for when doing an examination on the eyes regarding the external structures is?
A. Eyelash texture, shape of eyes, redness
B. Shape of eyes, pupils reactivity, iris’s color
C. Drainage, possible tumors, irritation
D. Eyelash distribution, coloring, drainage
16) A 40-year-old female came for evaluation of abdominal pain. She stated that it is worse after eating, especially if she has a meal that is spicy or high in fat. She has taken antacids, but they have not helped the pain. After examining her abdomen, you strongly suspect cholecystitis. Which sign on examination increases your suspicion for this diagnosis?
A. Murphy’s sign
B. Psoas sign
C. Grey Turner’s sign
D. Rovsing’s sign
17) During the percussion of a client’s abdomen, the nurse hears a loud high-pitched drum like tone. The nurse would document this sound as being:
A. Resonance
B. Tympany
C. Hyper-resonance
D. Flatness
18) What could the nurse assess based solely on the way the client walks into the room?
A. Signs of illness, well nourished
B. Dress and signs of illness
C. Gender and age
D. Gait and posture
19) Which of the following is a clinical manifestation of Bell’s palsy?
A. Asymmetry of the mouth
B. Asymmetry of the entire side of the face
C. Asymmetry of the lower face
D. Involuntary movements of the face
20) The nurse notices that a client walks with a limp and has long legs. Which of the following aspects of the general survey is this nurse assessing?
A. Physical appearance
B. Behavior
C. Mental status
D. Mobility
21) Test for shifting dullness is performed to assess:
A. Liver abscess
B. Ascites
C. Cholecystitis
D. Peritonitis
22) When a nurse performing the eye examinations, which piece of equipment does she/he use to inspect the eye structures?
A. Ultrasonic stethoscope
B. Sphygmomanometer
C. Ophthalmoscope
D. Otoscope
23) The normal liver span of an adult is:
A. 7-12 cm
B. 5-12 cm
C. 6-12 cm
D. 4-12 cm
24) A client comes into the clinic for a routine breast and axilla exam. Which assessment technique does the nurse use first during this examination?
A. Palpation
B. Auscultation
C. Inspection
D. Percussion
25) The clinic is sponsoring a client education session for breast cancer awareness month. Which of the following considerations should be included to support cultural differences about breast health?
A. Refer all clients to the American Cancer Society if they have questions.
B. Inform all about the low-cost breast cancer screening program…
C. A:
D. Encourage all females to increase their intake of vitamins A and E
26) Grade +2 pitting edema is:
A. 4 mm deep
B. 6 mm deep
C. 2 mm deep
D. 8 mm deep
27) The nurse is going to assess a client’s blood pressure. To do this, the nurse will need to have:
A. A stethoscope and sphygmomanometer
B. A tongue blade and tuning fork
C. A flashlight and gloves
D. A stethoscope and thermometer
28) The clinic is sponsoring a client education session for breast cancer awareness month. Which of the following considerations should be included to support cultural differences about breast health?
A. Refer all clients to the American Cancer Society if they have questions.
B. Encourage all females to increase their intake of vitamins A and E.
C. Inform all about the low-cost breast cancer screening program.
D. Encourage all females to complete monthly breast exams
29) After auscultating the bowel sounds of a client, the nurse realizes the sounds were long. Which of the following would be appropriate for the nurse to use to document this finding?
A. Intensity
B. Pitch
C. Quality
D. Duration
30) During the physical assessment of Mr. Ahsan’s skin, the nurse observed that Mr. Ahsan’s skin color is pale, the nurse expect that Mr. Ahsan may has:
A. Jaundice
B. Anemia
C. Heart failure
D. Pulmonary edema
31) The nurse assesses a client’s vision to be 20/150. The client asks for an explanation of the numbers. Which of the following would be a correct explanation for the nurse to say to the client?
A. You might need surgery to correct the nystagmus
B. You see at 20 feet what a person with normal vision sees at 150 feet.
C. You see at 150 feet what a person with normal vision sees at 20 feet.
D. You have impaired vision
32) A nurse conducting an assessment on a client’s head would do what first?
A. Inspect and palpate hair
B. Look at patient’s prior medical history
C. Inspect and palpate scalp
D. Inspect and palpate sinuses to control spread of germs
33) The nurse is planning to assess the abdomen of an adult male.
A. Place the client in side-lying position
B. Ask client to empty bladder
C. Tell client to raise arms above the head
D. Ask client to hold his breath for a few seconds
34) Normal angle at nail base is:
A. 10 degrees
B. 160 degrees
C. 180 degrees
D. 30 degrees
35) When performing an ear assessment, the nurse notes tenderness of the pinna and tragus to movement and the presence of drainage in the external canal. The nurse suspects which of the following?
A. Otitis Media
B. Otitis Externa
C. An inner ear infection
D. A negative rmberg’s sign
36) The nurse asks the client to move his eyes in the shape of an H and then in a large X. The portion of the physical assessment the nurse is completing with this client is:
A. Assessing the optic nerve
B. Assessing extra ocular muscle movements
C. Assessing the eyelids
D. Assessing the red reflex
37) As the nurse introduces the otoscope into a client’s ear, the client starts to jerk his head and complains of pain. Which of the following should the nurse do?
A. Remove the otoscope and reinsert taking care not to touch the sides of the ear canal.
B. Begin to remove the embedded cerumen.
C. Instill ear drops.
D. Document “unable to complete the examination.
38) Which cranial nerve is affected by Bell’s palsy?
A. Facial (CN VII)
B. Trigeminal (CN V)
C. Vagus (X)
D. Abducens (CN VI)
39) In medical which term is used for “impaired near vision”?
A. Amblyopia
B. Myopia
C. Presbyopia
D. Diplopia
40) During the physical examination of a male client’s scrotum, the nurse palpates a mass. What should the nurse do next with this information?
A. Perform transillumination to further assess the finding.
B. Nothing. This is a normal finding.
C. Document mass palpated, left testicle.
D. Ask the client how long he’s had a tumor in his testicle.
41) During the breast exam, the nurse asks the client to raise her arms over her head. Why did the nurse change the client’s position?
A. The client has small breasts.
B. The client has large breasts.
C. The nurse couldn’t palpate the axillae correctly.
D. Skin dimpling is accented in this position

 

Health assessment MCQs

1) When doing an assessment on a client’s eyes the very first thing that a nurse should look at is?
A. Eye internal structures
B. Eye external structures
C. The pupils reactivity to light
D. Color of the irises of the eye

2) While the nurse is inspecting the throat of a client with a tongue blade, the client begins to gag. What does this response indicate to the nurse?
A. The client is nauseated.
B. The client has nerve damage to his tongue.
C. The client has a functioning response.
D. The client has a malfunctioning response

3) During the health history, a client begins to talk about her dog and the trouble she is having housebreaking the new pet. To help the client return to the health interview, the nurse could use the communication skill:
A. Listening
B. Reflecting
C. Questioning
D. Focusing

4) After inspecting a client’s abdomen, which assessment technique should the nurse use next ?
A. Light Palpation
B. Percussion
C. Auscultation
D. Deep Palpation

5) Nurse Tara asks her client Farhan to clench his jaw as she continues to palpate his head. When she asks him to do this what is Nurse Tara most likely trying to palpate?
A. Faran’s submandibular joint
B. Farhan’s submental joint
C. Farhan’s temporomandibular joint
D. Faran’s temporal artery

6) The nurse is planning to palpate a client’s bladder. Which area of the abdomen should this palpation be done?
A. Hypogastric region
B. Right hypochondriac region
C. Right Lower Quadrant
D. Left lumbar region

7) A 70-year-old male client comes into the clinic with weight loss and difficulty swallowing. Which of the following should the nurse document for this client?
A. Odynophagia
B. Bulimia
C. Dysphagia
D. Aphasia

8) A 15-year-old high school student came to the clinic with a 1-day history of nausea and anorexia. He describes the pain as generalized yesterday, but today it has localized to the right lower quadrant. You palpate the left lower quadrant and the patient experiences pain in the right lower quadrant. What is the name of this sign?
A. Murphy’s sign
B. Psoas sign
C. Grey Turner’s sign
D. Rovsing’s sign

9) During eye assessment when you asked the patient to follow your finger or pencil as you move it in toward the bridge of the nose. Which of the following test you are performing?
A. Visual acuity
B. Visual Fields by Confrontation
C. Test for convergence
D. Visual fields

10) A nurse doing her assessment proceeds to palpate a client’s frontal and maxillary sinuses. What should she make sure she checks for?
A. Tactile signs of carcinoma
B. Swelling
C. Lesions
D. Tenderness

11) A nurse would use either a Snelling chart or the finger wiggle test to assess a client’s what?
A. Hearing
B. Vision
C. Consensual light reflex
D. Bone conduction

12 ) During assessment of pharynx you as the client to say “Ah” and uvula and soft palate rise centrally. It determine the function of which cranial nerve:
A. Spinal accessory
B. Vagus
C. Trochlear
D. Trigeminal

13) During the assessment of a client, the nurse gently touches the tip of a sterile cotton swab in the client’s eye. Which of the following would be considered an expected response for the client to make?
A. Begin sneezing.
B. Blink.
C. Scream in pain.
D. Swat the nurse’s hand away.

14) If assessing a client for kidney tenderness, where would you begin?
A. External Oblique Angle
B. Left Upper Quadrant
C. Right Upper Quadrant
D. Costovertebral Angle

15) The three things a nurse needs to check for when doing an examination on the eyes regarding the external structures is?
A. Eyelash texture, shape of eyes, redness
B. Shape of eyes, pupils reactivity, iris’s color
C. Drainage, possible tumors, irritation
D. Eyelash distribution, coloring, drainage

16) A 40-year-old female came for evaluation of abdominal pain. She stated that it is worse after eating, especially if she has a meal that is spicy or high in fat. She has taken antacids, but they have not helped the pain. After examining her abdomen, you strongly suspect cholecystitis. Which sign on examination increases your suspicion for this diagnosis?
A. Murphy’s sign
B. Psoas sign
C. Grey Turner’s sign
D. Rovsing’s sign

17) During the percussion of a client’s abdomen, the nurse hears a loud high-pitched drum like tone. The nurse would document this sound as being:
A. Resonance
B. Tympany
C. Hyper-resonance
D. Flatness

18) What could the nurse assess based solely on the way the client walks into the room?
A. Signs of illness, well nourished
B. Dress and signs of illness
C. Gender and age
D. Gait and posture

19) Which of the following is a clinical manifestation of Bell’s palsy?
A. Asymmetry of the mouth
B. Asymmetry of the entire side of the face
C. Asymmetry of the lower face
D. Involuntary movements of the face

20) The nurse notices that a client walks with a limp and has long legs. Which of the following aspects of the general survey is this nurse assessing?
A. Physical appearance
B. Behavior
C. Mental status
D. Mobility

21) Test for shifting dullness is performed to assess:
A. Liver abscess
B. Ascites
C. Cholecystitis
D. Peritonitis

22) When a nurse performing the eye examinations, which piece of equipment does she/he use to inspect the eye structures?
A. Ultrasonic stethoscope
B. Sphygmomanometer
C. Ophthalmoscope
D. Otoscope

23) The normal liver span of an adult is:
A. 7-12 cm
B. 5-12 cm
C. 6-12 cm
D. 4-12 cm

24) A client comes into the clinic for a routine breast and axilla exam. Which assessment technique does the nurse use first during this examination?
A. Palpation
B. Auscultation
C. Inspection
D. Percussion

25) The clinic is sponsoring a client education session for breast cancer awareness month. Which of the following considerations should be included to support cultural differences about breast health?
A. a. Refer all clients to the American Cancer Society if they have questions.
B. b. Inform all about the low-cost breast cancer screening program…
C. A:
D. c. Encourage all females to increase their intake of vitamins A and E

26) Grade +2 pitting edema is:
A. 4 mm deep
B. 6 mm deep
C. 2 mm deep
D. 8 mm deep

27) The nurse is going to assess a client’s blood pressure. To do this, the nurse will need to have:
A. A stethoscope and sphygmomanometer
B. A tongue blade and tuning fork
C. A flashlight and gloves
D. A stethoscope and thermometer

28) The clinic is sponsoring a client education session for breast cancer awareness month. Which of the following considerations should be included to support cultural differences about breast health?
A. Refer all clients to the American Cancer Society if they have questions.
B. Encourage all females to increase their intake of vitamins A and E.
C. Inform all about the low-cost breast cancer screening program.
D. Encourage all females to complete monthly breast exams

29) After auscultating the bowel sounds of a client, the nurse realizes the sounds were long. Which of the following would be appropriate for the nurse to use to document this finding?
A. Intensity
B. Pitch
C. Quality
D. Duration

30) During the physical assessment of Mr. Ahsan’s skin, the nurse observed that Mr. Ahsan’s skin color is pale, the nurse expect that Mr. Ahsan may has:
A. Jaundice
B. Anemia
C. Heart failure
D. Pulmonary edema

31) The nurse assesses a client’s vision to be 20/150. The client asks for an explanation of the numbers. Which of the following would be a correct explanation for the nurse to say to the client?
A. You might need surgery to correct the nystagmus
B. You see at 20 feet what a person with normal vision sees at 150 feet.
C. You see at 150 feet what a person with normal vision sees at 20 feet.
D. You have impaired vision

32) A nurse conducting an assessment on a client’s head would do what first?
A. Inspect and palpate hair
B. Look at patient’s prior medical history
C. Inspect and palpate scalp
D. Inspect and palpate sinuses to control spread of germs

33) The nurse is planning to assess the abdomen of an adult male.
A. Place the client in side-lying position
B. Ask client to empty bladder
C. Tell client to raise arms above the head
D. Ask client to hold his breath for a few seconds

34) Normal angle at nail base is:
A. 10 degrees
B. 160 degrees
C. 180 degrees
D. 30 degrees

35) When performing an ear assessment, the nurse notes tenderness of the pinna and tragus to movement and the presence of drainage in the external canal. The nurse suspects which of the following?
A. Otitis Media
B. Otitis Externa
C. An inner ear infection
D. A negative rmberg’s sign

36) The nurse asks the client to move his eyes in the shape of an H and then in a large X. The portion of the physical assessment the nurse is completing with this client is:
A. Assessing the optic nerve
B. Assessing extra ocular muscle movements
C. Assessing the eyelids
D. Assessing the red reflex

37) As the nurse introduces the otoscope into a client’s ear, the client starts to jerk his head and complains of pain. Which of the following should the nurse do?
A. Remove the otoscope and reinsert taking care not to touch the sides of the ear canal.
B. Begin to remove the embedded cerumen.
C. Instill ear drops.
D. Document “unable to complete the examination.

38) Which cranial nerve is affected by Bell’s palsy?
A. Facial (CN VII)
B. Trigeminal (CN V)
C. Vagus (X)
D. Abducens (CN VI)

39) In medical which term is used for “impaired near vision”?
A. Amblyopia
B. Myopia
C. Presbyopia
D. Diplopia

40) During the physical examination of a male client’s scrotum, the nurse palpates a mass. What should the nurse do next with this information?
A. Perform transillumination to further assess the finding.
B. Nothing. This is a normal finding.
C. Document mass palpated, left testicle.
D. Ask the client how long he’s had a tumor in his testicle.

41) During the breast exam, the nurse asks the client to raise her arms over her head. Why did the nurse change the client’s position?
A. The client has small breasts.
B. The client has large breasts.
C. The nurse couldn’t palpate the axillae correctly.
D. Skin dimpling is accented in this position