Health Assessment 29 Questions and Answers

Answer Key 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. A, B, D A A B D C D B C A D A B D B C B C B B D C D A B D A C A 1. A nurse has completed the general survey of a client who has been transferred to the unit. The information gathered during the general survey primarily provides the nurse with which of the following? Select all that apply. A) An indication of the level of physical distress experienced by the client B) Clues about the overall health of the client C) A direct link to the client's medical diagnosis D) Indications about normal variations in the status of body systems E) Data relating to the patient's level of social support 2. A nurse is preparing to assess an adult client's body temperature. At which time of the day would the nurse expect to obtain the lowest body temperature? A) Early morning B) Early afternoon C) Late afternoon D) Late evening 3. The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first? A) Temperature B) Pulse C) Respiration D) Blood pressure 4. A nurse is reviewing a colleague's documentation of a client assessment. The nurse reads that the client's radial pulse was 2+. How should the nurse interpret this assessment finding? A) The client's radial pulse occluded easily. B) The client's radial pulse occluded with moderate pressure. C) The client's radial pulse occluded with very firm pressure. D) The client's radial pulse could not be manually occluded. 5. The nurse is conducting an assessment of an older adult client who has a diagnosis of chronic heart failure. How can the nurse best assess the effects of the client's stroke volume? A) Take the blood pressure while the client is standing. B) Measure the strength of the radial pulse. C) Add the radial pulse and the systolic blood pressure. D) Calculate the difference between the diastolic and systolic pressures. Page 1 6. A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the client's blood pressure reading in light of what principle? A) The client's blood pressure will be slightly highly than the client's norm. B) Position rarely affects the client's blood pressure. C) The client's blood pressure will be slightly lower than standing readings. D) There will be questionable accuracy of the blood pressure reading. 7. The nurse is completing an initial assessment of a client who is new to the ambulatory clinic. Before assessing the client's blood pressure, a nurse asks him what his usual blood pressure is. The nurse bases this action primarily on what rationale? A) It provides identifiable data about the client. B) It verifies the client's cardiac function. C) It assesses the client's distant memory recall. D) It indicates the client's involvement in his health care. 8. The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate? A) The cuff is wrapped loosely around the arm. B) The cuff is placed about 1 inch above the antecubital area. C) The bladder inside the cuff encircles 50% of the arm circumference. D) The nurse can fit three to four fingers under the inflated cuff. 9. Which of the following would be most important for the nurse to do when assessing a client's blood pressure? A) Palpate the pulsations of the ulnar artery. B) Hold the client's arm slightly flexed with palm down. C) Inflate the cuff 30 mm Hg above where the radial pulse disappears. D) Deflate the cuff about 5 mm Hg per second. 10. The nurse is auscultating a client's blood pressure and identifies the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds. This is known as which of the following? A) Auscultatory gap B) Korotkoff sounds C) Phase V D) Diastolic value Page 2 11. When assessing an older adult client with osteoporotic thinning and vertebral collapse, which of the following findings would the nurse expect to identify? A) Lordosis B) Increased arm swing C) Narrowed gait D) Kyphosis 12. A nurse observes the posture of a male client and finds him leaning forward and bracing himself while sitting on the exam table. Which of the following would the nurse most likely suspect? A) Chronic obstructive pulmonary disease B) Neurological deficit C) Metabolic disorder D) Vestibular disorder 13. The nurse is completing the general survey of a client and determines that the client's temperature is 102∞F. Which of the following would the nurse also expect to find? A) Weak, thready pulse B) Heart rate greater than 100 bpm C) Respiratory rate between 12 and 20 breaths/minute D) Diastolic blood pressure 10 mm Hg greater than normal 14. The nurse is completing the assessment of a client who takes a beta-adrenergic blocker and a diuretic. Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents? A) Noting a widened pulse pressure B) Asking whether the client is experiencing headaches C) Assessing for a rise in blood pressure when standing D) Evaluating for orthostatic hypotension 15. A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates correct technique for this assessment? A) Application of firm pressure on the wrist area along the side of the fifth digit B) Use of two middle fingers lightly applied to wrist area along the thumb side C) Use of the thumb and index finger applied to obliterate the wrist area along the thumb side D) Application of the bell of the stethoscope to the antecubital area of the upper extremity Page 3 16. The nurse is assessing the skin condition and color of an African-American client. Which of the following would the nurse document as an abnormal finding? A) Evenly distributed color B) Light to medium dark brown skin C) Ashen gray skin color D) Lack of visible pores 17. The nurse is admitting a client to surgical daycare and is assessing the client's vital signs. When obtaining the client's oral temperature, where should the nurse insert the thermometer? A) At the gum line between the check and tongue B) Deep in the posterior sublingual pocket C) On either side of the frenulum at gingival level D) Just past the teeth, below the tongue 18. An older adult client has been admitted to the medical unit after suffering an exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following should the nurse do to assess the depth of the client's respirations? A) Count the respirations for 30 seconds and multiply by 2. B) Place the client's arm across the chest while palpating the pulse. C) Observe the client's chest expansion bilaterally. D) Percuss the client's posterior thorax 19. Due to a change in the client's level of consciousness, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4∫F. Which finding would the nurse interpret as corresponding most closely to the client's previous temperature? A) 97.0∫F B) 97.4∫F C) 98.9∫F D) 99.4∫F 20. A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably “stooped” posture. How should the nurse best follow up this abnormal assessment finding? A) Facilitate a referral to the hospital's rheumatology department B) Perform a focused assessment of the client's musculoskeletal system C) Obtained a detailed family health history from the client D) Document the assessment finding and inform the anesthesiologist Page 4 21. A nurse is completing a general survey of a client's health and is beginning by measuring the client's vital signs. What assessment question constitutes the “fifth vital sign”? A) “Can you tell me the date and month?” B) “Can I check your oxygen saturation level?” C) “Are you experiencing any shortness of breath?” D) “Are you having any pain right now?” 22. An 84-year-old man has been admitted to the emergency department from an extended care facility. Facility staff suspect that the client has pneumonia, and his malaise, productive cough, shortness of breath, and adventitious breath sounds are consistent with this diagnosis. However, the nurse's assessment of the client's vital signs yields an oral temperature of 97.5∞F. How should the nurse best interpret this assessment finding? A) The client likely has a cardiac health problem, not a respiratory health problem. B) The client's signs and symptoms are related to hypothermia rather than infection. C) The client's normothermic temperature does not rule out the presence of an infection. D) The client's infection is no longer localized and has become systemic. 23. The nurse is performing an assessment of a hospital client at the beginning of a shift. When assessing the client's heart rate, the nurse will most likely palpate what artery? A) Femoral artery B) Aorta C) Ulnar artery D) Radial artery 24. The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure? A) 44 mm Hg B) 92 mm Hg C) 114 mm Hg D) 184 mm Hg Page 5 25. A nurse at an ambulatory clinic is preparing to begin the collection of objective assessment data from a female client. After meeting the client and bringing her into the examination room, what instruction should the nurse provide? A) “I'll get you to lay down flat on the exam table, please.” B) “Please have a seat on the edge of the exam table.” C) “I'll start the assessment with you standing up and then help you onto the table.” D) “Where would you like me to conduct your health assessment?” 26. The nurse has assisted a 74-year-old woman from a chair to the examination table during an assessment, and the nurse observes that the client moves particularly slowly and stiffly. The nurse should question the client regarding a possible history of what health problem? A) Rhabdomyolysis B) Diabetes C) Kyphosis D) Arthritis 27. A community health nurse is conducting a home visit to a client who requires wound care. The nurse observes that the client is diaphoretic and wishes to measure the client's temperature. The nurse asks if the client has a thermometer in her home, and she states that she owns an “ear thermometer.” What principle should guide the nurse's use of a tympanic thermometer? A) Tympanic temperature is slightly higher than oral temperature. B) Tympanic temperature is only used if all other methods are unavailable. C) Tympanic temperature varies more widely than oral, rectal, and axillary temperatures. D) In adults, tympanic temperature is equal to axillary temperature. 28. The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. How should the nurse respond to this assessment finding? A) Call a code blue from the bedside and prepare for resuscitation. B) Assess the client's jugular venous pressure. C) Assess the client's pulse at the carotid site. D) Palpate the client's femoral pulse. Page 6 29. The nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding? A) Auscultate the client's apical pulse. B) Palpate the client's ulnar pulse. C) Administer a dose of nitroglycerin. D) Reposition the client in a side-lying position. Page 7