Health Assessment Exam 2

1- When assessing the abdomen, the nurse performs the following examination techniques. In which sequence should the nurse complete the assessment? Place the answers in the correct order. A) Auscultation B) Palpation C) Inspection D) Percussion Ans: Inspection Auscultation Palpation Percussion 2- When assessing the client's abdomen, the nurse should position the client in which of the following positions? A) supine with pillow under head B) supine with pillow under knees and head C) sitting with head upright at 90 degree angle D) standing with feet slightly apart 3- During assessment of abdomen, the nurse would perform which maneuver to palpate the spleen? A) lift client with right hand under rib cage and palpate the right upper quadrant with the left hand B) lift client with left hand under rib cage and palpate the left upper quadrant with right hand C) palpate for pulsations by placing a hand below xiphoid process D) palpate for rebound tenderness by pressing into abdomen with steady pressure while asking if client is experiencing pain. 4- During when percussing the liver, the nurse would expect to document which of the following findings? A) Resonance B) Tympany C) Dullness D) Hyperresonance 5- During inspection of the abdomen, the nurse notes silvery, shiny stretch marks. The nurse would document this finding as which of the following? A) shadows B) scars C) ascites D) striae 6- The nurse finds ascites during assessment of the abdomen. The nurse would conclude that this is most likely associated with which of the following health problems? A) overhydration B) cirrhosis C) a mass D) trauma 7- While performing a head-to-toe assessment of a client the nurse hears dullness over the left upper quadrant during percussion. what would be the next assessment the nurse should perform? A) inspection of area B) palpation of area C) Auscultation of entire abdomen D) inspection of respiratory excursion 8- During the assessment of the abdomen, the nurse would perform which maneuver to palpate the liver? A) Lift the client with the right hand under the rib cage and palpate the right upper quadrant with the left hand. B) Lift the client with the left hand under the rib cage and palpate the left upper quadrant with the right hand C) Palpate for pulsations by placing as hand below the xiphoid process. D) Palpate for rebound tenderness by pressing into the abdomen with steady pressure while asking if the client experiencing pain. 9- During a gastrointestinal assessment the client tells the nurse about experiencing chronic flatulence. which question should the nurse ask the client next? A) are you eating large amounts of broccoli and cauliflower? B) are you consuming bread products? C) is fish a staple in your diet? D) do you consume two quarts of water per day? 10- The client is vomiting fecal-like material the nurse would expect to prepare the client for diagnostic testing to evaluate the client for which health problem? A) appendicitis B) diarrhea C) intestinal obstruction D) a disorder of throat 11- During a peripheral vascular assessment the nurse finds a bluish tinge on the client's lip, fingers, and toes. What is the appropriate documentation for this finding? A) Central cyanosis B) Peripheral cyanosis C) Central and peripheral cyanosis D) Cyanosis 12- The nurse is testing a client for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. The client tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse performing on this patient? A) Ballottement B) Tinel’s C) McMurray’s D) Phalen’s 13- When assessing a client's strength, it is necessary to implement what assessment? a) Compare one side to the other b) Compare upper and lower extremities c) Assess upper and lower extremities at the same time d) Assess the extremities at the same time 14- What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor? a) Abduction b) Extension c) Flexion d) Rotation 15- The nurse instructs the client to raise his arm out to the side and overhead. The nurse is asking the client to adduct his arm. A) TRUE B) FALSE 16- The nurse is assessing a client with joint pain and is trying to decide whether it is inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process? A) Tenderness B) Ecchymosis C) Cool temperature D) Nodules 17- What finding should a nurse expect when performing the Phalen's test on a client with suspected carpal tunnel syndrome? A) Inability to perform active range of motion with the involved wrist B) A change in the color of the fingers from red to white (pale) C) Reports of tingling, numbness, and pain in the involved wrist D) Stiffness in the hands and fingers after holding and releasing a tight fist 18- A nurse is inspecting a client's gait. Which of the following would indicate an abnormal finding? A) Weight is evenly distributed B) Arms swing in opposition C) Toes point out D) Posture is erect 19- While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for a) ganglion cyst. b) carpal tunnel syndrome. c) arthritis. d) nerve damage. 20- A client has uneven height of the shoulders and hips. What should the nurse suspect this client is demonstrating? A) Kyphosis B) Scoliosis C) Sacroiliitis D) Lordosis 21- While assessing the range of motion in an adult client's shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. The nurse plans to refer the client to a physician for possible A) tendonitis. B) rotator cuff tear C) nerve damage. D) cervical disc degeneration. 22- To determine alleviating factors for symptoms of a musculoskeletal injury, it is essential that the nurse ask the client which questions? A) when were you injured? B) how were you injured? C) have you been able to carry out your regular activities? D) have you used over the counter medications? 23- When performing an assessment of the client presenting with a musculoskeletal problem, which action should the nurse take first? A) palpate area that is the source of the problem B) inspect area of pain or inflammation C) assess range of motion to determine the extent of the area involved D) palpate area to determine the presence of pulses and edema 24- What action would the nurse take to examine the temporomandibular joint? A) have the client open and close mouth while palpating joint in front of tragus B) assess function of cranial nerve II C) have client shrug shoulders and observe for symmetry D) have client lift arms and observe for symmetry 25- When testing range of motion of a client's shoulders, the nurse hears a grating sound. the nurse should document which of the following assessment findings? A) clicking B) crepitus C) strain D) sprain 26- The client reports shoulder pain without palpation or movement. the nurse should evaluate the client further for which health problem? A) strain B) sprain C) cardiac problem D) rotator cuff tear 27- The nurse has assessed the client's shoulder strength and finds that the client has full resistance and range of motion. the nurse should document this finding with which of the following ratings? A) normal (5) B) good (4) C) fair (3) D) poor (2) 28- The nurse palpates a round, fluid-filled cyst on the dorsum of the wrist. The nurse interprets this finding as consistent which of the following? A) Carpal Tunnel Syndrome B) A ganglion C) Rheumatoid Arthritis D) Crepitus 29- The nurse is assessing the client's knee for ballottement. after having the client lie supine with the leg in extension, the nurse should take which action? A) grasp the thigh above the knee and push fluid in the suprapatellar bursa to move between the femur and patella. 30- The nurse is examining the spine of a client who is experiencing an extreme curvature of the lumbar area how should the nurse document this finding? A) kyphosis B) scoliosis C) lordosis D) A list 31- The nurse is examining an elderly client and notes an exaggerated curvature at the thoracic spine. the nurse should document this finding as which of the following? A) scoliosis B) kyphosis C) lordosis D) tendonitis 32- To detect a small amount of fluid in the supra patellar bursa the nurse should perform which action to elicit the bulge sign? A) place client supine and stroke medial aspect of knee, applying pressure to the lateral aspect of the knee and observing the medial aspect for fluid B) place client supine and stroke lateral aspect of knee and observe lateral aspect for fluid. C) squeeze thigh with fingers and thumb and observe fluid in suprapatellar bursa move between the patella and femur. D) squeeze quadriceps muscle and palpate bursa. 33- The client has a history of gouty arthritis and reports pain and swelling of elbow. the nurse concludes that these manifestations are consistent with which disorder? A) osteoarthritis B) olecranon bursitis C) rheumatoid arthritis D) ulnar deviation 34- The nurse is teaching the client about manifestations of gout. the nurse evaluates that the client understands he instruction when the client states which of the following as symptoms of gout? A) synovial effusion and pain in small toe B) inflammation and pain of bursa C) tophi, erythema, pain and edema D) adducted great toe and pain 35- To test cranial nerve V the nurse would have the client engage in which activity. A) open and close mouth, push out lower jaw and move it side to side B) smile and then return the face to a normal position C) read a magazine held at fourteen inches from face D) shrug shoulders and then allow them to relax to normal position 36- The adult client presents to the ambulatory care clinic with reports of not being able to chew and swallow easily. the nurse should evaluate the client for which possible contributing factor? A) bloating B) missing teeth or ill-fitting dentures C) GI bleeding D) pain 37- The nurse is assessing a child and notes a protruding umbilicus. How would she document this finding? A) A round abdomen B) Ascites C) A hernia D) A central Striae 38- When assessing the abdomen, the nurse would expect to auscultate which sound? A) high-pitched gurgling B) low-pitched rumbling C) bruits D) friction rubs 39- When auscultating abdomen of adult client, the nurse is unable to hear bowel sounds. for how many minutes should the nurse listen to each quadrant of abdomen? A) 1 minute B) 2 minutes C) 3 minutes D) 5 minutes 40- The nurse performing a cardiovascular assessment observes splinter hemorrhages. The nurse should evaluate this client for which of the following? A) Endocarditis