NUR 2092 HEALTH ASSESSMENT Final exam QUESTIONS WITH ANSWERS GRADED A 2023 LATEST UPDATED, Exams of Nursing

Download NUR 2092 HEALTH ASSESSMENT Final exam QUESTIONS WITH ANSWERS GRADED A 2023 LATEST UPDATED and more Exams Nursing in PDF only on Docsity! NUR 2092 HEALTH ASSESSMENT Final exam QUESTIONS WITH ANSWERS GRADED A 2023 LATEST UPDATED Question 1 1.5 out of 1.5 points When assessing a 2-3 year old child, what is important to consider? Answers: Assess least invasive to most invasive. Start with examining the ears and mouth. Make sure to examine the child lying on the exam table. It’s easier to examine the child if the The nurse palpates the left upper quadrant of abdomen with the knowledge that which organs are located in that area? Ans wer s : Liver and gallbladder. Pancreas and spleen Large intestine and liver Left ureter and gallbladder Question 4 1.5 out of 1.5 points Identify which reflex is being tested in this picture. Ans wer s : Plantar Patellar Triceps Achille’s Question 5 1.5 out of 1.5 points The clinic nurse assesses the skin of a white client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder? Ans wer s : Clear, thin nail beds Red-purple raised areas Oily skin and no episodes of pruritus Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions The nurse is preparing to complete a musculoskeletal examination on a client. Which two assessment techniques would the nurse plan to use during this exam? Ans wer s : Inspection and percussion Percussion and palpation Auscultation and percussion Inspection and palpation Question 8 1.5 out of 1.5 points While assessing edema on a client’s lower leg, the nurse notices a deep imprint of his fingers where the leg was palpated which takes several minutes to resolve. How would the nurse document this finding? Ans wer s : No edema 1+ edema 3+ edema 4+ edema Question 9 1.5 out of 1.5 points The nurse is performing an assessment on an older client having difficulty sleeping at night. Which statement indicates that teaching about improving sleep is necessary? Answers: "I drink hot chocolate before bed" Has any one ever touc hed you r geni tals and you did not wan t the m to? Question 12 1.5 out of 1.5 points "During a breast health interview, a client states that she has noticed pain in her left breast. The nurse s most appropriate response to this would be:" Answers: I would like some more information about the pain in your left breast. Don t worry about the pain; breast cancer is not painful. I would like some more information about the pain in your right breast. Breast pain is almost always the result of benign breast disease and so let s just ignore it. Question 13 0 out of 1.5 points The Glasgow Coma Scale is used to grade neurological responses to which three parameters? Ans wer s : Eye opening, verbal response, motor response Verbal response, pain response, reflexes Pupil response, motor response, reflexes : Reflexes Intelligence Cranial atrophy Thalmus function Question 16 1.5 out of 1.5 points An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: Ans wer s : of the shortening of the vertebral column. long bones tend to shorten with age. there is a significant loss of subcutaneous fat. there is a thickening of the intervertebral discs. Question 17 1.5 out of 1.5 points A client asks, “Why is touching my toes necessary? This is a sports physical examination not an exercise class.” How would the nurse reply? Ans wer s : “This is the best way to check for symmetry of your arms.” “I am looking at the stretch of your ham strings.” “This allows me to see how straight your spinal column is.” “It is considered abnormal if you can’t touch your toes from this position.” Question 18 1.5 out of 1.5 points Medication administration or procedural errors can be prevented by completing which task? Ans wer s : A client s respirations are 44. These respirations are considered to be which of the following? Ans wer s : Tachypneic Apneic Eupneic Bradypneic Question 21 1.5 out of 1.5 points The client complains of ringing, crackling or buzzing in the ear. Choose the best term. Answers Tinnitus : Tympanic Otitis media Pinna Question 22 1.5 out of 1.5 points Which data do nurses document under the category of Family Health History? Ans wer s : Present illness Allergies to medications Maternal Diseases Name and date of birth Question 23 0 out of 1.5 points The client has stiffness and fixation of a joint. Choose the correct term for this. Ans wer s : Contracture Ankylosis Dislocation Subluxation Ans wer s : Achilles Femoral Scapula Abdomen Question 27 1.5 out of 1.5 points What would the nurse ask in order to gain insight into a disabled client’s functional ability? Ans wer s : “When did the disability first begin?” “How has your disability affected your daily life?” “Why did you come to the clinic today?” “How do you feel about your disability?” Question 28 1.5 out of 1.5 points What is an example of objective data? Ans wer s : A client receiving chemotherapy complains of nausea. A client states that they are feeling very anxious about their tests A client with an inner ear infection complains of dizziness The skin of a client who has liver failure has a yellowish tint. Question 29 1.5 out of 1.5 points The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the clients peripheral response to pain? Ans wer s : Nail bed pressure Sternal rub Pressure on the orbital rim A client has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: Ans wer s : peritonitis. diarrhea. laxative use. gastroenteritis. Question 32 0 out of 1.5 points What activity would the nurse perform first when assessing a client’s urinary elimination status? Ans wers : Obtain a nursing history Interpret results of diagnostic tests Perform a physical examination Goal setting with the client. Question 33 1.5 out of 1.5 points An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is his primary caregiver. The nurse should assess for signs of caregiver burnout. What is a sign of this burnout? Ans wer s : Anxiety or depression Weight gain Hypertension Respiratory status Question 34 1.5 out of 1.5 points When assessing the range of motion of the client’s knee, the nurse expects the client to be able to perform which movement? Ans wer s : Flexion and extension Circumduction and external rotation Adduction and rotation join ts and muscles of each leg and compare the findings Question 37 1.5 out of 1.5 points The sac that surrounds and protects the heart is called the: Answers: Pericardium Myocardium Endocardium Pleural space Question 38 1.5 out of 1.5 points What does thoracic expansion assess? Ans wer s : Vibrations Voice sounds Breath sounds Chest movement Question 39 1.5 out of 1.5 points The nurse asks the client to puff out their cheeks and lift their eyebrows. Which cranial nerve is the nurse assessing? Ans wer s : Optic nerve, cranial nerve II Facial nerve, cranial nerve VII Trigeminal nerve, cranial nerve V Abducens nerve, cranial nerve VI Question 40 1.5 out of 1.5 points What is the meaning of the term PERRLA? Ans wer s : Vert ebral foramen Question 42 1.5 out of 1.5 points The nurse auscultates a blowing, swooshing sound of an area of abnormal blood flow. Choose the best term. Ans wer s : Dysphagia Macro cephalic Kinesthesia Bruit Question 43 0 out of 1.5 points The nurse has determined that the client’s bowel sounds are normal. What sounds did the nurse hear? Ans wer s : Loud, high pitched, rushing, and tinkling sounds Like two pieces of leather being rubbed together Rare bubbly or blowing sound High pitched, irregular gurgling sounds Question 44 1.5 out of 1.5 points A client is seen in the clinic for a routine blood pressure assessment and states they have been experiencing the normal pain associated with aging. Which statement by the nurse is most therapeutic? Ans wer s : “You must have osteoarthritis.” “Do you take medications for the discomforts you are experiencing?” “Normal aging can be quite painful.” “Tell me more about your pain and discomfort.” Question 45 1.5 out of 1.5 points pain assessment tool would be the best choice when assessing this child’s pain? Answers: Descriptor scale Numeric rating scale Brief pain inventory Faces pain scale Question 47 1.5 out of 1.5 points "The nurse notes that a client has had a black, tarry stool and recalls that a possible cause would be:" Ans wer s : gast roin testi nal blee ding gallbladder disease overuse of laxatives localized bleeding around the anus Question 48 1.5 out of 1.5 points Which of the following statements is true regarding the internal structures of the breast? Answers: "The breast is composed of fibrous, glandular, and adipose tissue." "The breast is mainly muscle, with very little fibrous tissue." "The breast is composed mostly of milk ducts, known as lactiferous ducts." The breast is composed of only glandular tissue. Question 49 Ans wer s : Colonoscopy Proctoscope Ultrasound A rectal exam with an examining finger Question 52 1.5 out of 1.5 points "During a health history of a patient who complains of chronic constipation, she asks the nurse about high-fiber foods. The nurse relates that an example of a high- fiber food would be:" Ans wer s : broccoli hamburger french fries white dinner roles Question 53 1.5 out of 1.5 points Which pulse site is typically used to obtain a pulse rate from a client? Ans wer s : Radial Temporal Posterior tibial Femoral Question 54 1.5 out of 1.5 points Chose the best term for the sound will the nurse will hear at the left midclavicular, fifth intercostal space? Ans wer s : Thrill Heave Apical Pulse The client complains of a sense that the room is spinning around. Choose the best term. Ans wer s : Disequilibrium Vertigo Presyncope Fixation Question 58 1.5 out of 1.5 points In which situation should the nurse screen for intimate partner violence (IPV)? Ans wer s : Wh en IPV is susp ected When a woman has an unexplained injury As a routine part of each health care encounter When a history of abuse in the family is known Question 59 0 out of 1.5 points What would the nurse expect to note when assessing a lesion diagnosed as malignant melanoma? Ans wer s : An asy mm etric blac k lesi on A sma ll pap ule with a dry, roug h scal e A patient states, “Whenever I open my mouth real wide, I feel this popping sensation in front of my ears.” How would the nurse further examine this complaint? Answers: Place the stethoscope over the temporomandibular joint, and listen for bruits. Place the hands over the client’s ears, and ask the client to open their mouth “really wide. ” Place one hand on the client’s forehead and the other on their jaw, and ask the client to try to open their mouth. Place a finger over each of the client’s temporomandibular joints, and ask the client to open and close their mouth. Question 63 1.5 out of 1.5 points A client has a normal pupillary light reflex. The nurse recognizes that this indicates that: Ans wer s : constriction of both pupils occurs in response to bright light the eyes converge to focus on the light ligh t is refl ected at the same spot in both eyes they focuses the image in the center of the pupil. Question 64 0 out of 1.5 points Which assessments would be appropriate for evaluating cerebellar function? (Select all that apply) Posi tive Ro mbe rg's sign Lac k of time and spac e. Pataxia Negative Homan's sign Question 67 1.5 out of 1.5 points A client tells the nurse, “I have to sleep propped up with 3 pillows so I can breathe at night.” How would the nurse document this? Ans wer s : Orthopnea. Acute Emphysema. Paroxysmal Nocturnal Dyspnea. Acu te Shortness of Breath Episode. Question 68 1.5 out of 1.5 points "During an annual physical exam, a 43- year-old client states that she doesn t perform monthly breast self- examinations. She tells the nurse that she believes that mammograms do a much better job than I ever could to find a lump. The nurse should explain to her that:" Answers: mammography may not detect all palpable lumps. breast self-examination is unnecessary until the age of 50 years. 0 out of 1.5 points On auscultating lung sounds in the adult client, the nurse documents which finding as normal? Ans wer s : Bronchial sounds heard over the trachea and larynx Bronchovesicular sounds heard over the majority of the lung fields posteriorly Vesicular sounds near the sternal border bilaterally Tracheal sounds over the periphery of the lung fields + Question 71 1.5 out of 1.5 points A nurse is inspecting the ear canal of an adult client. Which is the best method to move the pinna in order to straighten the ear canal to better visualize the area? Ans wer s : There is no need to move the pinna Gently pull the pinna up and back Gently pull the pinna down and back Pull the pinna horizontal to the side of the head Question 72 1.5 out of 1.5 points these respirations be documented? Ans wer s : Apneic Eupneic Tachypneic Bradypneic Question 75 1.5 out of 1.5 points The nurses assesses the posterior tibial pulse by lightly palpating in which location? Answers Behind the knee in the popliteal fossa : The inner aspect of the ankle below and slightly behind the medial malleolus Over the dorsum of the foot between the extensor tendon of the 1st and 2nd toe The outer aspect of the ankle below and slightly behind the lateral malleolus Question 76 0 out of 1.5 points What risk factors for osteoporosis? Ans wer s : Smoking Steroid use Hea vy bone structure Being Caucasian Male gender Question 77 1.5 out of 1.5 points The nurse is assessing an adult who has a pulse rate of 180 beats/minute. Which condition would the nurse document? Ans wer s : Tachycardia Pulse amplitude What is the purpose of the side to side pattern used during respiratory assessment? Ans wer s : Prevent fatiguing the client Tightly organize the assessment Allow comparison of like areas of the lungs Conserve time Question 81 1.5 out of 1.5 points "A nurse notes that a client has ascites, which indicates that which of the following is present?" Ans wer s : Fluid Feces Flatus Fibroid tumors Question 82 0 out of 1.5 points What should the nurse do when there is difficulty eliciting a patellar reflex? Ans wer s : Stri ke the kne e hard er "W ork hist ory, hyp erte nsion, stress, age" "Personality type, high cholesterol, diabetes, intense exercise" "Sugar consumption, anorexia, diabetes, stress, high cholesterol" Question 85 0 out of 1.5 points The nurse is performing an abdominal assessment and inspects the skin on the abdomen. The nurse performs which assessment technique next? Ans wer s : Palpates the abdomen for size Palpates the liver at the right rib margin Listens to bowel sounds in all four quadrants Percusses the right lower abdominal quadrant Question 86 1.5 out of 1.5 points A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings? Ans wer s : Cerebellum Thalamus Brainstem Extrapyramidal tract Question 87 1.5 out of 1.5 points “I only have a few more questions to go, then I’ll leave you alone for a while. ” “Everyone has ups and downs in their marriage. What problems are you having?” “I see that you are upset. Is there something you’d like to discuss? Question 89 1.5 out of 1.5 points "During report, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to a/an:" Ans wers : enlarged liver. enlarged stomach distended bowels excessive diarrhea Question 90 0 out of 1.5 points On performing a spinal assessment on your client, it is noted that the left shoulder is higher than the right and the right hip is higher than the left. What might this be related to? Ans wer s : Kyphosis Lordosis Scoliosis Spondylosis Question 91 0 out of 1.5 points