Nursing Assessment Quiz
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Questions and Answers

What is the most appropriate action for assessing the femoral pulse in an obese patient?

  • Ask the patient to bend his or her knees to the side in a froglike position. (correct)
  • Have the patient assume a prone position.
  • Press firmly against the bone with the patient in a semi-Fowler position.
  • Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.
  • What sound indicates arterial flow when using a Doppler ultrasonic stethoscope?

  • Swishing, whooshing sound (correct)
  • Steady, even, flowing sound
  • Low humming sound
  • Regular 'lub, dub' pattern
  • What does a '2+' reading of the radial pulse indicate?

  • Normal (correct)
  • Weak
  • Absent
  • Bounding
  • Which statement best describes the purpose of a functional assessment?

    <p>It helps to determine how a person is managing day-to-day activities.</p> Signup and view all the answers

    During a functional assessment on an 82-year-old patient who recently had a stroke, which question would be most important to ask?

    <p>Are you able to dress yourself?</p> Signup and view all the answers

    Which questions are appropriate to ask the parents during a developmental history for a 5-year-old child? (Select all that apply)

    <p>Is he able to tie his shoelaces?</p> Signup and view all the answers

    During an examination, the nurse can assess mental status by which activity?

    <p>Observing the patient and inferring health or dysfunction</p> Signup and view all the answers

    As the nurse begins the mental status portion of an assessment on a 75-year-old man, what should the nurse expect?

    <p>May take a little longer to respond, but his general knowledge and abilities should not have declined.</p> Signup and view all the answers

    Which statement is true regarding the mental status examination?

    <p>It is usually sufficient to gather mental status information during the health history interview.</p> Signup and view all the answers

    Which question should the nurse ask to assess a patient's affect during a mental status examination?

    <p>How do you feel today?</p> Signup and view all the answers

    Which question by the nurse best assesses a person's judgment during a mental status assessment?

    <p>Tell me about what you plan to do once you are discharged from the hospital.</p> Signup and view all the answers

    Which statement about the assessment of mental status is true?

    <p>Mental status functioning is inferred through assessment of an individual's behaviors.</p> Signup and view all the answers

    When performing a physical assessment, which technique will the nurse always use first?

    <p>Inspection.</p> Signup and view all the answers

    What is the best technique to assess a patient's skin temperature?

    <p>Dorsal surface of the hand because the skin is thinner than on the palms.</p> Signup and view all the answers

    How should the nurse proceed when preparing to assess a patient's abdomen by palpation?

    <p>Start with light palpation to detect surface characteristics.</p> Signup and view all the answers

    In which situation would the nurse use bimanual palpation technique?

    <p>Palpating the kidneys and uterus.</p> Signup and view all the answers

    When percussing over the liver, a nurse notices a dull sound. What should the nurse consider?

    <p>Consider this a normal finding.</p> Signup and view all the answers

    What is the best action if the nurse is unable to palpate the right radial pulse on a patient?

    <p>Use a Doppler device to check for pulsations.</p> Signup and view all the answers

    Which statement describes the most appropriate action a nurse should take when performing a physical examination?

    <p>Wash hands before and after every physical patient encounter.</p> Signup and view all the answers

    When should the nurse elicit the Moro reflex during an infant examination?

    <p>At the end of the examination.</p> Signup and view all the answers

    What should the nurse do first when examining a 6-month-old infant who is sleeping?

    <p>Auscultate the lungs and heart while the infant is still sleeping.</p> Signup and view all the answers

    Which assessment findings would be considered normal for an 80-year-old male patient?

    <p>The presence of kyphosis and flexion in the knees and hips.</p> Signup and view all the answers

    Regarding the strength of a pulse, the nurse recalls that it:

    <p>Is a reflection of the heart's stroke volume.</p> Signup and view all the answers

    Which question should the nurse ask to assess the quality of a patient's pain?

    <p>What does your pain feel like?</p> Signup and view all the answers

    What concern exists regarding the nutritional status of a 68-year-old woman complaining of constipation?

    <p>The absorption of nutrients may be impaired.</p> Signup and view all the answers

    Why is it important for the nurse to ask a patient about medications during a nutritional assessment?

    <p>Certain drugs can affect the metabolism of nutrients.</p> Signup and view all the answers

    Which factor is most likely to affect the nutritional status of an elderly person?

    <p>Living alone on a fixed income.</p> Signup and view all the answers

    What type of hearing loss occurs with aging?

    <p>Presbycusis</p> Signup and view all the answers

    What symptom indicates tinnitus?

    <p>Tinnitus</p> Signup and view all the answers

    Which changes in hearing occur with aging? (Select all that apply)

    <p>The aging person may find it harder to hear consonants than vowels</p> Signup and view all the answers

    The left lung consists of how many lobes?

    <p>Two</p> Signup and view all the answers

    What are expected assessment findings in a normal adult lung? (Select all that apply)

    <p>Muffled voice sounds and symmetrical tactile fremitus</p> Signup and view all the answers

    What should the nurse assess for when a patient reports being awakened from sleep with shortness of breath?

    <p>Assess for other signs of paroxysmal nocturnal dyspnea</p> Signup and view all the answers

    Where is tactile fremitus felt most intensely?

    <p>Between the scapulae</p> Signup and view all the answers

    What causes tactile fremitus?

    <p>Sounds generated from the larynx</p> Signup and view all the answers

    Which statement is true regarding note-taking during an interview?

    <p>Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.</p> Signup and view all the answers

    What type of breath sounds are normally heard over the posterior lower lobes?

    <p>Vesicular breath sounds</p> Signup and view all the answers

    What does dullness in percussion indicate?

    <p>Abnormal lung density</p> Signup and view all the answers

    Which verbal skill is used when the nurse states, 'You mentioned shortness of breath. Tell me more about that'?

    <p>Open-ended question</p> Signup and view all the answers

    The question, 'You don't smoke, drink, or take drugs, do you?' is an example of:

    <p>Using biased or leading questions.</p> Signup and view all the answers

    What indicates fine crackles in auscultation?

    <p>The immediate newborn period</p> Signup and view all the answers

    If bronchophony is present, what condition should the nurse assess for?

    <p>Pulmonary consolidation</p> Signup and view all the answers

    What does a change in a parent's posture from an open position to a closed position suggest?

    <p>Uncomfortable talking about his son's treatment.</p> Signup and view all the answers

    What technique would be most beneficial in communicating with a patient with a hearing impairment?

    <p>Determine the communication method he prefers.</p> Signup and view all the answers

    What adventitious sound is produced by air passing through narrowed bronchioles?

    <p>Wheezes</p> Signup and view all the answers

    Which interpreter choice is the most appropriate for a female patient who does not speak English well?

    <p>A trained interpreter</p> Signup and view all the answers

    What indicates asthma based on assessment findings?

    <p>Wheezing with difficulty breathing during yard work</p> Signup and view all the answers

    Which statements regarding open-ended questions are true? (Select all that apply)

    <p>They build and enhance rapport.</p> Signup and view all the answers

    How should a nurse auscultate breath sounds?

    <p>Listen at each location for one full respiration</p> Signup and view all the answers

    What is the best use of a computer during an interview in an outpatient clinic?

    <p>Collect the patient's data in a direct, face-to-face manner.</p> Signup and view all the answers

    What does the coarse, crackling sensation over the skin indicate?

    <p>Crepitus</p> Signup and view all the answers

    What indicates atelectatic crackles?

    <p>They stop after a few breaths</p> Signup and view all the answers

    What action is appropriate when the nurse notices a patient handling a small charm?

    <p>Ask the patient about the item and its significance.</p> Signup and view all the answers

    How do many Mexican-Americans perceive coughing, sweating, and diarrhea?

    <p>As a part of normal living.</p> Signup and view all the answers

    Which normal finding indicates that voice sounds are muffled during assessment?

    <p>Normal voice sounds clearly distinguished</p> Signup and view all the answers

    What does a blowing, swishing sound over the carotid artery indicate?

    <p>Blood flow turbulence</p> Signup and view all the answers

    In Asian cultures, what does the yin/yang theory reflect?

    <p>All aspects of the person are in perfect balance.</p> Signup and view all the answers

    What is the likely belief of an individual with a magicoreligious perspective on illness?

    <p>Illness was caused by supernatural forces.</p> Signup and view all the answers

    Where is the apical impulse normally palpated?

    <p>Fifth left intercostal space at the midclavicular line</p> Signup and view all the answers

    What is the correct technique for auscultating heart sounds?

    <p>Inch the stethoscope from the base to the apex in a Z pattern</p> Signup and view all the answers

    When seeking help with diabetes, what might an American Indian consider?

    <p>May also seek assistance from a shaman or medicine man.</p> Signup and view all the answers

    What would a culturally sensitive nurse do for a Mexican-American woman with traditional beliefs?

    <p>Further assess cultural beliefs and offer assistance.</p> Signup and view all the answers

    Regarding the apical impulse, which statement is true?

    <p>Its location may be indicative of heart size</p> Signup and view all the answers

    Which statement is true regarding pain?

    <p>Patients vary in their perceptions and expressions of pain.</p> Signup and view all the answers

    What normal physiologic change is associated with aging?

    <p>Peripheral blood vessels growing more rigid</p> Signup and view all the answers

    What does the 'profile sign' help detect?

    <p>Early clubbing</p> Signup and view all the answers

    Why might working with children from different cultural perspectives be challenging?

    <p>Children have spiritual needs influenced by development.</p> Signup and view all the answers

    If the ulnar pulses are not palpable but capillary refill is normal, what should the nurse do next?

    <p>Consider this a normal finding</p> Signup and view all the answers

    What is the most appropriate question to assess cultural beliefs with an elderly American Indian patient?

    <p>What cultural or spiritual beliefs are important to you?</p> Signup and view all the answers

    What component should be included in a cultural assessment?

    <p>Health-related beliefs</p> Signup and view all the answers

    When evaluating the reliability of a patient's responses, which statement is correct?

    <p>Provided consistent information and is therefore reliable.</p> Signup and view all the answers

    What note would be most accurate for a patient denying childhood illnesses?

    <p>Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.</p> Signup and view all the answers

    What would be an appropriate response to a mother regarding her child's earache?

    <p>Please describe what she is doing to indicate she is having pain.</p> Signup and view all the answers

    What information should the nurse collect before a 5-year-old's tonsil procedure?

    <p>Reactions to previous hospitalizations</p> Signup and view all the answers

    When evaluating the mid-upper arm circumference and triceps skinfold of an 82-year-old man, which is important for the nurse to remember?

    <p>These measurements may not be accurate because of changes in skin and fat distribution.</p> Signup and view all the answers

    The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true?

    <p>Height measurements may not be accurate because of changes in bone.</p> Signup and view all the answers

    The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include:

    <p>Slowed gastrointestinal motility.</p> Signup and view all the answers

    The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's:

    <p>Circulatory status.</p> Signup and view all the answers

    A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. What additional finding would the nurse be concerned with?

    <p>Color variation.</p> Signup and view all the answers

    An elderly woman is brought to the emergency department after being found lying on the kitchen floor for 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination?

    <p>Dry mucous membranes and cracked lips.</p> Signup and view all the answers

    A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?

    <p>Clubbing of the nails.</p> Signup and view all the answers

    The nurse has discovered decreased skin turgor in a patient. This is an expected finding in which of these conditions?

    <p>Severe dehydration.</p> Signup and view all the answers

    A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. The nurse would:

    <p>Refer the patient because of the suspicion of melanoma on the basis of her symptoms.</p> Signup and view all the answers

    The nurse is assessing for clubbing of the fingernails and would expect to find:

    <p>An angle of the nail base of 180 degrees or greater with a nail base that feels spongy.</p> Signup and view all the answers

    A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails?

    <p>Pitting.</p> Signup and view all the answers

    The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?

    <p>Tachycardia.</p> Signup and view all the answers

    During an examination, what assessment finding would Paget's disease indicate?

    <p>Headache, vertigo, tinnitus, and deafness.</p> Signup and view all the answers

    A woman comes to the clinic with puffy eyes, coarse dry hair and eyebrows. The nurse will assess for signs of:

    <p>Myxedema.</p> Signup and view all the answers

    The physician reports that a patient with a neck tumor has a tracheal shift. What does this indicate?

    <p>Pushed to the unaffected side.</p> Signup and view all the answers

    During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. What condition does this suggest?

    <p>Dehydration.</p> Signup and view all the answers

    The nurse is performing an assessment on a 7-year-old child with symptoms of chronic allergies. What characteristic findings might be observed?

    <p>A transverse line across the bridge of the nose.</p> Signup and view all the answers

    A mother asks when her newborn infant's eyesight will be developed. What should the nurse reply?

    <p>By about 3 months, infants develop more coordinated eye movements and can fixate on an object.</p> Signup and view all the answers

    During an eye assessment on an 80-year-old patient, which finding is considered abnormal?

    <p>Unequal pupillary constriction in response to light.</p> Signup and view all the answers

    The nurse notices periorbital edema when assessing a 70-year-old patient. What should the nurse do next?

    <p>Ask the patient if he or she has a history of heart failure.</p> Signup and view all the answers

    After a boxing match, a patient presents with a swollen eye and concerns about possible retinal damage. What are signs of retinal detachment?

    <p>Shadow or diminished vision in one quadrant or one half of the visual field.</p> Signup and view all the answers

    A 68-year-old woman struggles with reading and has some loss of central vision. What does this suggest?

    <p>She may have macular degeneration.</p> Signup and view all the answers

    An ophthalmic examination reveals papilledema. What does this finding indicate?

    <p>Increased intracranial pressure.</p> Signup and view all the answers

    During an examination, a patient states she was diagnosed with open-angle glaucoma 2 years ago. Which characteristics should the nurse assess?

    <p>Vision loss begins with peripheral vision.</p> Signup and view all the answers

    The nurse is taking the history of a patient who may have a perforated eardrum. What is an important question to ask?

    <p>Was there any relationship between the ear pain and the discharge you mentioned?</p> Signup and view all the answers

    During an ear examination of an 80-year-old patient, which finding would be considered normal?

    <p>A high-tone frequency loss.</p> Signup and view all the answers

    Study Notes

    Note-Taking in Nursing Interviews

    • Note-taking can disrupt the observation of patients' nonverbal cues and their narrative flow.
    • It is important to maintain eye contact and focus on the patient to enhance their sense of importance.

    Verbal Skills in Health Assessments

    • Open-ended questions are used to encourage detailed responses from patients about specific issues, facilitating in-depth exploration of topics.

    Question Bias in Health History

    • Leading questions can influence patient responses, potentially forcing them to conform to perceived expectations.

    Nonverbal Cues in Parent-Child Interviews

    • Changes in posture, such as crossing arms, may indicate discomfort with the topic being discussed, signaling a need for sensitivity in the conversation.

    Communicating with Hearing-Impaired Patients

    • It's essential to understand preferred communication methods, such as sign language or lip reading, to ensure effective interaction.

    Language Barriers in Assessments

    • Utilize simple language free from medical jargon when questioning patients with language barriers, focusing on direct and clear inquiries.

    Choosing an Interpreter

    • Prioritize trained interpreters who are familiar with medical terminology for effective communication with patients who have language difficulties.

    Utilization of Open-Ended Questions

    • Open-ended questions enhance patient self-expression and build rapport, leading to richer narrative responses.

    Efficient Use of Technology in Interviews

    • Data should be recorded after fully exploring a patient’s narrative to avoid distractions and maintain engagement; the patient should be able to see the monitor to promote transparency.

    Cultural Significance of Personal Items

    • Inquire about meaningful objects, like charms, to understand their cultural significance and enhance the therapeutic relationship.

    Cultural Perspectives on Health

    • Recognize that beliefs about symptoms may differ across cultures, with some viewing certain symptoms as normal rather than indicative of illness.

    Yin/Yang Beliefs and Health

    • Health in cultures embracing the yin/yang philosophy is perceived as a balance of all aspects of life, focusing on holistic well-being.

    Magicoreligious Perspective on Illness

    • Illness is often viewed as a consequence of supernatural forces rather than biological factors.

    Seeking Holistic Healing

    • Patients from diverse cultural backgrounds may seek additional support from traditional healers, highlighting the need for culturally competent care.

    Culturally Sensitive Nursing

    • Assess cultural beliefs of patients, respecting their preferences for spiritual and traditional healing methods in conjunction with biomedical care.

    Variability in Pain Perception

    • Pain expression varies by culture; nurses should anticipate different responses based on individual and cultural backgrounds.

    Spiritual Needs in Children

    • Children’s spiritual needs are influenced by their developmental stages and family context, necessitating sensitive handling during health assessments.

    Initiating Cultural Assessments

    • Open-ended questions about spiritual beliefs facilitate a better understanding of the cultural context that shapes a patient's health perspectives.

    Components of Cultural Assessment

    • Include health-related beliefs and practices as key components in a cultural assessment to personalize patient care.

    Evaluating Patient Reliability

    • A patient is deemed reliable if they consistently provide information, emphasizing the importance of careful evaluation in nursing assessments.

    Documenting Childhood Illnesses Accurately

    • Ensure accurate documentation of past illnesses by specifically naming conditions to avoid ambiguity in patient history.

    Addressing Pain in Children

    • Engage parents to describe signs of pain in very young children to obtain accurate assessments before clinical examination.

    Preoperative Assessments in Pediatric Patients

    • Reactions to past hospitalizations are crucial to tailor preparatory interventions for children undergoing procedures.

    Purpose of Functional Assessments

    • Functional assessments focus on how well individuals manage daily life, aiding in identification of support needs and care planning.

    Importance of Daily Activities Assessment in Elderly

    • Questions about daily activities, such as dressing, are vital in evaluating functional independence, especially after health events like strokes.

    Developmental History in Pediatric Assessments

    • Collecting appropriate developmental history aids in evaluating childhood milestones and identifying potential concerns.### Developmental Assessment Questions
    • Appropriate developmental questions include abilities like tying shoelaces and telling time.
    • Nutritional-related questions cover junk food intake and vitamins; food allergies are not part of developmental history.

    Mental Status Assessment Techniques

    • Mental status is assessed by observing behaviors, not direct examination like physical signs.
    • Age does not significantly affect general knowledge, but response time does slow.
    • Basic mental status information is often adequately gathered during health history interviews.

    Assessing Affect and Judgment

    • To assess affect, asking "How do you feel today?" is effective.
    • Assessing judgment can be done by inquiring about future plans post-discharge.

    Overall Mental Status Examination

    • Full mental status examinations may not be necessary; context from health history is often sufficient.
    • A dull sound during liver percussion is considered normal.
    • The best technique to check skin temperature is the dorsal surface of the hand.

    Palpation Techniques

    • Light palpation should be done first during abdominal assessments.
    • Bimanual palpation is appropriate for kidneys and uterus, while general tenderness should be evaluated last.

    Safety and Infection Control

    • Hand washing is crucial before and after every patient interaction to prevent infection transmission.

    Examination of Infants

    • The Moro reflex should be elicited at the examination's end as it may distress the infant.
    • Auscultation of respiratory systems is best done while the infant is asleep.

    Aging and Nutritional Assessment

    • Kyphosis and knee/hip flexion are normal postural changes in the elderly.
    • Living alone on a fixed income impacts elderly nutritional status.

    Anthropometric Measurements

    • Weight measures may be hard to interpret in older adults due to varied normal ranges.
    • Accurate height measurements might be challenging in elderly patients due to osteoporosis.

    Physiological Changes in the Elderly

    • Slowed gastrointestinal motility significantly affects nutritional status.
    • Changes in skin may provide insights into circulatory status.

    Skin Assessment and Danger Signs

    • Important signs for pigmented lesions include asymmetry, border irregularity, color variation, and diameter over 6 mm.
    • A patient with a bleeding, burning mole should raise concerns regarding color variation.

    Emergency Situations

    • In cases of extreme dehydration in elderly patients, thorough skin assessment is vital for identifying circulatory issues.### Dehydration and Mucous Membranes
    • Dry mucous membranes and cracked lips are signs of dehydration.
    • Dehydration results in parched lips and dry mucous membranes.

    Clubbing of Nails

    • Clubbing of the nails is associated with pulmonary diseases, including emphysema and bronchitis.
    • The nail base feels spongy, with an angle of 180 degrees or greater, indicating clubbing.

    Skin Turgor

    • Decreased skin turgor is typically an expected finding in severe dehydration.
    • Severe weight loss can also result in decreased skin turgor.

    Suspected Melanoma

    • Changes in a mole’s size, color, or texture, including itching, burning, and bleeding, warrant suspicion of melanoma.
    • The ABCD criteria for melanoma: Asymmetry, Border irregularity, Color variation, Diameter changes.

    Assessment Findings for Various Conditions

    • Decreased skin turgor indicates severe dehydration.
    • Paget's disease may result in symptoms such as headache, vertigo, tinnitus, and deafness.
    • Myxedema, associated with hypothyroidism, leads to puffiness and coarse hair.

    Tracheal Shift

    • A tracheal shift to the unaffected side can indicate conditions like an aortic aneurysm, tumor, or pneumothorax.

    Depressed Fontanels in Infants

    • Depressed and sunken fontanels suggest dehydration, not rickets or increased intracranial pressure.

    Chronic Allergy Symptoms

    • Chronic allergies may show signs like a transverse nasal crease, dark shadows under the eyes, and changes in eyelid creasing.

    Infant Eye Development

    • By 3 months, infants typically develop coordinated eye movements and can fixate on objects.

    Normal Findings in Aging Eyes

    • Unequal pupillary responses to light in an elderly patient is abnormal; constriction should still be symmetric.

    Periorbital Edema

    • Periorbital edema in older adults may indicate systemic issues such as heart failure or renal failures, rather than infections like blepharitis.

    Retinal Detachment Signs

    • Shadowing or diminished vision, particularly in one quadrant, indicates potential retinal detachment.

    Macular Degeneration Indicators

    • Loss of central vision with intact peripheral vision suggests the possibility of macular degeneration, a common cause of blindness.

    Papilledema

    • Papilledema is indicative of increased intracranial pressure; it’s characterized by optic disc elevation and blurred margins.

    Open-Angle Glaucoma Characteristics

    • Open-angle glaucoma typically has few symptoms; vision loss begins in peripheral vision and can lead to tunnel vision in late stages.

    Perforated Eardrum Inquiry

    • Assessing the relationship between ear pain and discharge is crucial for diagnosing a suspected perforated eardrum.

    Normal Ear Examination Findings in Older Adults

    • High-tone frequency loss is common in older adults; the eardrum may appear thicker and more opaque with age.

    Tinnitus Recognition

    • Tinnitus is the perception of ringing, buzzing, or crackling sounds in the ears, often associated with ear disorders.

    Tactile Fremitus Assessment

    • Tactile fremitus should feel most intense between the scapulae; pronounced alternate findings over the lung fields may indicate underlying issues.

    Palpable Vibrations

    • Tactile fremitus results from sounds from the larynx transmitted through the lungs to the chest wall; it is a clinical indicator of lung health.

    Vesicular Breath Sounds

    • Normal lung assessment reveals vesicular breath sounds over the posterior lower lobes, characterized by low-pitched, softer sounds with longer inspiration.

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    Test your knowledge on nursing assessments, focusing on techniques to evaluate the femoral pulse in patients with varying body types. This quiz will help reinforce appropriate nursing actions and considerations for effective patient care.

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