Health Assessment Past Paper PDF

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds onto the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing: Objective vertigo. During an exam...

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds onto the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing: Objective vertigo. During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates: Tinnitus The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique? The best time to perform BSE is 4 to 7 days after the first day of the menstrual period. The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct? BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations. 1. The nurse is performing an otoscopic examination on an adult. Which of the following is true? Pull the pinna up and back before inserting the speculum.  1. In performing a voice test to assess hearing, which of the following would the nurse do? Whisper two-syllable words and ask the patient to repeat them. 2. In performing a voice test to assess hearing, which of the following would the nurse do? Stand about 4 feet away to ensure that the patient can really hear at this distance 3. Which of the following cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti? CN VIII 4. A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? Shorten the distance between the patient and the chart until the letters are seen, and record that distance. 5. A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: Hordeolum (stye) 6. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: stimulated by CNs III, IV, and VI 7. A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: The patient can read at 20 feet what a person with normal vision can read at 30 feet. 8. A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: Has poor vision. 9. When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: consider this a normal finding 10. The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: Ask the patient if he or she has a history of heart failure. 11. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? A pulsating mass is usually present. 12. When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? Spleen 13. Which of these statements is true regarding the arterial system? The arterial system is a high-pressure system. 14. The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease? Person who has been on bed rest for 4 days 15. A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: Claudication. 16. A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing: Problems related to arterial insufficiency. 17. During an assessment, the nurse uses the "profile sign" to detect: Early clubbing. 18. The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next? Consider this a delayed capillary refill time, and investigate further. 19. The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _____ pulse. Bounding 20. The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? To evaluate the adequacy of collateral circulation before cannulating the radial artery 21. A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? Brownish discoloration to the skin of the lower leg 22. When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulses: Paradoxus. 25. During an assessment the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse should expect a normal finding at this point would be: Venous filling within 15 second 26. During a clinic visit, a woman in her seventh month of pregnancy complains that her legs feel "heavy in the calf" and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins in her lower legs. Which condition is reflected by these findings? Varicose veins 27. The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? Normal 28. The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: Elevated pressure related to heart failure. 29. Mr. Worrigan is a 67-year-old patient who comes with his son to the ambulatory health centre. On examination of Mr. Worrigan, you note a pulsus alternans. This is associated with: heart failure. 30. The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the lobe. Frontal 31. 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 that is related to these findings would concern the nurse? Cerebellum 32. During the taking of the health history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this finding as: Vertigo 33. During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? Motor component of CN VII S 34. The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient Moves the head and shoulders against resistance with equal strength 35. When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: Positive Romberg sign. 36. The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? Dysfunction of the cerebellum 37. The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, What would the nurse suspect? Peripheral neuropathy 38. A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? Spastic hemiparesis 39. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)? Cerebrum 40. During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes May indicate disease of the cerebellum or brainstem. 41. The nurse is reviewing a patients medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? 6 42. The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patients toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as Positive Babinski sign, which is abnormal for adults. 43. The nurse is assessing a patient for carpal tunnel syndrome. Which test is appropriate for this condition? A) Phalen test 44. A patient states, “I can hear a crunching or grating sound when I kneel.” She also states that “it is very difficult to get out of bed in the morning because of stiffness and pain in my joints.” The nurse should assess for signs of what problem? Crepitation. 45. A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: Medial and lateral epicondyle. 46. When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: Proximal to distal 47. A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: The woman could be at increased risk for infection and lesions because of her chronic disease. 48. While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? Heart failure 49. During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: Ascites. 50. your client cannot feel the temperature of a hot over, which lobe could be dysfunctional? Parietal 51. The ballottement test indicated? Increase fluid in the joint. 52. What are the risk factors for venous stasis? Vein wall trauma, obesity, pregnancy, hypercoagulable states, varicose veins. 53. Which media diagnosis involves excessive secretion of adrenocorticotropic hormone? Cushing syndrome 54. The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to: hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. 55. When assessing muscle strength, the nurse observes that a patient has a complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? 5 56. The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should: suspect that the infant may have weakness of the shoulder muscles. 57.The nurse should use which test to check for large amounts of fluid around the patella? Ballottement 58. Cushing syndrome - moon face 59. When is the perfect time to perform a breast exam ? One week after menstruation end 45- 54 years old 61. When is the mcburney point located ? Right lower quadrant , which affects appendicitis 62. During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of Arterial ischemic ulcer. 63. A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. Intense, sharp pain, with the deep muscle tender to the touch Sudden onset Warm, red, and swollen calf 64. A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. Patient has a history of diabetes and cigarette smoking Skin of the patient is pale and cool. He states that the pain gets worse when walking. 65. Mrs. Lukianchuk is a 65-year-old patient who presents to the ambulatory health centre with a complaint of bilateral foot pain. On examination, you note delayed venous filling. This occurs with: arterial insufficiency. 67. Brawny edema is also known as? Non-pitting edema. 68. PT has Cushing disease and high cortisol levels. Which is the priority assessment? Daily weights. 69. your client cannot feel the temperature of a hot over, which lobe could be dysfunctional? Parietal 70. An ulcer with little/ no drainage, pale or necrotic granulation tissue, with a.. round appearance is most likely … arterial. 71. if a family member has a heart problem at a young age, your risk for it is? Increased by 50% 72. What are the risk factors for venous stasis? Vein wall trauma, obesity, pregnancy, hypercoagulable states, varicose veins. 73. pain, pallor, pulselessness, paraesthesia, poikilothermic, and paralysis are symptoms of Ans. Arterial insufficiency. 74. A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?" The nurse's response would be: "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life."