Health Assessment and Physical Examination

1. The position that maximizes the nurse’s ability to assess the client’s body for symmetry is:

1.
Sitting
2.
Supine
3.
Prone
4.
Dorsal recumbent

ANS: 1

Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts. The supine position maximizes the nurse’s ability to assess pulse sites. The prone position is used only to assess extension of the hip joint.

The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles.

PTS: 1 DIF: A REF: 559 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

2. When assessing the pallor of a client with dark skin, the nurse will specifically look at the:

1.
Buccal mucosa of the mouth
2.
Dorsal surface of the hands
3.
Ear lobe
4.
Sclera

ANS: 1

Pallor is more easily seen in the face, buccal mucosa of the mouth, conjunctiva, and nail beds. The palmar surface of the hands may be used to detect color hues in dark-skinned clients. The ear lobe is not a good site to assess for color changes, such as pallor, in a dark-skinned client. The best site to inspect for jaundice, not pallor, is the sclera.

PTS: 1 DIF: A REF: 567 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

3. A female client is seen in the outpatient clinic for numerous cuts, bruises, and apparent burns. In a discussion with the client, the nurse finds that the injuries are inconsistent with the stated cause. The client also states that she is having trouble sleeping, and she appears anxious. Based on these findings, the nurse suspects that the client may be experiencing:

1.
Substance abuse
2.
Domestic violence
3.
Vascular disease
4.
Mental illness

ANS: 2

Injuries and trauma that are inconsistent with the reported cause; multiple injuries including bruises, cuts, and burns; and behavioral findings of difficulty sleeping and appearing anxious are all indicators of possible domestic violence. The findings are not consistent with substance abuse. Indicators of substance abuse may include frequent missed appointments or emergency department visits, having a history of changing doctors, history of activities that place the client at risk for HIV infections, complaints of insomnia or chest pain, and a family history of addiction. People who abuse substances may have cuts, burns (especially of the fingers), needle marks, homemade tattoos, or increased vascularity of the face. These findings are not indicative of vascular disease. Symptoms of vascular disease may include edema, color changes of the lower extremities, and weakened pedal pulses. These findings are not indicative of mental illness. The client is coherent.

PTS: 1 DIF: C REF: 563 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

4. A client in the clinic has been having severe headaches and some visual disturbances. The nurse performs an eye examination. Which of the following is true concerning the procedure for this assessment?

1.
The red reflex should be assessed with the ophthalmoscope.
2.
To evaluate the lower eyelids, the nurse uses a syringe with sterile water.
3.
Accommodation is tested by asking the client to comply with the nurse’s requests.
4.
The lacrimal apparatus is assessed with a dull object to stimulate normal reflex conditions.

ANS: 1

To visualize internal eye structures, the nurse uses an ophthalmoscope to focus on the red reflex. To evaluate the lower eyelids, the nurse asks the client to open the eyes for inspection. A syringe and sterile water are not necessary for this assessment. Accommodation is tested by asking the client to gaze at a distant object and then at a test object held by the nurse approximately 10 cm from the client’s nose. The pupils normally converge and accommodate by constricting when looking at close objects. The lacrimal apparatus is best assessed by inspecting for edema and redness; and palpating it gently to detect tenderness, which cannot be felt normally.

PTS: 1 DIF: A OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

5. In preparing to conduct a physical examination on a client, the nurse plans to:

1.
Perform painful procedures at the end of the exam
2.
Take long, detailed notes of all the findings during the exam
3.
Keep the TV or radio on to distract the client throughout the exam
4.
Assess the dominant side of the client’s body only in the examination

ANS: 1

In organizing a physical examination, the nurse should perform painful procedures near the end of the examination. The nurse should record quick notes during the examination to avoid keeping the client waiting. Observations can be completed at the end of the examination. The TV or radio should be turned off so as to not distract the client throughout the examination, and to provide an environment conducive to auscultation.

Both sides of the body should be assessed for comparison to determine symmetry. A degree of asymmetry is normal in the dominant versus nondominant arm.

PTS: 1 DIF: A REF: 562 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

6. The client has an enlarged thyroid gland and is currently admitted to a medical nursing unit. Which of the following is accurate regarding the procedure for a thyroid assessment for this client?

1.
Deep palpation should be used anterior and posterior.
2.
Swallowing sips of water causes the isthmus of the thyroid gland to rise.
3.
The posterior approach is used when the fingers are placed over the trachea.
4.
The diaphragm of the stethoscope is best used for the auscultation of bruits.

ANS: 2

During assessment of the thyroid gland, the client holds a cup of water and takes a sip to swallow once instructed by the nurse. As the client swallows, the isthmus of the thyroid gland rises. The nurse should feel if it is enlarged. Normally the thyroid gland is small, smooth, and free of nodules. Light, gentle palpation is needed to feel any abnormalities.

For the posterior approach, both of the nurse’s hands are placed around the neck, with two fingers of each hand on the sides of the trachea just beneath the cricoid cartilage.

The bell of the stethoscope is best for auscultation of bruits.

PTS: 1 DIF: A REF: 591 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

7. When auscultating the client’s lungs, a nurse notes normal vesicular sounds as:

1.
Medium-pitched blowing sounds with inspirations that equal expirations
2.
Loud, high-pitched, hollow sounds with expiration longer than inspiration
3.
Soft, breezy, low-pitched sounds with longer inspiration
4.
Sounds created by air moving through small airways

ANS: 3

Normal vesicular sounds are soft, breezy, and low-pitched. The inspiratory phase is 3 times longer than the expiratory phase. Medium-pitched blowing sounds with inspiration equaling expiration are bronchovesicular breath sounds. Loud, high-pitched, hollow sounds with longer expiration are bronchial breath sounds. Vesicular sounds are created by air moving through smaller airways. Abnormal breath sounds result from air passing through narrowed airways.

PTS: 1 DIF: A REF: 596 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

8. The nurse could best auscultate the point of maximum impulse (PMI) in an 8-year-old child at the:

1.
Fourth intercostal space, left of the midclavicular line
2.
Fifth intercostal space, left of the midclavicular line
3.
Second intercostal space, right of the midclavicular line
4.
Third intercostal space, right of the midclavicular line

ANS: 2

By the age of 7, a child’s PMI is in the same location as in adults; that is, the fifth intercostal space, left of the midclavicular line. The PMI of an 8-year-old child is more likely to be located at the fifth intercostal space, left of the midclavicular line.

The PMI is not located to the right of the midclavicular line. The PMI of an infant is at the third or fourth intercostal space, left of the midclavicular line.

PTS: 1 DIF: A REF: 598 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

9. The nurse suspects that the client may have vascular disease. During the examination, the nurse is alert to the client’s complaints of:

1.
Headache, dizziness, and tingling of body parts
2.
Diplopia, floaters, and headaches
3.
Leg cramps, numbness of extremities, and edema
4.
Pain and cramping in the lower extremities relieved by walking

ANS: 3

Leg cramps, numbness or tingling in extremities, sensation of cold hands or feet, pain in legs, or swelling or cyanosis of feet, ankles, or hands are indicative of vascular disease.

Headache, dizziness, and tingling of body parts are more likely associated with a neurological problem, not vascular disease. Diplopia, floaters, and headaches are indicative of an eye problem, not vascular disease. Pain and cramping in the lower extremities are usually worsened with activity in vascular disease.

PTS: 1 DIF: A REF: 602 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

10. A 21-year-old woman asks when she should perform a breast self-examination during the month. The nurse should inform the client:

1.
“Any time you think of it.”
2.
“At the same time each month.”
3.
“On the first day of your menstrual period.”
4.
“Two to three days after your menstrual period.”

ANS: 4

The best time for a BSE is 2 to 3 days after the menstrual period ends, when the breast is no longer swollen or tender from hormone elevations. The woman should check her breasts the same time each month 2-3 days after the menstrual period ends. At the same time each month is partially true. The client also should be informed to perform the BSE 2 to 3 days after the menstrual period ends. On the first day of the menstrual period is not the best time for a woman to perform a BSE. The breasts will be enlarged and tender from hormone elevations.

PTS: 1 DIF: A REF: 610 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

11. During an assessment of the client’s integument, the nurse notes a flat, nonpalpable change in skin color that is smaller than 1 cm. This finding is documented by the nurse as a:

1.
Macule
2.
Papule
3.
Vesicle
4.
Nodule

ANS: 1

This finding is consistent with the definition of a macule. A papule is a palpable, circumscribed, solid elevation in skin, smaller than 0.5 cm. A vesicle is a circumscribed elevation of skin filled with serous fluid, smaller than 0.5 cm. A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5-2.0 cm.

PTS: 1 DIF: A REF: 570 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

12. The nurse asks a client to explain the meaning of the phrase, “Every cloud has a silver lining.” This part of the examination is designed to measure:

1.
Knowledge
2.
Judgment
3.
Association
4.
Abstract thinking

ANS: 4

Interpreting abstract ideas or concepts, such as in explaining the meaning of this phrase, reflects the capacity for abstract thinking. The client with altered mentation will likely interpret the phrase literally or merely rephrase the words. An example of assessing knowledge would be asking the client their reason for seeking health care. This example is not designed to measure knowledge. The nurse is not attempting to measure judgment. An example of assessing judgment would be to ask the client what they would do if they suddenly became ill when alone at home. The nurse is not attempting to measure association. An example of assessing association would be to ask the client to complete a phrase, such as “a dog is to a beagle as a cat is to a _____.”

PTS: 1 DIF: A REF: 633 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

13. Measurement of the client’s ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?

1.
Optic
2.
Facial
3.
Trigeminal
4.
Oculomotor

ANS: 3

The trigeminal nerve is tested by lightly touching the cornea with a wisp of cotton, by assessing the corneal reflex, and by measuring sensation of light pain and touch across the skin of the face. The optic nerve is tested by using the Snellen chart or asking the client to read printed material. The facial nerve is tested by having the client smile, frown, puff out cheeks, and raise and lower eyebrows while looking for asymmetry. Also, having the client identify salty or sweet taste on the front of the tongue tests the facial nerve. The oculomotor nerve is tested by assessing directions of gaze and testing papillary reaction to light and accommodation.

PTS: 1 DIF: A REF: 634 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

14. Assessment of the client’s skin reveals a fluid-filled circumscribed elevation of 0.4 cm. The nurse identifies this as a:

1.
Nodule
2.
Macule
3.
Vesicle
4.
Wheal

ANS: 3

This finding is consistent with the definition of a vesicle. A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5-2.0 cm. A macule is a flat, nonpalpable change in skin color, smaller than 1 cm. A wheal is an irregularly-shaped, elevated area or superficial localized edema that varies in size.

PTS: 1 DIF: A REF: 570 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

15. The expected appearance of the oral mucosa in a light-skinned adult is:

1.
Pinkish-red, smooth, and moist
2.
Light pink, rough, and dry
3.
Cyanotic, with rough nodules
4.
Deep red, with rough edges

ANS: 1

Normal mucosa in a light-skinned adult is glistening, pinkish-red, soft, moist, and smooth. Oral mucosa may appear more dry in an older adult because of reduced salivation but is not rough. Cyanotic mucosa with rough nodules would be an abnormal finding. Oral mucosa should not appear deep red with rough edges in a light-skinned adult.

PTS: 1 DIF: A REF: 587 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

16. The nurse notes an exaggeration of the posterior curvature of the thoracic spine, during the assessment of a 90-year-old client, as:

1.
Lordosis
2.
Osteoporosis
3.
Scoliosis
4.
Kyphosis

ANS: 4

Kyphosis is an exaggeration of the posterior curvature of the thoracic spine (hunchback).

Lordosis is an increased lumbar curvature (swayback). Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone. Scoliosis is a lateral curvature of the spine.

PTS: 1 DIF: A REF: 627 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

17. The best position for the nurse to position the client in order to auscultate the apical site, if a low-pitched murmur is suspected during prior assessment, is:

1.
Sitting up
2.
Standing
3.
Lying on the left side
4.
Dorsal recumbent

ANS: 3

Extra heart sounds or heart murmurs are heard more easily with the client lying on the left side (lateral recumbent) with the stethoscope at the apical site. Sitting upright is used for assessing lung expansion and symmetry of the upper extremities. Standing is not the best position for auscultating a heart murmur. The dorsal recumbent position is best used for abdominal assessment.

PTS: 1 DIF: A REF: 559 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

18. As part of the examination, the nurse will be assessing the client’s balance. The test that should be administered is the:

1.
Weber test
2.
Allen test
3.
Romberg test
4.
Rinne test

ANS: 3

The Romberg test assesses the client’s balance. The Weber test assesses for unilateral deafness. The Allen test assesses for patency of the arteries of the hand (usually before arterial puncture). The Rinne test compares bone conduction hearing with air conduction.

PTS: 1 DIF: A REF: 636-637 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

19. Part of the neurological exam is evaluating the response of the cranial nerves. To test cranial nerve VIII, the nurse should:

1.
Ask the client to read printed material
2.
Assess the directions of gaze
3.
Assess the client’s ability to hear the spoken word
4.
Ask the client to say “ah”

ANS: 3

To test cranial nerve VIII (auditory), the nurse should assess the client’s ability to hear the spoken word. To test cranial nerve II (optic), the nurse should assess the client’s ability to read printed material. To test cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), the nurse should assess the client’s directions of gaze. To assess cranial nerve X (vagus), the nurse should ask the client to say “ah.”

PTS: 1 DIF: A REF: 634 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

20. A student nurse is working with a client who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. The student expects to hear:

1.
Coarse crackles and bubbling
2.
High-pitched musical sounds
3.
Dry, grating noises
4.
Loud, low-pitched rumbling

ANS: 2

Wheezes are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration. Coarse crackles and bubbling are not descriptive of wheezes. Dry, grating noises are heard with a pleural friction rub. Loud, low-pitched rumbling is characteristic of rhonchi.

PTS: 1 DIF: A REF: 596 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

21. The nurse instructs the male client that the protocol for testicular self-examination is to:

1.
Perform the examination annually after age 35
2.
Use both hands to roll the testicles and feel the consistency
3.
Perform the examination before bathing or showering
4.
Contact the physician if a cordlike structure is felt on the top and back of the testicle

ANS: 2

The nurse instructs the male client that the protocol for testicular self-examination is to use both hands to gently roll the testicle, feeling for lumps, thickening, or a change in consistency (hardening). All men 15 years and older should perform the testicular self-exam monthly. The examination should be performed after a warm bath or shower when the scrotal sac is relaxed. A cordlike structure on the top and back of the testicle is a normal finding. It is the epididymis.

PTS: 1 DIF: A REF: 623 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment