1 Exam (elaborations) NUR2092 Health Assessment / Health Assessment Exam 2 Review Questions 2 Exam (elaborations) NUR2092 Health Assessment / Health Assessment Final Exam: Review Questions 3 Exam (elaborations) NUR2092 Health Assessment / Health Assessment Practice Questions (Test 1) good 4 Exam (elaborations) NUR2092 Health Assessment / Health Ass
NUR2092 Health Assessment /
Health Assessment Exam 1
(Ch. 1,3,4,8,9,10,12,18,27,29)
What does the health history provide? – ANSWER Subjective and
objective data
What is subjective data? what is an example? – ANSWER SD is
what the patient tells you
Example: headache, chest pain
What is objective data? what is an example? – ANSWER OD are
the signs perceived by the examiner through physical examination during
assessment
Example: rash seen by a nurse, or temp taken with a thermometer
In what order are skills performed during a typical assessment? – ANSWER
- Inspection
- Palpation
- Percussion
- Auscultation
If a patient has abdomen pain, what order do you do the assessment? Why? –
ANSWER 1. Inspection - AUSCULTATION
- Palpation
- Percussion
Because of pain, don’t touch or tap the tender area first. Start by inspecting and
then listening before you feel the area.
What occurs during inspection, the first step? – ANSWER –
ALWAYS COMES FIRST
-begins when you first meet a person w/ a general survey
-you should start assessment of each body system with inspection
-requires: good lighting, adequate exposure, use of instruments including otoscope,
opthalmoscope, penlight, or specula
What occurs during palpation, the second step? – ANSWER
Palpation applies sense of touch to assess
Can include:
temperature, texture, moisture, organ location and size, swelling, vibration or
pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, presence
of tenderness or pain
-use fingers unless taking temperature
How can you assess factors during the palpation step? – ANSWER
by using different parts of the hands
During palpation, what should fingertips be used to feel? – ANSWER
-best for fine tactile discrimination of skin texture, swelling, pulsation, and
determining presence of lumps
During palpation, what should fingers and thumb be used for? – ANSWER
-detection of position, shape, and consistency of an organ or mass
During palpation, what should the dorsa of hands and fingers be used for? –
ANSWER -best for determining temperature because skin here is
thinner than on palms
During palpation, what should the base of fingers or the ulnar surface of hand be
used for? – ANSWER -best for vibration
**-vibrations are felt on the ulnar side of hand
During palpation, what type of palpation should you start with and why? What
steps are next? – ANSWER 1. start with LIGHT palpation to
detect surface characteristics and accustom person to being touched
-1 cm
- then deeper palpations when needed
-intermittent pressure better than one long continuous palpation
-5 to 8 cm or 2-3 in
ALSO: bimanual palpation- requires use of both hands to envelop or capture
certain body parts or organs such as kidneys, uterus or adnexa for precise
delimitation
What occurs during percussion, the third step? – ANSWER –
consists of tapping a person’s skin with short, sharp strokes to assess underlying
structures
What uses does percussion have? – ANSWER -mapping location
and size of organs
-signaling density of a structure by a characteristic note
-detecting a superficial abnormal mass - percussion vibrations penetrate about 5 cm
deep - deeper mass would give no change in percussion
-eliciting pain if underlying structure is inflamed
-eliciting deep tendon reflex using percussion hammer
NUR2092 Health Assessment /
Health Assessment – Exam 1
A patient is admitted to the medical-surgical unit with a diagnosis of
hypertension. The nurse is using the nursing process to develop the plan of care.
Which steps should the nurse incorporate?
A. Assessment, treatment, planning, evaluation, discharge, follow-up
B. Admission, assessment, diagnosis, treatment, discharge planning
C. Admission, diagnosis, treatment, evaluation, discharge planning
D. Assessment, diagnosis, outcome identification, planning, implementation,
evaluation – ANSWER D. Assessment, diagnosis, outcome
identification, planning, implementation, evaluation
The nursing process is a method of problem solving that includes assessment,
diagnosis, outcome identification, planning, implementation, and evaluation. The
nurse must analyze and interpret these data before initiating a plan of care.
The nurse is incorporating the principles of the quality and safety competencies
from the Institute of Medicine (IOM) recommendations into the health
assessment of a patient in the long-term care setting. What principles should the
nurse consider? Select all that apply:
A. Use evidence to support interventions.
B. Evaluate the plan of care.
C. Use a step-by-step approach to problem solving.
D. Use technologies and informatics in delivering care.
E. Place the patient at the center of care.
F. Include other disciplines in the plan of care. – ANSWER A,
D, E, F
Use Evidence to support interventions
Use technologies and informatics in delivering care
Place the patient at the center of care
Include other disciplines in care
The Institute of Medicine identified five core competencies as essential for health
care professionals to demonstrate how to respond effectively to patient care
needs: provide patient-centered care, work in interdisciplinary teams, use
evidence-based practice, apply quality improvements, and use informatics.
The student nurse is preparing to assess a patient in the hospital clinical setting.
Which components best describe the concept of health assessment? Select all
that apply:
A. Collection of objective data
B. Collection of subjective data
C. Collection of data and identification of nursing diagnosis
D. Planning and evaluation of data
E. Analysis of data
F. Physical exam
G. Documentation of data – ANSWER A, B, F, G
Collection of objective data
Collection of subjective data
Physical exam
Documentation of Data
Components of health assessment include conducting a health history (the
collection of subjective data), performing a physical examination (the collection of
objective data), and documenting the findings.
The nurse is documenting the findings from the health assessment. Which
example of data documentation reflects the opinion of the nurse?
A. The patient is uncooperative and unfriendly.
B. The patient avoids eye contact.
C. The patient states, “I do not want to get out of bed.”
D. The patient states, “I am very angry.” – ANSWER A. The
patient is uncooperative and unfriendly
Nurses must record data accurately, concisely, and without bias or opinion. In this
example, the nurse is offering an opinion, which may contain bias.
The nurse is assessing a patient for the first time in the outpatient diabetic clinic.
A __ type of health assessment would be most appropriate for this
visit?
A. Focused assessment
B. Episodic follow-up assessment
C. Shift assessment
D. Comprehensive health assessment – ANSWER D.
Comprehensive health assessment
The type of health assessment performed by the nurse is also driven by patient
need. A comprehensive health assessment involves a detailed history and physical
examination performed at the onset of care in a primary care setting or upon
admission to a hospital or long-term care facility.
A patient complains of a cough for 4 days unrelieved with position changes. The
nurse interprets this as a symptom and documents the finding under
____________on the patient’s chart.
A. The nursing care plan
B. Assessment
C. History
D. Vital signs – ANSWER C. History
A symptom is something described by the patient and considered subjective;
therefore it would be documented under “History.”
The nurse is administering an influenza (flu) shot to a patient in a retail health
setting. Of which level of prevention is this an example?
A. Primary
B. Secondary
C. Post secondary
D. Tertiary – ANSWER A. Primary Prevention
Vaccinations protect from disease and are considered primary prevention.
NUR 2092 Health Assessment
Health Assessment Practice Questions
Which is not a skills requisite?
A: Inspection
B: Palpation
C: Vital signs
D: Percussion – ANSWER C: Vital Signs
What are some things you are looking for during palpation? – ANSWER
Temperature, Moisture, Texture, Lumps
Over what tissue would you expect to hear resonance?
A: Stomach
B: Lungs
C: Brain
D: Bones – ANSWER B: Lungs
Over what tissue would you expect to hear tympany?
A: Lungs
B: Bone
C: Brain
D: Stomach – ANSWER D: Stomach
Over what tissue would you expect to hear a dull sound?
A: Stomach
B: Bone
C: Liver
D: Lungs – ANSWER C: Liver
Over what tissue would you expect to hear a flat sound?
A: Lung
B: Bone
C: Muscle
D: Stomach
E: B&C – ANSWER E: Bone & Muscle
When is NOT best to use the diaphragm of the stethoscope?
A: Heart murmur
B: Breathing
C: Bowl sounds
D: High-pitched – ANSWER A: Heart murmer
How should you listen to heart and lung sounds?
A: Over a gown
B: Touching the skin – ANSWER B: Touching the skin
What position is correct for inserting a rectal suppository?
A: Lithotomy
B: Sims
C: Dorsal Recumbent
D: Supine – ANSWER B: Sims
Taking an axillary temperature on an adult will result in a temperature reading
that is:
A: One degree lower
B: Accurate
C: One degree higher
D: Same as Oral – ANSWER A: One degree lower
What is a full & bounding pulse force?
A: 3+
B: 2+
NUR2092 Health Assessment /
HEALTH ASSESSMENT EXAM 1
PRACTICE QUESTIONS
- Mr. Mosley has shortness of breath that has persisted for the past 10 days; it is
worse with activity and relieved by rest. What type of data is this? – ANSWER
Subjective - The 7 attributes of a symptom include: – ANSWER
OLD CART
A. Associated symptoms
B. Aggravating and/or relieving factors
C. Location
D. ALL OF THE ABOVE - The steps of the nursing process include: (check all that are correct) –
ANSWER ADPIE
A. IMPLEMENTATION
B. DIAGNOSIS
C. ASSESSMENT
D. Setting up the environment for the interview
Match the Therapeutic Communication Techniques with the appropriate
statements: Having this procedure must have made you very nervous –
ANSWER VALIDATION
Match the Therapeutic Communication Techniques with the appropriate
statements: Eye contact, facial expression, tone, volume – ANSWER
NON VERBAL COMMUNICATION
Match the Therapeutic Communication Techniques with the appropriate
statements: “Now you have said that the pain began one week ago, and comes
and goes several time a day” – ANSWER
SUMMARIZATION
Match the Therapeutic Communication Techniques with the appropriate
statements: Begin with open-ended questions then getting more specific –
ANSWER GUIDED QUESTIONING
NUR2092 Health Assessment
Health Assessment Test 1 Chapters 1-4
- After completing an initial assessment of a patient, the nurse has charted that
his respirations are eupneic and his pulse is 58 beats per minute. These types of
data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective. – ANSWER a. Objective.
Objective data are what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination.
Subjective data is what the person says about him or herself during history taking.
The terms reflective and introspective are not used to describe data. - A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.”
These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective. – ANSWER c. Subjective.
Subjective data are what the person says about him or herself during history
taking. Objective data are what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination. The
terms reflective and introspective are not used to describe data.
- The patient’s record, laboratory studies, objective data, and subjective data
combine to form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary. – ANSWER ANS: A
Together with the patient’s record and laboratory studies, the objective and
subjective data form the data base. The other items are not part of the patient’s
record, laboratory studies, or data. - When listening to a patient’s breath sounds, the nurse is unsure of a sound that
is heard. The nurse’s next action should be to:
a. Immediately notify the patient’s physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present. –
ANSWER ANS: C
When unsure of a sound heard while listening to a patient’s breath sounds, the
nurse validates the data to ensure accuracy. If the nurse has less experience in an
area, then he or she asks an expert to listen.
- The nurse is conducting a class for new graduate nurses. During the teaching
session, the nurse should keep in mind that novice nurses, without a background
of skills and experience from which to draw, are more likely to make their
decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors. – ANSWER
ANS: B
Novice nurses operate from a set of defined, structured rules. The expert
practitioner uses intuitive links. - Expert nurses learn to attend to a pattern of assessment data and act without
consciously labeling it. These responses are referred to as:
NUR2092 Health Assessment
/ Health Assessment Exam 1- PPT and
quiz questions
Which of the following is an open-ended question?
a. What brought you in today?
b. Where does it hurt?
c. Have you been checking your blood pressure?
d. When was the last time you were seen by
a doctor? – ANSWER Answer:A. It is the only choice that
would invite a paragraph for an answer rather than a short statement.
Which of the following is the most basic function and therefore should be tested
first
in an assessment of mental status?
a.Behavior
b. Consciousness
c. Judgment
d. Language – ANSWER Answer: B. According to your
textbook, consciousness is the most fundamental of these particular
characteristics; therefore, it would be tested first.
Which of the following is not a significant contributor to the assessment of mental
status?
a.Known illness or health problem
b. Current medications known to affect mood or cognition
c. Racial background
d. Personal history; current stress, social habits, sleep habits, drug and alcohol use
- ANSWER Answer: C. The other choices are all elements of
the interview that contribute to interpretation of the findings of the examination.
Correct order of physical examination skills: – ANSWER
Inspection, Palpation, Percussion, Auscultation
NCLEX question
The nurse is preparing to percuss the abdomen of a patient. The purpose of the
percussion is to assess the underlying tissue:
A) turgor.
B)texture.
C)density.
D)consistency. – ANSWER ANSWER: C
Percussion yields a sound that depicts the location, size, and density of the
underlying organ. Turgor and texture are assessed with palpation.
NCLEX question
The nurse is reviewing percussion techniques with a newly graduated nurse.
Which technique, if used by the new nurse, indicates that more review is needed?
The nurse:
A)percusses once over each area.
B)lifts the striking finger off quickly after each stroke.
C)strikes with the finger tip, not the finger pad.
D)uses the wrist to make the strikes, not the arm. – ANSWER
ANSWER: A
For percussion, the nurse should percuss two times over each location. The
striking finger should be lifted off quickly because a resting finger damps off
vibrations. The tip of the striking finger should make contact, not the pad of the
finger. The wrist must be relaxed, and it is used to make the strikes, not the arm
NCLEX question
The nurse is teaching a class on basic assessment skills. Which of these
statements is true regarding the stethoscope and its use?
A)The slope of the earpieces should point posteriorly (toward the occiput).
B)The stethoscope does not magnify sound but does block out extraneous room
noise.
C)The fit and quality of the stethoscope are not as important as its ability to
magnify sound.
D)The ideal tubing length should be 22 inches to dampen distortion of sound. –
ANSWER ANSWER: B
The stethoscope does not magnify sound but does block out extraneous room
sounds. The slope of the earpieces should point forward toward the examiner’s
nose. Longer tubing will distort sound. The fit and quality of the stethoscope are
important.
NUR2092 Health Assessment
/ Health Assessment Practice
Questions (Test 1) good
The practitioner, entering the examining room to meet a patient for the first time,
states “Hello, I’m M.M., and I’m here to gather some information. This will take
about 30 minutes. D.D. is a student working with me. If it’s all right with you, she
will remain during the examination.” Which of the following must be added to
cover all aspects of the interview contract?
A) A statement regarding confidentiality, patient costs and the expectations of
each person
B) the purpose of the interview and the role of the interviewer
C) Time and place of the interviewer and a confidentiality statement
D) An explicit purpose of the interview and a description of the physical
examination including diagnostic studies – ANSWER A) A
statement regarding confidentiality, patient costs and the expectations of each
person
8 items of information that should be communicated to the client concerning the
terms or expectations of the interview:
- Time and place of the interview and succeeding physical examination
- Introduction of yourself and a brief explanation of your role
- The purpose of the interview
- How long it will take
- Expectation of participation of each person
- Presence of any other people
- Confidentiality
- Any cost to the client
(pg. 27 Jarvis)
__ is exhibiting an accurate understanding of the other person’s feelings
within a communication context
A) Empathy
B) Liking others
C) Facilitation
D) A Nonverbal listening technique – ANSWER A) Empathy: means
viewing the world from the other persons inner frame of reference while
remaining you. Recognition of another person’s feelings without criticism.
(pg. 28 Jarvis)
You conduct an admission interview. Because you are expecting a phone call, you
stand near the door. Which would be a more appropriate approach?
A) Arrange to have someone page you so you can sit on the side of the bed
B) Have someone answer the phone so you can sit facing the patient
C) Use this approach given the circumstances
D) Arrange for time free of interruptions after the initial physical examination is
complete – ANSWER B) Have someone answer the phone so you
can sit facing the patient
Refuse Interruptions: Inform support staff of your interview and ask them not to
interrupt you during this time. Any interruption can destroy any rapport you had
previously built.
Sit eye level with patient and avoid barriers such as desks, and avoid standing,
standing assumes superiority and takes away control from the patient. Keep a
distance of 4 to 5 feet for personal space.
(pg.29 Jarvis)
A patient asks the nurse, “May I ask you a question?” This is an example of:
A) An open-ended question
B) A reflective question
C) A closed question
D) A double-barreled question – ANSWER C) A closed question:
elicits a “yes” or “no” answer or a forced choice.
**Avoid Double-barreled questions are questions that ask more than one
question, to where a “yes” or “no” answer would not fully satisfy the question
(pg. 32 Jarvis)
Which statement best describes interpretation as a communication technique?
A) interpretation is the same as clarification
B) interpretation is a summary of a statement made by the patient
C) interpretation is used to focus on a particular aspect of what the patient has
just said
D) interpretation is based on the interviewer’s inference from the data that have
been presented – ANSWER D) interpretation is based on the
interviewer’s inference from the data that have been presented
NUR2092 Health Assessment / Health
Assessment Final Exam: Review Questions
An elderly patient is admitted to the hospital. While performing a skin
assessment, the nurse discovers bruises in various stages of healing all over the
patient’s body. Why is it important for the nurse to promptly document and
report these findings?
a.The patient may have been abused.
b.The patient is elderly.
c.The patient may have peripheral vascular disease.
d.The patient may have a cognitive deficit. – ANSWER a.
The patient may have been abused
When the nurse observes the patient for general characteristics including age,
gender, and level of alertness, what aspect of assessment are you performing?
a.Inspecting
b.Interviewing
c.Palpating
d.Ausculating – ANSWER a. Inspecting
The four areas to consider during the general survey include:
a. Dress, medical history, nonverbal behavior, and mobility.
b.Ethnicity, gender, age, and socioeconomic status.
c.Physical appearance, gender, ethnicity, and medical history.
d.Physical appearance, body structure, mobility, and behavior. – ANSWER
d. Physical appearance, body structure, mobility, and behavior.
When reading the patient’s medical record, the nurse sees the following notation:
Patient states, “I have had a cold for about a week, and I am having difficulty
breathing.” This is an example of:
a.A past health history.
b.A review of systems.
c.A functioning assessment.
d.A chief compliant. – ANSWER d.A chief compliant.
Normal cervical lymph nodes are:
a.Smaller than 1 cm
b.Warm and red
c.Fixed
d.Firm – ANSWER a.Smaller than 1 cm
The first step to cultural competency by a nurse is to:
a.Identify the meaning of health to the patient.
b.Understand their own heritage and its basis in cultural values.
c.Develop a frame of reference to traditional health care practices.
d.Understand how a health care delivery system works. – ANSWER
b.Understand their own heritage and its basis in cultural values.
The nurse is conducting a physical assessment of a new patient. What data does
the nurse collect that are measurable?
a.Objective
b.Effective
c.Subjective
d.Affective – ANSWER a.Objective
While assessing a patient, the nurse is asking questions that help the nurse
perceive and communicate an understanding of what the patient is feeling. What
is this called?
a.Caring
b.Therapeutic communication
c.Sympathy
d.Empathy – ANSWER d.Empathy
Checking for skin temperature is best accomplished by using:
NUR2092 Health Assessment /
Health Assessment Exam 2
Review Questions
A palpable vibration increased with lobar pneumonia is also known as:
A. Rhonchi
B. Resonance
C. Fremitus
D. Crackles – ANSWER C. Fremitus (key term is “palpable”
Your patient is exhibiting rapid shallow breathing, with a respiratory rate >24
respirations per minute. Which of the following conditions are they experiencing?
A. hypoxemia
B. tachypnea
C. fremitus
D. resonance – ANSWER B. tachypnea
Increased tactile fremitus would be evident in an individual who has which of the
following conditions?
A. emphysema
B. pneumonia
C. crepitus
D. pneumothorax – ANSWER B. pneumonia
Fremitus is a palpable vibration. Increased fremitus occurs with compression or
consolidation of lung tissue (ex. lobar pneumonia)
Which of the following terms is used to describe a decreased level of oxygen (O2)
in the blood?
A. anemia
B. hypercapnia
C. hypoxemia
D. emphysema – ANSWER C. hypoxemia
The nurse is assessing a patient who has emphysema. They note a course,
crackling sensation that is palpable over the skin surface. This is known as:
A. hypoxemia
b. crackles
C. fremitus
D. crepitus – ANSWER D. crepitus
Upon receiving the patient’s lab results, the nurse notes the patient has an
increased level of carbon dioxide in the blood. Which of the following conditions
would the patient be experiencing?
A. resonance
B. hypercapnia
C. fremitus
D. tachypnea – ANSWER B. hypercapnia
The nurse is auscultating a patient’s lungs and hears discontinuous, high-pitched,
short, popping sounds heard during inspiration, and not cleared by coughing.
These are described as:
A. bradypnea
B. rhonchi
C. crackles
D. wheezing – ANSWER C. crackles
The nurse is assessing a patient’s lungs by using the percussion technique. Which
sound would the nurse expect to hear over healthy lung tissue?
A. resonance
B. orthopnea
C. crackles
D. tachypnea – ANSWER A. resonance
A clinical manifestation common in an individual with chronic obstructive
pulmonary disease (COPD) is:
A. periodic breathing patterns
B. pursed lip breathing
C. unequal chest expansion
D. hyperventilation – ANSWER B. pursed lip breathing
An individual with COPD may purse the lips in a whistling position. By exhaling
slowly and against a narrow opening, the pressure in the bronchial tree remains
positive, and fewer airways collapse.
Which of the following are functions of the respiratory system? (Select all that
apply)
A. supplying oxygen to the body for energy production
B. removing carbon dioxide as a waste product
C. wound repair
D. maintaining acid-base balance
E. maintenance of heat exchange
F. identification – ANSWER A. supplying oxygen to the body
for energy production
B. removing carbon dioxide as a waste product
D. maintaining acid-base balance
E. maintenance of heat exchange
Stridor is a high pitched, inspiratory crowing sound commonly associated with:
A. upper airway obstruction
B. atelectasis
C. congestive heart failure
D. Pneumothorax – ANSWER A. upper airway obstruction
Stridor is associated with upper airway obstruction from swollen, inflamed tissues
or a lodged foreign body.