Physical Assessment NCLEX Practice Questions

Physical Assessment NCLEX Practice Questions ScienceMedicineNursing lizzyrose6 Save Chapter 30 Health Assessment and ...40 terms quizlette225193 Preview Cultural Awareness - NCLEX Style Q...12 terms manda__cPreview Medication Administration NCLEX Q...60 terms Spiritinthesky67 Preview Prioriti 28 terms ma Which neurological function is the nurse assessing when asking a client to interpret a maxim such as "a watched pot never boils"?

1.Abstract thinking 2.Thought processes 3.Long-term memory 4.Short-term memory 5.Thought processes

ANSWER: 1

Rationales

Option 1:

The nurse is assessing the capability of the client for abstract thinking by interpreting the maxim "a watched pot never boils".

Option 2:

If the client answers questions in an appropriate manner, the nurse is assessing the client's thought processes.

Option 3:

The nurse would ask the client about his/her childhood to determine long-term memory.

Option 4:

Asking the client what he/she did yesterday would be a way to assess short-term memory.

Which is a normal finding when percussing the abdominal area?

1.Overall dullness, with tympany over organs or structures 2.Overall tympany, with dullness over organs or structures 3.Dull sounds throughout 4.Fremitus throughout

ANSWER: 2

Rationales

Option 1:

Dullness is percussed over solid structures, and tympany over air-filled cavities.

Option 2:

Tympany is heard over hollow organs, and dullness over structures or bone.

Option 3:

The abdomen contains structures and solid organs, which result in a dull sound. Otherwise, the abdomen is hollow.

Option 4:

Fremitus describes vibrations from speaking. It is part of the respiratory system assessment.Test Taking Tip: Percussion of the abdomen should take place after inspection and auscultation to avoid disruption of bowel sounds. Normal findings are tympany over the cavity and dullness over organs and structures.Which are nursing considerations when performing a physical assessment on an elderly client? Select all that apply.

1.Assessment of support systems 2.Limiting position changes to make the exam less taxing 3.More client cooperation, since the client has been assessed before 4.Stiff muscles and joints making positioning difficult 5.Limited ability to comprehend 6.Adapting techniques to accommodate decreased vision and hearing abilities

ANSWERS: 2, 4, 6

Rationales

Option 1:

An evaluation of support systems can help determine the overall health of an elderly client.

Option 2:

An elderly client may have limited movement, and adjustments and modifications to the exam may need to be made.

Option 3:

Previous assessments and age do not have an impact on how cooperative a client is during a physical exam.

Option 4:

Extra time should be allotted to account for slower movements and any positioning modifications.

Option 5:

A client being of advanced age does not have an impact on the understanding of instructions.

Option 6:

An elderly client may have sensory deficits, and the physical assessment may need to be modified to accommodate this.Test Taking Tip: Allow extra time when performing a comprehensive assessment on an elderly client. An elderly client may have vision or hearing impairment, and may have changes in physical ability that makes positioning difficult.

The parents and their toddler present to the clinic for a well-child check-up. Which differences would the nurse incorporate into the assessment since the client is a child? Select all that apply.

1.Allow the toddler to make choices.

2.Let the child play with the equipment.

3.Administer needed immunizations last.

4.Hold the toddler against the parent's chest.

5.Promote and support the child's independence.

ANSWERS: 1, 3

Rationales

Option 1:

The nurse should allow the child choices such as removing the shirt or being weighed first. This will encourage cooperation.

Option 2:

A pre-school aged child can be allowed to examine and play with the equipment, but not a toddler as the equipment may have small pieces that could be dangerous.

Option 3:

The nurse should perform all invasive procedures last as this can upset the toddler and make it difficult to complete the exam.

Option 4:

Infants, not toddlers, may be more comfortable being held against the parent's chest.

Option 5:

The nurse should promote and support a school-age child's independence, not a toddler.Test Taking Tip: Toddlers are interested in exploring the environment, but they also like to stay close by a parent, often in the parent's lap.Toddlers are developmentally distinguished from infants and preschoolers.

Which are included as parts of the assessment of the integumentary system? Select all that apply.

1.Skin 2.Hands 3.Ears 4.Nails 5.Hair

ANSWERS: 1, 4, 5

Rationales

Option 1:

The skin is the largest organ of the body, and it is the main part of the integumentary system.

Option 2:

The skin on the back of the hands is assessed as part of the integumentary system, but the hands are not specifically assessed.

Option 3:

Ears are not part of the integumentary system assessment.

Option 4:

Nails are part of the integumentary system. Dry, discolored, or thick nails can be important assessment findings

Option 5:

The hair is an important part of the assessment of the integumentary system. Dry, brittle, or disheveled hair are important assessment findings.Test Taking Tip: The integumentary system can reveal a great deal about the overall health of the client. Skin, hair, and nails are assessed as part of the integumentary system assessment.Which are reasons for a nurse to perform a nursing assessment of a client? Select all that apply.

1.To obtain baseline information 2.To develop a plan for nursing care 3.To evaluate effectiveness of interventions 4.To receive reimbursement for services provided 5.To determine the presence of disease and its pathology

ANSWERS: 1, 2, 3

Rationales

Option 1:

The nurse assesses a client on a first visit or encounter to obtain baseline information. This is used to determine changes in health.

Option 2:

A physical assessment is used to obtain data to develop a plan of nursing care for a client.

Option 3:

Evaluation is part of the nursing process; therefore, the nurse assesses the client to determine if interventions are effective.

Option 4:

A nurse practitioner or physician assesses a client and document these findings to receive reimbursement for services provided.

Option 5:

The primary health care provider performs a medical assessment of a client to determine the presence of disease and its pathology.