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NUR 168: CONCEPTS 3: CHAPTER 26: HEALTH ASSESSMENT: QUESTIONS WITH COMPLETE SOLUTIONS
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NUR 168: CONCEPTS 3: CHAPTER 26: HEALTH ASSESSMENT: QUESTIONS WITH COMPLETE SOLUTIONS
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NUR 168 CONCEPTS 3: CHAPTER 26: HEALTHASSESSMENT: QUESTIONS WITH COMPLETE
SOLUTIONS
1. An RN working in a hospital setting is responsible for patient
assessment. For which patient would the nurse perform a
focused assessment?
A) A patient newly admitted to the unit
B) A patient with diabetes who develops secondary hypertension
C) A patient who presents with signs of acute respiratory
distress syndrome (ARDS)
D) A patient who is recovering from abdominal surgery with no
complications Correct Answers B) A patient with diabetes who
develops secondary hypertension
10. A nurse auscultates the thorax and lungs and hears coarse,
low-pitched, continuous sounds on expiration. When the patient
coughs, the sounds clear up somewhat. What would be the
nurse's response to this finding?
A) Document and report the finding of abnormal Rhonchi breath
sounds
B) Document the finding of normal bronchovesicular breath
sounds
C) Document and report the finding of abnormal stridor breath
sounds
D) Document the finding of normal bronchial sounds Correct
Answers A) Document and report the finding of abnormal
Rhonchi breath sounds
,11. A nurse is assessing a patient's eyes for accommodation.
What actions would the nurse perform during this test? Select all
that apply.
A) Bring a penlight from the side of the patient's face and briefly
shine the light on the pupil.
B) Hold a forefinger, a pencil, or other straight object about 10
to 15 cm (4 to 6 in) from the bridge of the patient's nose.
C) Hold a finger about 6 to 8 in from the bridge of the patient's
nose.
D) Darken the room.
E) Ask the patient to look straight ahead.
F) Ask the patient to first look at a close object, then at a distant
object, then back to the close object. Correct Answers B) Hold
a forefinger, a pencil, or other straight object about 10 to 15 cm
(4 to 6 in) from the bridge of the patient's nose.
F) Ask the patient to first look at a close object, then at a distant
object, then back to the close object.
12. A nurse is using the circular technique to palpate the breast
of a woman during an assessment. The nurse uses the pads of
the first three fingers to gently compress the breast tissue against
the chest wall. How would the nurse proceed with the palpation?
A) Start at the tail of Spence and move in increasing smaller
circles.
B) Start at the outer edge of the breast and palpate up and down
the breast.
C) Work in a counterclockwise direction and palpate from the
periphery toward the areola.
D) Start at the inner edge of the breast and palpate up and down
the breast. Correct Answers A) Start at the tail of Spence and
move in increasing smaller circles.
,13. During a physical assessment, a nurse inspects a patient's
abdomen. What assessment technique would the nurse perform
next?
A) Percussion
B) Palpation
C) Auscultation
D) Whichever is more comfortable for the patient Correct
Answers C) Auscultation
14. A nurse is assessing the level of consciousness of a patient
who sustained a head injury in a motor vehicle accident. The
nurse notes that the patient appears drowsy most of the time but
makes spontaneous movements. The nurse is able to wake the
patient by gently shaking him and calling his name. What level
of consciousness would the nurse document?
A) Awake and alert
B) Lethargic
C) Stuporous
D) Comatose Correct Answers B) Lethargic
15. A nurse is conducting an assessment of a patient's cranial
nerves. The nurse asks the patient to raise the eyebrows, smile,
and show the teeth to assess which cranial nerve?
A) Olfactory
B) Optic
C) Facial
D) Vagus Correct Answers C) Facial
, 2. A nurse caring for patients in a long-term care facility is
performing a functional assessment of a new patient. Which
questions would the nurse ask? Select all that apply.
A) Are you able to dress yourself?
B) Do you have a history of smoking?
C) What is the problem for which you are seeking care?
D) Do you prepare your own meals?
E) Do you manage your own finances?
F) Whom do you rely on for support? Correct Answers A) Are
you able to dress yourself?
D) Do you prepare your own meals?
E) Do you manage your own finances?
3. A nurse is assessing a patient's eyes for extraocular
movements. Which action correctly describes a step the nurse
would take when performing this test?
A) Ask the patient to sit about 3 ft away facing the nurse.
B) Keep a penlight about 1 ft from the patient's face and move it
slowly through the cardinal positions.
C) Move a penlight in a circular motion in front of the patient's
eyes.
E) Ask the patient to cover one eye with a hand or index card.
Correct Answers B) Keep a penlight about 1 ft from the
patient's face and move it slowly through the cardinal positions.
4. Which actions would the nurse perform when using the
technique of palpation during the physical assessment of a
patient? Select all that apply.
A) The nurse compares the patient's bilateral body parts for
symmetry.
B) The nurse takes a patient's pulse.
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