ADVANCED HEALTH ASSESSMENT BASIC
PHYSICAL EXAM WITH QUESTIONS &
CORRECT ANSWERS GRADED A+
A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control? - ANSWER-The client exhibits signs of adequate GI perfusion with normal bowel sounds.
An older adult reports being cold in the room even though the thermostat is set at 75°F (24°C). The nurse can tell the client that older adults may feel cold for which reason? - ANSWER-decreased ability to thermoregulate.
An older adult client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking properly.Upon physical assessment, the nurse notes tachycardia, hypotension, and hyperthermia. Which admission order would the nurse implement first? - ANSWER-intravenous fluid hydration
When teaching a group of middle-aged women, what would the nurse include when discussing primary prevention? - ANSWER-prevention of osteoporosis, the importance of regular breast self-examinations, and Pap smears
The nurse notes serous discharge when an abdominal dressing is changed. The nurse would document this drainage as which of the following? - ANSWER-clear, watery, yellow-tinged drainage
The nurse is assessing a client's respiratory status. Which assessment data indicate a problem? - ANSWER-28 breaths/min and audible 1 / 3
A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate? - ANSWER-ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel
The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessments? Select all that apply. - ANSWER-suicide or self-harm ideation recent use of substances of abuse allergic reactions or adverse drug reactions
The nurse receives morning lab work after shift hand-off. Based on the analysis of lab values, which client would the nurse assess first? - ANSWER-a client diagnosed with renal disease and a serum potassium level of 6.1 mEq/dL (6.1 mmol/L) who has limited output
A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest? - ANSWER-thrombophlebitis
A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should - ANSWER-use the bell of the stethoscope.
A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client? - ANSWER-broth, gelatin cubes, and tea
A client's face, neck, and chest have been burned in a fire 1 hour ago. What is the nurse's priority assessment at this time? - ANSWER-airway obstruction
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The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action? - ANSWER-Palpate for the bladder above the symphysis pubis.
Which finding in a client who recently underwent a total hip replacement would require a nurse to take immediate action? - ANSWER-red painful area on the calf of the affected leg
For which client is the nursing assessment of pain most likely to result in undertreatment? - ANSWER-an older adult who grimaces and states no pain after a gastrostomy tube placement
The most appropriate way for the nurse to assess a client's ability to perform activities of daily living is to: observe client performing varied activities of daily living. - ANSWER-observe client performing varied activities of daily living.
To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site? - ANSWER-carotid
When assessing a dark-skinned client for cyanosis, what area of the body will best reveal cyanosis? - ANSWER-oral mucous membranes
A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem? - ANSWER-ineffective breathing pattern
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? - ANSWER-every 15 minutes
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