pg. 1
Test Bank for Nursing Health Assessment / Best Practice Approach 4 th Edition /Questions with Correct Answers/ All Chapters Covered
The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment?
- Auscultate, percuss, palpate, inspect
- Inspect, auscultate, palpate, percuss
- Inspect, auscultate, percuss, palpate
- Palpate, percuss, auscultate, inspect - Correct Answer - Inspect, auscultate, percuss, palpate
The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse should document this as being
- cyanosis.
- jaundice.
- pallor.
- erythema. - Correct Answer - jaundice
While performing an assessment of the integument system, the nurse notes the client's eyeballs are protruding and the upper eyelids are elevated. What term should the nurse use to document this finding?
- Erythema
- Cyanosis
- Exophthalmos
- Normocephalic - Correct Answer - Exophthalmos
- / 4
pg. 2 The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel?
- Vital signs
- Filling of water pitchers
- Skull and face assessment
- Ambulation of surgical clients - Correct Answer - Skull and face assessment
The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should the nurse report to the physician immediately?
- Chest symmetrical
- Breath sounds equal bilaterally
- Asymmetrical chest expansion
- Bilateral symmetric vocal fremitus - Correct Answer - Asymmetrical chest expansion
While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins?
- 90-degree angle
- 30- to 45-degree angle
- 15-degree angle
- 60-degree angle - Correct Answer - 30- to 45-degree angle
The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which finding should the nurse report to the physician immediately?
- Pulses equal bilaterally
- Full pulsations
- Thready pulses
- Pulses present bilaterally - Correct Answer - Thready pulses
During the assessment of a client's breasts, the nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What should the nurse do next? 2 / 4
pg. 3
- Notify the charge nurse.
- Notify the physician.
- Document the findings in the nurse's notes as normal.
- Document the findings in the nurse's notes as abnormal. - Correct Answer - Document the findings in
the nurse's notes as normal
The nurse is preparing a client for an abdominal examination. What should the nurse done before beginning the examination?
- Ask the client to urinate.
- Ask the client to drink 8 ounces of water.
- Assess vital signs.
- Assess heart rate. - Correct Answer - Ask the client to urinate
The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to perform which action?
- Grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out.
- Hold an arm up and resist while the nurse tries to push it down.
- Flex each arm and then try to extend it against the nurse's attempt to keep the arm in flexion.
- Shrug the shoulders against the resistance of the nurse's hands - Correct Answer - Grasp the nurse's
index and middle fingers while the nurse tries to pull the fingers out.
The nurse is preparing to conduct a mental status assessment. What should the nurse include in this assessment?
- Cognitive and affective functions
- Cognitive and effective functions
- Affective and memory functions
- Affective and knowledge functions - Correct Answer - Cognitive and affective functions
The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he is unable to respond by speech or writing. What type of aphasia should the nurse realize this patient is demonstrating? 3 / 4
pg. 4
- Auditory aphasia
- Acoustic aphasia
- Sensory aphasia
- Expressive aphasia - Correct Answer - Expressive aphasia
The nurse is preparing to assess a client's reflexes. What equipment should the nurse gather before entering the room?
- Sterile gloves
- Clean gloves
- Percussion hammer
- Penlight - Correct Answer - Percussion hammer
The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. What should the nurse expect the health care provider to perform?
- Pap test
- Breast exam
- Rectal exam
- Abdominal exam - Correct Answer - Pap test
The nurse is preparing the morning assignments. Which assessment could the nurse delegate to unlicensed assistive personnel?
- Neurological assessment
- Musculoskeletal assessment
- Vital signs assessment
- Female genital assessment - Correct Answer - Vital signs assessment
The nurse is preparing to administer a cardiotonic drug to a client. Which assessment should the nurse perform before administering the medication?
- Respiratory rate
- Apical pulse
- / 4