Nursing 101- Chapter 27: Health Assessment UPDATED ACTUAL Questions and
CORRECT Answers
The nurse is asking questions about the client's pain "What seems to make the pain worse?"
experience during the interview. Which questions are "How long does the pain last?"
important to address when assessing pain? Select all that "Where is the pain located and does it move anywhere else?"
apply. Intensity
"What seems to make the pain worse?"
"Why do you have the pain?"
"How long does the pain last?"
"Where is the pain located and does it move anywhere
else?"
"Have you taken acetaminophen for the pain?"
Intensity
A client has been reporting persistent headaches. Which Pain is 4 out of 10 on a pain scale.
is an example of subjective data?
Temperature is 104.1°F (40.1°C)
The client us slow to respond to questions
The client is oriented to person, place, and time.
Pain is 4 out of 10 on a pain scale.
An older adult client admitted 4 days ago is being "Can you tell me where you are right now?"
treated for chronic obstructive pulmonary disease
(COPD) and now appears confused. What question will
the nurse ask to determine the client's level of
orientation?
"How are you feeling?"
"Have you been more confused?"
"Do you know what day this is?"
"Can you tell me where you are right now?"
The nurse has performed a Romberg test in the context falls risk
of a client's neurologic assessment. The client has failed
the test. The nurse should consequently identify what
nursing concern for care planning?
altered thought processes
chronic confusion
acute confusion
falls risk
,A 56-year-old client has a medium skin tone and a Measure the pulse oximetry.
diagnosis of heart failure. The nurse’s morning lung
assessment of the client reveals crackles in the mid to
lower lungs and respiratory rate of 32 breaths/min. The
nurse notices that the client is restless and their skin has
an ashen appearance. Which nursing action is the priority
intervention?
Assess capillary refill.
Measure the pulse oximetry.
Assess fluid intake.
Limit the client’s activity.
The nurse is asking admission interview questions and the Client states, "I feel winded all of the time and yesterday I started spitting up a lot
client has explained the reason for seeking care. What is of phlegm."
the most appropriate way to document the response?
Client states, "I feel winded all of the time and yesterday I
started spitting up a lot of phlegm."
Client describes shortness of breath and increased
sputum production.
Client reports breathlessness and productive cough.
Client reports respiratory distress and frequent spitting.
A nurse is caring for a client with paraplegia. Using An intact red area on the buttocks.
observation to examine the client's skin, what finding
might indicate the presence of a pressure injury?
A circular red, scaly area that itches on the top of the
forearm arm.
An intact faded purple area on the shoulder blades, with
a yellowish tint.
An intact red area on the buttocks.
An area of swollen, pale red bumps on the front of the
neck.
The gerontologic nurse is inspecting the genitalia of an Increased size of the labia unilaterally
older adult female client. Which assessment findings are Scant red vaginal discharge
of the most concern? Select all that apply.
Increased size of the labia unilaterally
Smooth skin and slightly drier mucosa
Darker pigmentation to vulva
Decreased amount of pubic hair
Scant red vaginal discharge
During a head-to-toe assessment of a client, the nurse To assess capillary refill and oxygenation
carefully palpates the client's nails. Which is the best
rationale for this technique?
To assess capillary refill and oxygenation
To assess for edema
To assess for infection
To assess for melanoma
, Upon admission to the hospital, the client states, "I am chief concern.
having surgery to correct my back. I have pain in the
lower back and the health care provider is going to do a
lumbar laminectomy." This statement reflects the client's:
symptoms.
review of systems.
chief concern.
objective assessment.
The nurse detects a weak, thready pulse found from a Decreased cardiac output
client palpating peripheral pulses. What condition does
the nurse suspect the client is experiencing?
Hypertension and circulatory overload
Decreased cardiac output
Impaired kidney function
Inflammation of a vein
A 7-year-old child suffered an injury on the playground at
school that resulted in a fracture to the left forearm. The
child reports to the nurse's office the next day for
neurovascular assessment of the extremity.
While assessing a client's temporal mandibular joint (TMJ), crepitus
the nurse feels grating and hears noise when the client
opens and closes their jaw. The nurse should document
what finding?
inflammation
arthritis
crepitus
fremitus
A gerontologic nurse is inspecting the genitalia of an Bulge to the left inguinal area
older adult male client. Which assessment findings are of Scant yellow discharge
the most concern? Select all that apply.
Bulge to the left inguinal area
Decreased penis size
Less firmness of the testes
Scant amount of pubic hair
Scant yellow discharge
CORRECT Answers
The nurse is asking questions about the client's pain "What seems to make the pain worse?"
experience during the interview. Which questions are "How long does the pain last?"
important to address when assessing pain? Select all that "Where is the pain located and does it move anywhere else?"
apply. Intensity
"What seems to make the pain worse?"
"Why do you have the pain?"
"How long does the pain last?"
"Where is the pain located and does it move anywhere
else?"
"Have you taken acetaminophen for the pain?"
Intensity
A client has been reporting persistent headaches. Which Pain is 4 out of 10 on a pain scale.
is an example of subjective data?
Temperature is 104.1°F (40.1°C)
The client us slow to respond to questions
The client is oriented to person, place, and time.
Pain is 4 out of 10 on a pain scale.
An older adult client admitted 4 days ago is being "Can you tell me where you are right now?"
treated for chronic obstructive pulmonary disease
(COPD) and now appears confused. What question will
the nurse ask to determine the client's level of
orientation?
"How are you feeling?"
"Have you been more confused?"
"Do you know what day this is?"
"Can you tell me where you are right now?"
The nurse has performed a Romberg test in the context falls risk
of a client's neurologic assessment. The client has failed
the test. The nurse should consequently identify what
nursing concern for care planning?
altered thought processes
chronic confusion
acute confusion
falls risk
,A 56-year-old client has a medium skin tone and a Measure the pulse oximetry.
diagnosis of heart failure. The nurse’s morning lung
assessment of the client reveals crackles in the mid to
lower lungs and respiratory rate of 32 breaths/min. The
nurse notices that the client is restless and their skin has
an ashen appearance. Which nursing action is the priority
intervention?
Assess capillary refill.
Measure the pulse oximetry.
Assess fluid intake.
Limit the client’s activity.
The nurse is asking admission interview questions and the Client states, "I feel winded all of the time and yesterday I started spitting up a lot
client has explained the reason for seeking care. What is of phlegm."
the most appropriate way to document the response?
Client states, "I feel winded all of the time and yesterday I
started spitting up a lot of phlegm."
Client describes shortness of breath and increased
sputum production.
Client reports breathlessness and productive cough.
Client reports respiratory distress and frequent spitting.
A nurse is caring for a client with paraplegia. Using An intact red area on the buttocks.
observation to examine the client's skin, what finding
might indicate the presence of a pressure injury?
A circular red, scaly area that itches on the top of the
forearm arm.
An intact faded purple area on the shoulder blades, with
a yellowish tint.
An intact red area on the buttocks.
An area of swollen, pale red bumps on the front of the
neck.
The gerontologic nurse is inspecting the genitalia of an Increased size of the labia unilaterally
older adult female client. Which assessment findings are Scant red vaginal discharge
of the most concern? Select all that apply.
Increased size of the labia unilaterally
Smooth skin and slightly drier mucosa
Darker pigmentation to vulva
Decreased amount of pubic hair
Scant red vaginal discharge
During a head-to-toe assessment of a client, the nurse To assess capillary refill and oxygenation
carefully palpates the client's nails. Which is the best
rationale for this technique?
To assess capillary refill and oxygenation
To assess for edema
To assess for infection
To assess for melanoma
, Upon admission to the hospital, the client states, "I am chief concern.
having surgery to correct my back. I have pain in the
lower back and the health care provider is going to do a
lumbar laminectomy." This statement reflects the client's:
symptoms.
review of systems.
chief concern.
objective assessment.
The nurse detects a weak, thready pulse found from a Decreased cardiac output
client palpating peripheral pulses. What condition does
the nurse suspect the client is experiencing?
Hypertension and circulatory overload
Decreased cardiac output
Impaired kidney function
Inflammation of a vein
A 7-year-old child suffered an injury on the playground at
school that resulted in a fracture to the left forearm. The
child reports to the nurse's office the next day for
neurovascular assessment of the extremity.
While assessing a client's temporal mandibular joint (TMJ), crepitus
the nurse feels grating and hears noise when the client
opens and closes their jaw. The nurse should document
what finding?
inflammation
arthritis
crepitus
fremitus
A gerontologic nurse is inspecting the genitalia of an Bulge to the left inguinal area
older adult male client. Which assessment findings are of Scant yellow discharge
the most concern? Select all that apply.
Bulge to the left inguinal area
Decreased penis size
Less firmness of the testes
Scant amount of pubic hair
Scant yellow discharge
