**2024**NCLEX PREP: HEALTH ASSESSMENT
QUESTIONS WITH COMPLETE ANSWERS
The clinic nurse is preparing to assess the client's apical pulse. The nurse
correctly palpates over which area? Click on the image to indicate your answer.
Chest under Nipple
Rationale:The heart is located in the mediastinum. Its apex, or distal end, points to the
left and lies at the level of the fifth intercostal space. A stethoscope should be placed in
this area to pick up heart sounds most clearly. The other options are incorrect because
they do not represent the anatomical positioning of the heart's apex. Option 2 identifies
palpation of the carotid pulse. Option 3 identifies palpation of the brachial pulse. Option
4 identifies palpation of the popliteal pulse.
A home care nurse is assessing a client's activities of daily living (ADLs) after a
stroke. What should the nurse include in the client's focused assessment?
Self-care needs such as toileting, feeding, and ambulating
Rationale: ADLs refer to the client's ability to bathe, toilet, ambulate, dress, and self-
feed. These functional abilities are always assessed by the home care nurse. The
normal routine in the home is not a component of functional assessment. The capability
to drive a car or do housework relates to instrumental ADLs.
A child is seen in the school nurse's office with complaints of pain in his right
forearm. In reviewing the child's record the nurse notes that he has a history of
being physically abused by the mother. Which should be the initial intervention
with this child?
Assess the child's physical status.
Rationale: The initial intervention is to assess the child's physical status. The child
,should be initially assessed for injury to the right arm and for bruises, burns, scars, and
any other signs of abuse. The nurse would next report the case as suspected child
abuse to the appropriate authorities. Option 2 may or may not be appropriate,
depending on the situation because the child may be fearful of telling the truth about
how the injury occurred. Option 4, although appropriate for some situations, is not
appropriate as the initial intervention.
The nurse enters a client's room with a pulse oximetry machine and tells the
client that the primary health care provider (PHCP) has prescribed continuous
oxygen saturation readings. The client's facial expression changes to one of
apprehension. The nurse can alleviate the client's anxiety by providing which
information about pulse oximetry?
It is painless and safe.
Rationale: The nurse should reassure the client that pulse oximetry is a safe, painless,
noninvasive method of monitoring oxygen saturation levels. No discomfort is involved
because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe.
The machine does have an alarm that will sound in response to interference with
monitoring or when the percent of oxygen saturation falls below a preset level.
The nurse is documenting the findings of a physical examination in a client's
record. Which findings should the nurse determine to be objective data?
The client has a rash on the chest and arms.
Rationale: Subjective data, collected during the health history, consist of information
that the client says about himself or herself. Objective data are obtained through the
physical examination and vital sign measurements, what the nurse observes, and
laboratory study and diagnostic test results. The remaining options identify subjective
data.
The clinic nurse is preparing to perform a Romberg test on a client being seen in
the clinic. The nurse would perform this test for the purpose of determining which
status?
,The functional status of the vestibular apparatus in the inner ear
Rationale: The Romberg test assesses the ability of the vestibular apparatus in the
inner ear to help maintain standing balance. The Romberg test also assesses
intactness of the cerebellum and proprioception. Options 1, 2, and 3 are incorrect and
unrelated to this test.
The nurse is providing care to a client admitted for coronary artery disease (CAD)
and a history of tobacco use. What is the most important element of the nurse's
focused assessment of the client's smoking history?
Number of pack-years
Rationale: The number of cigarettes smoked daily and the duration of the habit are used
to calculate the number of pack-years, which is the standard method of documenting
smoking history. The brand of cigarettes may give a general indication of tar and
nicotine levels, but the information is of no immediate clinical use. Desire to quit and
number of past attempts to quit smoking may be useful when the nurse develops a
smoking cessation plan with the client.
A 52-year-old male client is seen in the primary health care provider's (PHCP's)
office for a physical examination after experiencing unusual fatigue over the last
several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb
(99.8 kg). Vital signs are as follows: temperature, 98.6º F (37º C) orally; pulse, 86
beats/min; and respirations, 18 breaths/min. The blood pressure reading is
184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which
question should the nurse ask the client first?
"When was the last time you had your blood pressure checked?"
Rationale:The client is hypertensive, which is a known major modifiable risk factor for
coronary artery disease (CAD). The other major modifiable risk factors not exhibited by
this client include smoking and hypercholesterolemia. The client is overweight, which is
a contributing risk factor. The client's nonmodifiable risk factors are age and gender.
, Because the client presents with several risk factors, the nurse places priority of
attention on the client's major modifiable risk factors.
The nurse performs a physical assessment on a client and gathers both
subjective and objective data. Which would the nurse document as subjective
data?
Client reports difficulty sleeping at night.
Rationale: The purpose of a physical assessment is to collect both subjective data and
objective data. Subjective data, collected during the health history, consist of
information that the client says about himself or herself. Objective data are obtained
through the physical examination and vital sign measurements, what the nurse
observes, and laboratory study and diagnostic test results.
The nurse is setting up the physical environment for an interview with a client
and plans to obtain subjective data regarding the client's health. Which
interventions are appropriate? Select all that apply.
-Set the room temperature at a comfortable level.
-Remove distracting objects from the interviewing area.
-Ensure comfortable seating at eye level for the client and nurse.
Rationale: When preparing the physical environment for an interview, the nurse should
provide sufficient lighting for the client and nurse to see each other. The nurse should
avoid having the client face a strong light because the client would have to squint into
the full light. The nurse should set the room temperature at a comfortable level. The
nurse should arrange seating so that both the nurse and the client are seated
comfortably at eye level. The distance between the nurse and the client should be set
by the nurse at 4 to 5 ft (1.2 to 1.5 meters). If the nurse places the client any closer, the
nurse will be invading the client's private space and may create anxiety in the client. If
the nurse places the client farther away, the nurse may be seen by the client as distant
and aloof. The nurse avoids facing the client across a desk or table because this
creates a barrier. Distracting objects and equipment should be removed from the
interview area.
QUESTIONS WITH COMPLETE ANSWERS
The clinic nurse is preparing to assess the client's apical pulse. The nurse
correctly palpates over which area? Click on the image to indicate your answer.
Chest under Nipple
Rationale:The heart is located in the mediastinum. Its apex, or distal end, points to the
left and lies at the level of the fifth intercostal space. A stethoscope should be placed in
this area to pick up heart sounds most clearly. The other options are incorrect because
they do not represent the anatomical positioning of the heart's apex. Option 2 identifies
palpation of the carotid pulse. Option 3 identifies palpation of the brachial pulse. Option
4 identifies palpation of the popliteal pulse.
A home care nurse is assessing a client's activities of daily living (ADLs) after a
stroke. What should the nurse include in the client's focused assessment?
Self-care needs such as toileting, feeding, and ambulating
Rationale: ADLs refer to the client's ability to bathe, toilet, ambulate, dress, and self-
feed. These functional abilities are always assessed by the home care nurse. The
normal routine in the home is not a component of functional assessment. The capability
to drive a car or do housework relates to instrumental ADLs.
A child is seen in the school nurse's office with complaints of pain in his right
forearm. In reviewing the child's record the nurse notes that he has a history of
being physically abused by the mother. Which should be the initial intervention
with this child?
Assess the child's physical status.
Rationale: The initial intervention is to assess the child's physical status. The child
,should be initially assessed for injury to the right arm and for bruises, burns, scars, and
any other signs of abuse. The nurse would next report the case as suspected child
abuse to the appropriate authorities. Option 2 may or may not be appropriate,
depending on the situation because the child may be fearful of telling the truth about
how the injury occurred. Option 4, although appropriate for some situations, is not
appropriate as the initial intervention.
The nurse enters a client's room with a pulse oximetry machine and tells the
client that the primary health care provider (PHCP) has prescribed continuous
oxygen saturation readings. The client's facial expression changes to one of
apprehension. The nurse can alleviate the client's anxiety by providing which
information about pulse oximetry?
It is painless and safe.
Rationale: The nurse should reassure the client that pulse oximetry is a safe, painless,
noninvasive method of monitoring oxygen saturation levels. No discomfort is involved
because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe.
The machine does have an alarm that will sound in response to interference with
monitoring or when the percent of oxygen saturation falls below a preset level.
The nurse is documenting the findings of a physical examination in a client's
record. Which findings should the nurse determine to be objective data?
The client has a rash on the chest and arms.
Rationale: Subjective data, collected during the health history, consist of information
that the client says about himself or herself. Objective data are obtained through the
physical examination and vital sign measurements, what the nurse observes, and
laboratory study and diagnostic test results. The remaining options identify subjective
data.
The clinic nurse is preparing to perform a Romberg test on a client being seen in
the clinic. The nurse would perform this test for the purpose of determining which
status?
,The functional status of the vestibular apparatus in the inner ear
Rationale: The Romberg test assesses the ability of the vestibular apparatus in the
inner ear to help maintain standing balance. The Romberg test also assesses
intactness of the cerebellum and proprioception. Options 1, 2, and 3 are incorrect and
unrelated to this test.
The nurse is providing care to a client admitted for coronary artery disease (CAD)
and a history of tobacco use. What is the most important element of the nurse's
focused assessment of the client's smoking history?
Number of pack-years
Rationale: The number of cigarettes smoked daily and the duration of the habit are used
to calculate the number of pack-years, which is the standard method of documenting
smoking history. The brand of cigarettes may give a general indication of tar and
nicotine levels, but the information is of no immediate clinical use. Desire to quit and
number of past attempts to quit smoking may be useful when the nurse develops a
smoking cessation plan with the client.
A 52-year-old male client is seen in the primary health care provider's (PHCP's)
office for a physical examination after experiencing unusual fatigue over the last
several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb
(99.8 kg). Vital signs are as follows: temperature, 98.6º F (37º C) orally; pulse, 86
beats/min; and respirations, 18 breaths/min. The blood pressure reading is
184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which
question should the nurse ask the client first?
"When was the last time you had your blood pressure checked?"
Rationale:The client is hypertensive, which is a known major modifiable risk factor for
coronary artery disease (CAD). The other major modifiable risk factors not exhibited by
this client include smoking and hypercholesterolemia. The client is overweight, which is
a contributing risk factor. The client's nonmodifiable risk factors are age and gender.
, Because the client presents with several risk factors, the nurse places priority of
attention on the client's major modifiable risk factors.
The nurse performs a physical assessment on a client and gathers both
subjective and objective data. Which would the nurse document as subjective
data?
Client reports difficulty sleeping at night.
Rationale: The purpose of a physical assessment is to collect both subjective data and
objective data. Subjective data, collected during the health history, consist of
information that the client says about himself or herself. Objective data are obtained
through the physical examination and vital sign measurements, what the nurse
observes, and laboratory study and diagnostic test results.
The nurse is setting up the physical environment for an interview with a client
and plans to obtain subjective data regarding the client's health. Which
interventions are appropriate? Select all that apply.
-Set the room temperature at a comfortable level.
-Remove distracting objects from the interviewing area.
-Ensure comfortable seating at eye level for the client and nurse.
Rationale: When preparing the physical environment for an interview, the nurse should
provide sufficient lighting for the client and nurse to see each other. The nurse should
avoid having the client face a strong light because the client would have to squint into
the full light. The nurse should set the room temperature at a comfortable level. The
nurse should arrange seating so that both the nurse and the client are seated
comfortably at eye level. The distance between the nurse and the client should be set
by the nurse at 4 to 5 ft (1.2 to 1.5 meters). If the nurse places the client any closer, the
nurse will be invading the client's private space and may create anxiety in the client. If
the nurse places the client farther away, the nurse may be seen by the client as distant
and aloof. The nurse avoids facing the client across a desk or table because this
creates a barrier. Distracting objects and equipment should be removed from the
interview area.
