NSG6020: Advanced Health and Physical Assessment
Final Exam South University
Breast Sagging in Older Adults:
A 65-year-old patient remarks that her breasts sag due to lack of exercise. The nurse
should explain that post-menopause, glandular and fat tissue atrophies, causing breast
size and elasticity to diminish, resulting in sagging breasts.
Recognition of Puberty in Boys:
The first sign of puberty is the enlargement of the testes.
Bilateral Pitting Edema:
A patient with bilateral pitting edema of the feet should have their venous function of the
lower extremities assessed primarily.
Severe Nystagmus:
Severe nystagmus in both eyes may indicate disease of the cerebellum or brainstem.
Musculoskeletal Assessment Approach:
The correct approach for a musculoskeletal examination is proximal to distal.
Breast Lump Evaluation:
A 43-year-old woman with a long-standing breast lump that has recently become harder
should be further evaluated by a physician due to the change in consistency.
Infant Hip Examination:
,During a hip examination of a 3-month-old infant, no "clunking" sounds indicate a
negative Ortolani's sign.
Blisters and Scabs in a Child:
A child with blisters and scabs on the face and buttocks, suspected to have impetigo,
should be further assessed.
Superficial Reflex Testing:
Stroking the lateral side of the sole and observing plantar flexion of the toes indicates a
present plantar reflex.
Cyclic Breast Changes:
A woman noticing monthly breast changes should be reassured that cyclic breast changes
are common due to hormonal fluctuations during the menstrual cycle.
New Breast Lump:
A patient who noticed a new breast lump in the shower near the axilla should have the
unaffected breast palpated first.
12-Lead ECG Assessment:
A 12-lead ECG reveals ST elevation; the nurse should suspect an acute myocardial
infarction and prepare for further intervention.
Cultural Considerations in Health Assessment:
When conducting a health history, the nurse should consider the patient's cultural
background to provide appropriate care.
Signs of Dehydration in the Elderly:
, Common signs of dehydration in the elderly include dry mucous membranes, decreased
skin turgor, and confusion.
Assessment of Jugular Venous Distention:
Elevating the head of the bed when assessing for jugular venous distention allows for a
more accurate evaluation.
Skin Assessment for Melanoma:
The ABCDE rule (Asymmetry, Border, Color, Diameter, Evolving) is used when assessing
moles for potential melanoma.
Hearing Loss in Older Adults:
Presbycusis, age-related hearing loss, is often characterized by a gradual loss of high-
frequency hearing.
Pediatric Growth Measurements:
In pediatric patients, growth should be assessed using percentiles on growth charts,
considering both height and weight.
Neurological Assessment with the Glasgow Coma Scale:
The Glasgow Coma Scale evaluates a patient’s level of consciousness, focusing on eye,
verbal, and motor responses.
Respiratory Assessment Techniques:
The best position for auscultating lung sounds in a patient is with the patient sitting
upright.
Family History during Assessment:
Final Exam South University
Breast Sagging in Older Adults:
A 65-year-old patient remarks that her breasts sag due to lack of exercise. The nurse
should explain that post-menopause, glandular and fat tissue atrophies, causing breast
size and elasticity to diminish, resulting in sagging breasts.
Recognition of Puberty in Boys:
The first sign of puberty is the enlargement of the testes.
Bilateral Pitting Edema:
A patient with bilateral pitting edema of the feet should have their venous function of the
lower extremities assessed primarily.
Severe Nystagmus:
Severe nystagmus in both eyes may indicate disease of the cerebellum or brainstem.
Musculoskeletal Assessment Approach:
The correct approach for a musculoskeletal examination is proximal to distal.
Breast Lump Evaluation:
A 43-year-old woman with a long-standing breast lump that has recently become harder
should be further evaluated by a physician due to the change in consistency.
Infant Hip Examination:
,During a hip examination of a 3-month-old infant, no "clunking" sounds indicate a
negative Ortolani's sign.
Blisters and Scabs in a Child:
A child with blisters and scabs on the face and buttocks, suspected to have impetigo,
should be further assessed.
Superficial Reflex Testing:
Stroking the lateral side of the sole and observing plantar flexion of the toes indicates a
present plantar reflex.
Cyclic Breast Changes:
A woman noticing monthly breast changes should be reassured that cyclic breast changes
are common due to hormonal fluctuations during the menstrual cycle.
New Breast Lump:
A patient who noticed a new breast lump in the shower near the axilla should have the
unaffected breast palpated first.
12-Lead ECG Assessment:
A 12-lead ECG reveals ST elevation; the nurse should suspect an acute myocardial
infarction and prepare for further intervention.
Cultural Considerations in Health Assessment:
When conducting a health history, the nurse should consider the patient's cultural
background to provide appropriate care.
Signs of Dehydration in the Elderly:
, Common signs of dehydration in the elderly include dry mucous membranes, decreased
skin turgor, and confusion.
Assessment of Jugular Venous Distention:
Elevating the head of the bed when assessing for jugular venous distention allows for a
more accurate evaluation.
Skin Assessment for Melanoma:
The ABCDE rule (Asymmetry, Border, Color, Diameter, Evolving) is used when assessing
moles for potential melanoma.
Hearing Loss in Older Adults:
Presbycusis, age-related hearing loss, is often characterized by a gradual loss of high-
frequency hearing.
Pediatric Growth Measurements:
In pediatric patients, growth should be assessed using percentiles on growth charts,
considering both height and weight.
Neurological Assessment with the Glasgow Coma Scale:
The Glasgow Coma Scale evaluates a patient’s level of consciousness, focusing on eye,
verbal, and motor responses.
Respiratory Assessment Techniques:
The best position for auscultating lung sounds in a patient is with the patient sitting
upright.
Family History during Assessment:
