C HAPTER 22: A SSESSING H EALTH S TATUS
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. The nurse who is assessing the patient with the Glasgow Coma Scale finds
a patient who can open his eyes spontaneousl y, obeys all commands, and
is oriented. The nurse documents a score of:
a. 7.
b. 10.
c. 12.
d. 15.
ANS: D
The Glasgow Coma Scale is used for the evaluation of neurologicall y
impaired patients: spontaneous eye opening = 4, obeying commands =
6, orientation = 5. This is the highest possible score of 15.
DIF: Cognitive Level: Anal ysis REF: p. 396|Table 22 -3
OBJ: Clinical Practice #4 TOP: Glasgow Coma Scale
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Health Promotion and Maintenance: Prevention and
Earl y Detection of Disease
2. Prior to preparing a female patient for a pelvic examination, the nu rse
should:
, a. encourage her to void in the bathroom.
b. provide a pillow for the head and the hips.
c. hand the patient a sheet and allow her to drape herself.
d. cleanse the external genitalia with soap and water.
ANS: A
Before a pelvic examination, the bladder s hould be emptied for a more
effective examination.
DIF: Cognitive Level: Application REF: p. 392 OBJ:
Theory #3 TOP: Special Focus Examinations KEY: Nursing
Process Step: Implementation MSC: NC LEX:
Physiological Integrity: Basic Care and Comfort
3. To perform the Weber test, the tuning fork is struck and placed:
a. at the nape of the neck.
b. in the middle of the bridge of the nose.
c. behind the right and then the left ear.
d. in the middle of the forehead or skull.
ANS: D
The Weber test is performed by strik ing the tuning fork and placing it
in the middle of the patient’s forehead or skull.
DIF: Cognitive Level: Comprehension REF: p. 393
OBJ: Theory #3 TOP: Auditory Examination KEY:
Nursing Process Step: Implementation MSC: NC LEX:
, Health Promotion and Maintenance: Prevention and Earl y
Detection of Disease
4. When examining a patient’s pupils with a light, the nurse notes that both
pupils constrict, regardless of which eye is stimulated by the light. The
nurse should document that the pupils exhibit:
a. consensual reflex
b. brisk reflex.
c. accommodation.
d. dilation reflex.
ANS: A
Consensual reflex is when both pupils constrict when either eye is
stimulated by light.
DIF: Cognitive Level: Comprehension REF: p. 394
OBJ: Clinical Practice #4 TOP: Pupillary Respo nse
KEY: Nursing Process Step: Assessment MSC: NC LEX:
Physiological Integrity: Physiological Adaptation
5. To correctl y determine the strength of a patient’s lower extremities during
a neurological examination, the nurse asks the patient to:
a. wiggle the toes of both feet at the same time.
b. push against his hand with the sole of one foot and then the other.
c. pull both feet up at the same time to stretch the Achilles tendons.
d. stand up independently.
ANS: B
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. The nurse who is assessing the patient with the Glasgow Coma Scale finds
a patient who can open his eyes spontaneousl y, obeys all commands, and
is oriented. The nurse documents a score of:
a. 7.
b. 10.
c. 12.
d. 15.
ANS: D
The Glasgow Coma Scale is used for the evaluation of neurologicall y
impaired patients: spontaneous eye opening = 4, obeying commands =
6, orientation = 5. This is the highest possible score of 15.
DIF: Cognitive Level: Anal ysis REF: p. 396|Table 22 -3
OBJ: Clinical Practice #4 TOP: Glasgow Coma Scale
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Health Promotion and Maintenance: Prevention and
Earl y Detection of Disease
2. Prior to preparing a female patient for a pelvic examination, the nu rse
should:
, a. encourage her to void in the bathroom.
b. provide a pillow for the head and the hips.
c. hand the patient a sheet and allow her to drape herself.
d. cleanse the external genitalia with soap and water.
ANS: A
Before a pelvic examination, the bladder s hould be emptied for a more
effective examination.
DIF: Cognitive Level: Application REF: p. 392 OBJ:
Theory #3 TOP: Special Focus Examinations KEY: Nursing
Process Step: Implementation MSC: NC LEX:
Physiological Integrity: Basic Care and Comfort
3. To perform the Weber test, the tuning fork is struck and placed:
a. at the nape of the neck.
b. in the middle of the bridge of the nose.
c. behind the right and then the left ear.
d. in the middle of the forehead or skull.
ANS: D
The Weber test is performed by strik ing the tuning fork and placing it
in the middle of the patient’s forehead or skull.
DIF: Cognitive Level: Comprehension REF: p. 393
OBJ: Theory #3 TOP: Auditory Examination KEY:
Nursing Process Step: Implementation MSC: NC LEX:
, Health Promotion and Maintenance: Prevention and Earl y
Detection of Disease
4. When examining a patient’s pupils with a light, the nurse notes that both
pupils constrict, regardless of which eye is stimulated by the light. The
nurse should document that the pupils exhibit:
a. consensual reflex
b. brisk reflex.
c. accommodation.
d. dilation reflex.
ANS: A
Consensual reflex is when both pupils constrict when either eye is
stimulated by light.
DIF: Cognitive Level: Comprehension REF: p. 394
OBJ: Clinical Practice #4 TOP: Pupillary Respo nse
KEY: Nursing Process Step: Assessment MSC: NC LEX:
Physiological Integrity: Physiological Adaptation
5. To correctl y determine the strength of a patient’s lower extremities during
a neurological examination, the nurse asks the patient to:
a. wiggle the toes of both feet at the same time.
b. push against his hand with the sole of one foot and then the other.
c. pull both feet up at the same time to stretch the Achilles tendons.
d. stand up independently.
ANS: B
