V1 and V2 REVIEW - Health Assessment
1
The nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should be expected for this client? - Question
and answersBarrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard
bowel sounds in the right upper quadrant. What action should the nurse take next? -
Question and answersNote the character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on
the back of the tongue which causes the client to gag. After removing the tongue blade,
what action should the nurse take? - Question and answersDocument an intact gag
reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse
should tell the client that it is most important to assess which part of the breast more
closely for changes? - Question and answersUpper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a
chest measurement of 42 inches, waist measurement of 45 inches, and hip
measurement of 50 inches. What important message should the nurse explain to the
client to promote health promotion? - Question and answersA waist circumference is
greater than 35 inches in women puts you at higher risk for type 2 diabetes and heart
disease."
The nurse performs a physical assessment on an older female client. Which change
from the prior exam may be an indication of osteoporosis? - Question and
answersHeight reduction of 1.5 inches.
While conducting an interview to obtain a health history, the nurse notices that the client
pauses frequently and looks at the nurse expectantly. Which response is best for the
nurse to provide? - Question and answersSit quietly to allow the client to respond
comfortably.
A client is in the clinical for a yearly physical examination. Which action should the
nurse take when preparing to examine the client's abdomen? - Question and
answersAsk the client to urinate before beginning the examination.
, Which respiratory condition should the nurse document after measuring a respiratory
rate of 8 breaths/minute? - Question and answersBradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - Question and
answersMeasure the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal
impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion
sound should the nurse expect to hear when percussing over the client's lower lobes? -
Question and answersDull, thud-like.
A client is being assessed upon admission to the medical-surgical unit. The nurse is
preparing to complete a head-to-toe assessment and will begin at the head of the client.
Which technique should the nurse use to begin the assessment? - Question and
answersInspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical examination.
Which assessment technique should the nurse implement when palpating the
abdominal aorta? - Question and answersDeep palpation above and to the left of the
umbilicus.
The nurse is conducting a family history as part of the assessment interview. Which
action should the nurse take to ensure that sufficient information about the client's blood
relatives is obtained? - Question and answersDocument at least 3 generations of the
client's family medical history.
The nurse is testing the client's shoulders for range of motion. What should the nurse
document to record normal internal rotation? - Question and answersRange of 90
degrees when the hands are placed at the small of the back.
A client presents with a rash along the occipital area of the hairline and reports intense
itching. How should the nurse begin the objective part of the examination? - Question
and answersInspect the scalp looking for nits.
The nurse is assessing a client's range of motion as the client bends the right knee up
to the chest while keeping the left leg straight, but is unable to keep the left thigh on the
table. The assessment is repeated for the left knee, and the client is unable to keep the
right thigh on the table. How should the nurse document this finding? - Question and
answersA flexion deformity referred to as a positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are dark
red in color and will not blanch. The lesions range from 1 to 3 mm in size. What is the
first question the nurse should ask the client? - Question and answersHave you notice
any irregular bleeding
1
The nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should be expected for this client? - Question
and answersBarrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard
bowel sounds in the right upper quadrant. What action should the nurse take next? -
Question and answersNote the character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on
the back of the tongue which causes the client to gag. After removing the tongue blade,
what action should the nurse take? - Question and answersDocument an intact gag
reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse
should tell the client that it is most important to assess which part of the breast more
closely for changes? - Question and answersUpper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a
chest measurement of 42 inches, waist measurement of 45 inches, and hip
measurement of 50 inches. What important message should the nurse explain to the
client to promote health promotion? - Question and answersA waist circumference is
greater than 35 inches in women puts you at higher risk for type 2 diabetes and heart
disease."
The nurse performs a physical assessment on an older female client. Which change
from the prior exam may be an indication of osteoporosis? - Question and
answersHeight reduction of 1.5 inches.
While conducting an interview to obtain a health history, the nurse notices that the client
pauses frequently and looks at the nurse expectantly. Which response is best for the
nurse to provide? - Question and answersSit quietly to allow the client to respond
comfortably.
A client is in the clinical for a yearly physical examination. Which action should the
nurse take when preparing to examine the client's abdomen? - Question and
answersAsk the client to urinate before beginning the examination.
, Which respiratory condition should the nurse document after measuring a respiratory
rate of 8 breaths/minute? - Question and answersBradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - Question and
answersMeasure the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal
impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion
sound should the nurse expect to hear when percussing over the client's lower lobes? -
Question and answersDull, thud-like.
A client is being assessed upon admission to the medical-surgical unit. The nurse is
preparing to complete a head-to-toe assessment and will begin at the head of the client.
Which technique should the nurse use to begin the assessment? - Question and
answersInspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical examination.
Which assessment technique should the nurse implement when palpating the
abdominal aorta? - Question and answersDeep palpation above and to the left of the
umbilicus.
The nurse is conducting a family history as part of the assessment interview. Which
action should the nurse take to ensure that sufficient information about the client's blood
relatives is obtained? - Question and answersDocument at least 3 generations of the
client's family medical history.
The nurse is testing the client's shoulders for range of motion. What should the nurse
document to record normal internal rotation? - Question and answersRange of 90
degrees when the hands are placed at the small of the back.
A client presents with a rash along the occipital area of the hairline and reports intense
itching. How should the nurse begin the objective part of the examination? - Question
and answersInspect the scalp looking for nits.
The nurse is assessing a client's range of motion as the client bends the right knee up
to the chest while keeping the left leg straight, but is unable to keep the left thigh on the
table. The assessment is repeated for the left knee, and the client is unable to keep the
right thigh on the table. How should the nurse document this finding? - Question and
answersA flexion deformity referred to as a positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are dark
red in color and will not blanch. The lesions range from 1 to 3 mm in size. What is the
first question the nurse should ask the client? - Question and answersHave you notice
any irregular bleeding
