Holistic Assessment Exam Questions With Complete
Solutions
A 60-year-old patient has difficulty hearing high-pitched sounds.
The nurse would document this finding as which of the
following?
-Otalgia
-Tinnitus
-Vertigo
-Presbycusis Correct Answer -Presbycusis
A client complains of scrotal pain & the nurse elicits a positive
prehn sign, the nurse would refer the client for treatment of what
condition
-tortuous varicocele
-scrotal mass
-strangulated hernia
-epididymitis Correct Answer -epididymitis
A client has presented w/ s/s that are suggestion of bell palsy,
what assessment finding is most consistent w/ this diagnosis
-closure of the affected eye from swelling
-muscle spasm of the lower face on the affected side
-inability to wrinkle the forehead
-inability to detect sharp & dull sensation Correct Answer -
inability to wrinkle the forehead
A client has sustained an injury to the cerebellum, which area
should be the nurses primary focus for assessment
,-respiratory status
-vital signs
-coordination
-cardiac function Correct Answer -coordination
A client's electronic health record reveals he had sx as an infant
to correct his urethra location on the ventral side of his penis,
what condition is this called
-paraphimosis
-hypospadias
-epispadias
-phimosis Correct Answer -hypospadias (ventral side)
-epispadias (dorsal side)
A male client has presented for follow-up to a diagnosis of
genital warts, the nurse should expect to assess for what type of
lesions
-firm, shiny nodules
-moist, fleshy papules
-reddened ulcers that occasionally bleed
-pimple-like vesicles Correct Answer -moist, fleshy papules
A nurse assesses a pt's epitrochlear nodes & finds them to be
enlarged & tender, what would the nurse do next
-examine the lower arm & hand for infection sites
-careful assess the cervical lymph nodes for enlargement
-ask the pt about any recent ear and throat infections
,-assess both legs for Homans sign Correct Answer -examine
the lower arm & hand for infection sites
A nurse examines an older adult patient. Which of the following
would the nurse document as a normal finding?
-Episcleritis
-Ectropion
-Exophthalmos
-Chalazion Correct Answer -Ectropion
A nurse has completed the general survey of a patient who has
been transferred to the unit. The information gathered during the
general survey primarily provides the nurse with which of the
following? SELECT ALL THAT APPLY.
-An indication of the level of physical distress experienced by
the patient.
-Clues about the overall health of the patient.
-A direct link to the patient's medical diagnosis.
-Indications about normal variations in the status of body
systems.
-Data relating to the patient's level of social support. Correct
Answer -An indication of the level of physical distress
experienced by the patient.
-Clues about the overall health of the patient.
-Indications about normal variations in the status of body
systems.
A nurse has received a report on a patient who will soon be
admitted to the medical unit from the emergency department.
, When preparing for the assessment phase of the nursing process,
what should the nurse do first?
-Validate important data.
-Collect subjective data.
-Document the data.
-Collect objective data. Correct Answer -Collect subjective
data.
A nurse is admitting a new patient to the subacute medical unit
and is completing a comprehensive assessment. The nurse is
appropriately applying standard precautions by performing
which action?
-Discarding in the trash can the safety pin that was used to
assess sensory perception.
-Wearing a gown, gloves, and mask during the physical exam.
-Wearing gloves to palpate the tongue and buccal membranes.
-Performing hand hygiene between examinations of each body
part Correct Answer -Wearing gloves to palpate the tongue and
buccal membranes.
A nurse is appraising a colleague's assessment technique as part
of a continuing education initiative. The nurse demonstrates the
proper technique for light palpation by performing which
action?
-Placing the non-dominant hand on top of the dominant hand for
improved sensation.
-Feeling the surface structures using a circular motion.
-Depressing the skin 1 to 2 inches with the dominant hand.
Solutions
A 60-year-old patient has difficulty hearing high-pitched sounds.
The nurse would document this finding as which of the
following?
-Otalgia
-Tinnitus
-Vertigo
-Presbycusis Correct Answer -Presbycusis
A client complains of scrotal pain & the nurse elicits a positive
prehn sign, the nurse would refer the client for treatment of what
condition
-tortuous varicocele
-scrotal mass
-strangulated hernia
-epididymitis Correct Answer -epididymitis
A client has presented w/ s/s that are suggestion of bell palsy,
what assessment finding is most consistent w/ this diagnosis
-closure of the affected eye from swelling
-muscle spasm of the lower face on the affected side
-inability to wrinkle the forehead
-inability to detect sharp & dull sensation Correct Answer -
inability to wrinkle the forehead
A client has sustained an injury to the cerebellum, which area
should be the nurses primary focus for assessment
,-respiratory status
-vital signs
-coordination
-cardiac function Correct Answer -coordination
A client's electronic health record reveals he had sx as an infant
to correct his urethra location on the ventral side of his penis,
what condition is this called
-paraphimosis
-hypospadias
-epispadias
-phimosis Correct Answer -hypospadias (ventral side)
-epispadias (dorsal side)
A male client has presented for follow-up to a diagnosis of
genital warts, the nurse should expect to assess for what type of
lesions
-firm, shiny nodules
-moist, fleshy papules
-reddened ulcers that occasionally bleed
-pimple-like vesicles Correct Answer -moist, fleshy papules
A nurse assesses a pt's epitrochlear nodes & finds them to be
enlarged & tender, what would the nurse do next
-examine the lower arm & hand for infection sites
-careful assess the cervical lymph nodes for enlargement
-ask the pt about any recent ear and throat infections
,-assess both legs for Homans sign Correct Answer -examine
the lower arm & hand for infection sites
A nurse examines an older adult patient. Which of the following
would the nurse document as a normal finding?
-Episcleritis
-Ectropion
-Exophthalmos
-Chalazion Correct Answer -Ectropion
A nurse has completed the general survey of a patient who has
been transferred to the unit. The information gathered during the
general survey primarily provides the nurse with which of the
following? SELECT ALL THAT APPLY.
-An indication of the level of physical distress experienced by
the patient.
-Clues about the overall health of the patient.
-A direct link to the patient's medical diagnosis.
-Indications about normal variations in the status of body
systems.
-Data relating to the patient's level of social support. Correct
Answer -An indication of the level of physical distress
experienced by the patient.
-Clues about the overall health of the patient.
-Indications about normal variations in the status of body
systems.
A nurse has received a report on a patient who will soon be
admitted to the medical unit from the emergency department.
, When preparing for the assessment phase of the nursing process,
what should the nurse do first?
-Validate important data.
-Collect subjective data.
-Document the data.
-Collect objective data. Correct Answer -Collect subjective
data.
A nurse is admitting a new patient to the subacute medical unit
and is completing a comprehensive assessment. The nurse is
appropriately applying standard precautions by performing
which action?
-Discarding in the trash can the safety pin that was used to
assess sensory perception.
-Wearing a gown, gloves, and mask during the physical exam.
-Wearing gloves to palpate the tongue and buccal membranes.
-Performing hand hygiene between examinations of each body
part Correct Answer -Wearing gloves to palpate the tongue and
buccal membranes.
A nurse is appraising a colleague's assessment technique as part
of a continuing education initiative. The nurse demonstrates the
proper technique for light palpation by performing which
action?
-Placing the non-dominant hand on top of the dominant hand for
improved sensation.
-Feeling the surface structures using a circular motion.
-Depressing the skin 1 to 2 inches with the dominant hand.
