Health Assessment NCLEX
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath
sounds. Which type of assessment is the nurse performing?
1) Ongoing assessment
2) Comprehensive physical assessment
3) Focused physical assessment
4) Psychosocial assessment - ANS-3) Focused physical assessment
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there
are no contraindications, how should the nurse position the patient for this portion of the
admission assessment?
1) Sitting upright
2) Lying flat on the back with knees flexed
3) Lying flat on the back with arms and legs fully extended
4) Side-lying with the knees flexed - ANS-1) Sitting upright
For all body systems except the abdomen, what is the preferred order for the nurse to perform
the following examination techniques?
A. Palpation
B. Auscultation
C. Inspection
D. Percussion
1) D, B, A, C
2) C, A, D, B
3) B, C, D, A
4) A, B, C, D - ANS-2) C, A, D, B
The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a
hip replacement 2 weeks ago. Which position should the nurse avoid when examining this
patient's rectal area?
1) Sims'
2) Supine
3) Dorsal recumbent
4) Semi-Fowler's - ANS-1) Sims'
How should the nurse modify an examination for a 7-year-old child?
1) Ask the parents to leave the room before the examination.
2) Demonstrate equipment before using it.
3) Allow the child to help with the examination.
,4) Perform invasive procedures (e.g., otoscopic) last. - ANS-2) Demonstrate equipment before
using it.
The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed.
How should she position the patient to begin and perform most of the physical examination?
1) Dorsal recumbent
2) Semi-Fowler's
3) Lithotomy
4) Sims' - ANS-2) Semi-Fowler's
The nurse should use the diaphragm of the stethoscope to auscultate which of the following?
1) Heart murmurs
2) Jugular venous hums
3) Bowel sounds
4) Carotid bruits - ANS-3) Bowel sounds
The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the
physician's office for a college physical. This patient is considered:
1) obese.
2) overweight.
3) average.
4) underweight. - ANS-4) underweight
Where should the nurse assess skin color changes in the dark-skinned patient?
1) Nailbeds
2) Any exposed area
3) Oral mucosa
4) Palms of the hands - ANS-3) Oral muscosa
The nurse should assess skin temperature by using the:
1) dorsum of the hand.
2) pad of the fingertip.
3) palm of the hand.
4) dorsum of the wrist. - ANS-1) dorsum of the hand
While assessing an older adult patient, the nurse notes clubbing of the fingers. This finding is a
sign of:
1) fungal infection.
2) poor circulation.
3) iron deficiency.
4) long-term hypoxia. - ANS-4) Long-term hypoxia
A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease.
Which finding might the nurse expect when assessing the patient's nails?
,1) Soft, boggy nails
2) Brittle nails
3) Thickened nails
4) Thick nail with yellowing - ANS-1) Soft, boggy nails
A patient's ankles appear swollen. When the nurse assesses the edema, the skin depresses 6
mm, and the depression lasts 2 minutes. The nurse should document this finding as:
1) trace edema.
2) +1 edema.
3) +2 edema.
4) +3 edema. - ANS-4) +3 edema
A nursing diagnosis is best described as:
A. a determination of the etiology of disease.
B. a pattern of coping.
C. an individual's perception of health.
D. a concise statement of actual or potential health concerns or level of wellness. - ANS-D
Nursing diagnoses are clinical judgments about a person's response to an actual or potential
health state.
Medical diagnoses determine the cause or etiology of disease.
Coping patterns include methods to relieve stress.
Health perception is how the person describes and defines personal health.
1. If the origin of a patient's pain was the muscles and joints, which pain source would you
expect?
A: Visceral pain
B: Deep somatic pain
C: Cutaneous pain
D: Referred pain - ANS-B: Deep somatic pain
Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles and
bones. May result from pressure, trauma or ischemia. It is often described as aching or
throbbing. The pain is well localized and easy to pinpoint.
Visceral pain-originates from the larger internal organs. It is often described as dull, deep,
squeezing or cramping. It may result from direct injury to the organ or stretching of the organ
from tumor, ischemia, distension or severe contraction.
Cutaneous pain-Derived from skin surface and subcutaneous tissues. Pain is often described as
superficial, sharp, or burning.
Referred pain-Pain that is felt at a particular site but originates from another location. Both sites
are innervated by the same spinal cord, and it is difficult for the brain to differentiate the point of
origin. Ex. Patient having myocardial infarction (MI) may have left arm or neck pain.
, A complete database is:
A. used to collect data rapidly and is often compiled concurrently with lifesaving measures.
B. used for a limited or short-term problem usually consisting of one problem, one cue complex,
or one body system.
C. used to evaluate the cause or etiology of disease.
D. used to perform a thorough or comprehensive health history and physical examination. -
ANS-D
A complete database includes a complete health history and a full physical examination; it
describes the current and past health state and forms a baseline against which all future
changes can be measured.
An emergency database is rapid collection of data often obtained concurrently with lifesaving
measures.
An episodic database is for a limited or short-term problem; this database concerns mainly one
problem, one cue complex, or one body system.
Medical diagnoses are used to evaluate the cause or etiology of disease.
Mrs. Casey is a 39-year-old patient with a herniated disk and neuropathic pain. Which is a
primary characteristic of neuropathic pain?
A: An abnormal degree of pain interpretation.
B: An abnormal processing of the pain sensation.
C: An abnormal transmission of pain signals.
D: An abnormal modulation of pain signals. - ANS-B: Neuropathic pain is an abnormal
processing of pain sensations or messages from an injury to nerve fibers. This type of pain is
the most difficult to assess and treat. It is often perceived long after the site of injury heals, and
evolves into a chronic condition.
A patient admitted to the hospital with asthma has the following problems identified based on an
admission health history and physical assessment. Which problem is a first-level priority?
A. Ineffective self-health management
B. Risk for infection
C. Impaired gas exchange
D. Readiness for enhanced spiritual well-being - ANS-C
First-level priority problems are problems that are emergent, life-threatening, and immediate.
Impaired gas exchange is an emergent and immediate problem.
Third-level priority problems are problems that are important to the patient's health but can be
addressed after more urgent health problems are addressed. Ineffective self-health
management is an example of a third-level priority.
Second-level priority problems are problems that are next in urgency; these problems require
prompt intervention to forestall further deterioration. Risk for infection is an example of a
second-level priority.
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath
sounds. Which type of assessment is the nurse performing?
1) Ongoing assessment
2) Comprehensive physical assessment
3) Focused physical assessment
4) Psychosocial assessment - ANS-3) Focused physical assessment
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there
are no contraindications, how should the nurse position the patient for this portion of the
admission assessment?
1) Sitting upright
2) Lying flat on the back with knees flexed
3) Lying flat on the back with arms and legs fully extended
4) Side-lying with the knees flexed - ANS-1) Sitting upright
For all body systems except the abdomen, what is the preferred order for the nurse to perform
the following examination techniques?
A. Palpation
B. Auscultation
C. Inspection
D. Percussion
1) D, B, A, C
2) C, A, D, B
3) B, C, D, A
4) A, B, C, D - ANS-2) C, A, D, B
The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a
hip replacement 2 weeks ago. Which position should the nurse avoid when examining this
patient's rectal area?
1) Sims'
2) Supine
3) Dorsal recumbent
4) Semi-Fowler's - ANS-1) Sims'
How should the nurse modify an examination for a 7-year-old child?
1) Ask the parents to leave the room before the examination.
2) Demonstrate equipment before using it.
3) Allow the child to help with the examination.
,4) Perform invasive procedures (e.g., otoscopic) last. - ANS-2) Demonstrate equipment before
using it.
The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed.
How should she position the patient to begin and perform most of the physical examination?
1) Dorsal recumbent
2) Semi-Fowler's
3) Lithotomy
4) Sims' - ANS-2) Semi-Fowler's
The nurse should use the diaphragm of the stethoscope to auscultate which of the following?
1) Heart murmurs
2) Jugular venous hums
3) Bowel sounds
4) Carotid bruits - ANS-3) Bowel sounds
The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the
physician's office for a college physical. This patient is considered:
1) obese.
2) overweight.
3) average.
4) underweight. - ANS-4) underweight
Where should the nurse assess skin color changes in the dark-skinned patient?
1) Nailbeds
2) Any exposed area
3) Oral mucosa
4) Palms of the hands - ANS-3) Oral muscosa
The nurse should assess skin temperature by using the:
1) dorsum of the hand.
2) pad of the fingertip.
3) palm of the hand.
4) dorsum of the wrist. - ANS-1) dorsum of the hand
While assessing an older adult patient, the nurse notes clubbing of the fingers. This finding is a
sign of:
1) fungal infection.
2) poor circulation.
3) iron deficiency.
4) long-term hypoxia. - ANS-4) Long-term hypoxia
A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease.
Which finding might the nurse expect when assessing the patient's nails?
,1) Soft, boggy nails
2) Brittle nails
3) Thickened nails
4) Thick nail with yellowing - ANS-1) Soft, boggy nails
A patient's ankles appear swollen. When the nurse assesses the edema, the skin depresses 6
mm, and the depression lasts 2 minutes. The nurse should document this finding as:
1) trace edema.
2) +1 edema.
3) +2 edema.
4) +3 edema. - ANS-4) +3 edema
A nursing diagnosis is best described as:
A. a determination of the etiology of disease.
B. a pattern of coping.
C. an individual's perception of health.
D. a concise statement of actual or potential health concerns or level of wellness. - ANS-D
Nursing diagnoses are clinical judgments about a person's response to an actual or potential
health state.
Medical diagnoses determine the cause or etiology of disease.
Coping patterns include methods to relieve stress.
Health perception is how the person describes and defines personal health.
1. If the origin of a patient's pain was the muscles and joints, which pain source would you
expect?
A: Visceral pain
B: Deep somatic pain
C: Cutaneous pain
D: Referred pain - ANS-B: Deep somatic pain
Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles and
bones. May result from pressure, trauma or ischemia. It is often described as aching or
throbbing. The pain is well localized and easy to pinpoint.
Visceral pain-originates from the larger internal organs. It is often described as dull, deep,
squeezing or cramping. It may result from direct injury to the organ or stretching of the organ
from tumor, ischemia, distension or severe contraction.
Cutaneous pain-Derived from skin surface and subcutaneous tissues. Pain is often described as
superficial, sharp, or burning.
Referred pain-Pain that is felt at a particular site but originates from another location. Both sites
are innervated by the same spinal cord, and it is difficult for the brain to differentiate the point of
origin. Ex. Patient having myocardial infarction (MI) may have left arm or neck pain.
, A complete database is:
A. used to collect data rapidly and is often compiled concurrently with lifesaving measures.
B. used for a limited or short-term problem usually consisting of one problem, one cue complex,
or one body system.
C. used to evaluate the cause or etiology of disease.
D. used to perform a thorough or comprehensive health history and physical examination. -
ANS-D
A complete database includes a complete health history and a full physical examination; it
describes the current and past health state and forms a baseline against which all future
changes can be measured.
An emergency database is rapid collection of data often obtained concurrently with lifesaving
measures.
An episodic database is for a limited or short-term problem; this database concerns mainly one
problem, one cue complex, or one body system.
Medical diagnoses are used to evaluate the cause or etiology of disease.
Mrs. Casey is a 39-year-old patient with a herniated disk and neuropathic pain. Which is a
primary characteristic of neuropathic pain?
A: An abnormal degree of pain interpretation.
B: An abnormal processing of the pain sensation.
C: An abnormal transmission of pain signals.
D: An abnormal modulation of pain signals. - ANS-B: Neuropathic pain is an abnormal
processing of pain sensations or messages from an injury to nerve fibers. This type of pain is
the most difficult to assess and treat. It is often perceived long after the site of injury heals, and
evolves into a chronic condition.
A patient admitted to the hospital with asthma has the following problems identified based on an
admission health history and physical assessment. Which problem is a first-level priority?
A. Ineffective self-health management
B. Risk for infection
C. Impaired gas exchange
D. Readiness for enhanced spiritual well-being - ANS-C
First-level priority problems are problems that are emergent, life-threatening, and immediate.
Impaired gas exchange is an emergent and immediate problem.
Third-level priority problems are problems that are important to the patient's health but can be
addressed after more urgent health problems are addressed. Ineffective self-health
management is an example of a third-level priority.
Second-level priority problems are problems that are next in urgency; these problems require
prompt intervention to forestall further deterioration. Risk for infection is an example of a
second-level priority.
