HEALTH ASSESSMENT EXAM PRACTICE

HEALTH ASSESSMENT EXAM PRACTICE Which of the following is an open ended question? a. What brought you in today? b. Where does it hurt? c. Have you been checking your blood pressure? d. When was the last time you were seen by a doctor? - CORRECT ANSWER-Answer:A. It is the only choice that would invite a paragraph for an answer rather than a short statement. Which of the following is the most basic function and therefore should be tested first in an assessment of mental status? a.Behavior b. Consciousness c. Judgment d. Language - CORRECT ANSWER-Answer: B. According to your textbook, consciousness is the most fundamental of these particular characteristics; therefore, it would be tested first. Which of the following is not a significant contributor to the assessment of mental status? a.Known illness or health problem b. Current medications known to affect mood or cognition c. Racial background d. Personal history; current stress, social habits, sleep habits, drug and alcohol use - CORRECT ANSWER-Answer: C. The other choices are all elements of the interview that contribute to interpretation of the findings of the examination. Correct order of physical examination skills: - CORRECT ANSWER-Inspection, Palpation, Percussion, Auscultation NCLEX question The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the underlying tissue: A) turgor. B)texture. C)density. D)consistency. - CORRECT ANSWER-ANSWER: C Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation. NCLEX question The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? The nurse: A)percusses once over each area. B)lifts the striking finger off quickly after each stroke. C)strikes with the finger tip, not the finger pad. D)uses the wrist to make the strikes, not the arm. - CORRECT ANSWER-ANSWER: A For percussion, the nurse should percuss two times over each location. The striking finger should be lifted off quickly because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed, and it is used to make the strikes, not the arm NCLEX question The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? A)The slope of the earpieces should point posteriorly (toward the occiput). B)The stethoscope does not magnify sound but does block out extraneous room noise. C)The fit and quality of the stethoscope are not as important as its ability to magnify sound. D)The ideal tubing length should be 22 inches to dampen distortion of sound. - CORRECT ANSWER-ANSWER: B The stethoscope does not magnify sound but does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner's nose. Longer tubing will distort sound. The fit and quality of the stethoscope are important. NCLEX question The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: A)auscultate over the area with a fetoscope. B)use a goniometer to measure the pulsations. C)use a Doppler device to check for pulsations over the area. D)check for the presence of pulsations with a stethoscope. - CORRECT ANSWERANSWER: C Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds. NCLEX question When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination?