C HAPTER 30: H EALTH A SSESSMENT AND
P HYSICAL E XAMINATION
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. The school -aged child is taken to the school nurse after experiencing a
nosebleed during a softball game. The appropriate intervention is for the
nurse to:
A. Have the child lean backward
B. Appl y pressure to the anterior nose
C. Appl y a warm cloth to the area
D. Have the child close his mouth and blow his nose
ANS: B
The nurse should have the child who is experiencing a nosebleed sit up
and lean forward to avoid aspiration of blood, appl y pressure to the
anterior nose with the thumb and forefinger as the c hild breathes
through the mouth, and appl y ice or a cold cloth to the bridge of the
nose if pressure fails to stop bleeding. The child should not lean
backward as this may cause the child to aspirate blood. A cold cloth
will slow bleeding and help blood to coagulate, not a warm cloth. The
child should breathe through the mouth. Blowing his nose may onl y
continue bleeding as it may disturb any clot formation
, PTS: 1 DIF: A REF: 586 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan de signation:
Reduction of Risk Potential/Techniques of Physical Assessment
2. An older adult client is visiting the physicians office for a check -up. The
client asks the nurse how often the influenza and pneumonia vaccines
should be obtained. The nurse respond s to the client that these
vaccinations should be done:
A. Every 6 months
B. Annuall y
C. Every 5 years
D. Every 7 years
ANS: B
Older adults should be counseled to receive annual influenza and
pneumonia vaccinations. It is not necessary to receive these
vaccinations every 6 months. The influenza and pneumonia vaccines
should be obtained annuall y in the older adult because of their greater
susceptibilit y to respiratory tract infection. It is recommended that
older adults receive the influenza and pneumonia vaccines ann uall y
because they have a greater susceptibilit y to respiratory tract infection.
PTS: 1 DIF: A REF: Chapter 34, 649 OBJ: Knowledge
TOP: Nursing Process: Assessment MSC: NC LEX test plan
designation: Reduction of Risk Potential/Techniques of Physical
Assessment
3. A pregnant client is seen by the nurse in the antenatal clinic. On
inspection, the nurse expects that this clients breasts will have:
, A. Softer tissue
B. Flatter nipples
C. Darkened areola
D. Diminished superficial veins
ANS: C
Normal changes of the breasts during pregnancy include the areola
becoming darker and the diameter increasing. Breast tissue becomes
softer during menopause, not pregnancy. Nipples become flatter in
older adulthood. Superficial veins become more prominent during
pregnancy.
PTS: 1 DIF: A REF: 612 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Reduction of Risk Potential/Techniques of Physical Assessment
4. At a medical clinic, a client with vascular insufficiency is seen frequentl y.
The nurse will give the client additional instruction about her condition if
the client:
A. Walks regularl y
B. Wears knee-length stockings
C. Elevates the feet when sitting
D. Alternates periods of sitting and standing
ANS: B
The client with risk or evidence of vascular insufficie ncy should not
wear tight clothing over the lower body or legs, such as knee -length
stockings. Walking regularl y is recommended for the client with
, vascular insufficiency. The client with vascular insufficiency should
elevate his or her feet when sitting. The client with vascular
insufficiency should avoid sitting or standing for long periods.
PTS: 1 DIF: A REF: 605 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Reduction of Risk Potential/Techniques of Physical Ass essment
5. During the physical examination, the nurse should assess the clients
glands by using the:
A. Dorsum of the hand
B. Pads of the fingers
C. Palmar surface of the hand
D. Fingertip grasp of the tissue
ANS: B
To assess the clients glands, the nurse should use t he pads of the
fingers and palpate gentl y. The dorsum of the hand may be used to
detect skin temperature, not to assess the clients glands. The palmar
surface of the hand is not used to assess the clients glands. The nurse
should not use a fingertip grasp of the tissue when assessing a clients
glands.
PTS: 1 DIF: A REF: 589 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Reduction of Risk Potential/Techniques of Physical Assessment
P HYSICAL E XAMINATION
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. The school -aged child is taken to the school nurse after experiencing a
nosebleed during a softball game. The appropriate intervention is for the
nurse to:
A. Have the child lean backward
B. Appl y pressure to the anterior nose
C. Appl y a warm cloth to the area
D. Have the child close his mouth and blow his nose
ANS: B
The nurse should have the child who is experiencing a nosebleed sit up
and lean forward to avoid aspiration of blood, appl y pressure to the
anterior nose with the thumb and forefinger as the c hild breathes
through the mouth, and appl y ice or a cold cloth to the bridge of the
nose if pressure fails to stop bleeding. The child should not lean
backward as this may cause the child to aspirate blood. A cold cloth
will slow bleeding and help blood to coagulate, not a warm cloth. The
child should breathe through the mouth. Blowing his nose may onl y
continue bleeding as it may disturb any clot formation
, PTS: 1 DIF: A REF: 586 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan de signation:
Reduction of Risk Potential/Techniques of Physical Assessment
2. An older adult client is visiting the physicians office for a check -up. The
client asks the nurse how often the influenza and pneumonia vaccines
should be obtained. The nurse respond s to the client that these
vaccinations should be done:
A. Every 6 months
B. Annuall y
C. Every 5 years
D. Every 7 years
ANS: B
Older adults should be counseled to receive annual influenza and
pneumonia vaccinations. It is not necessary to receive these
vaccinations every 6 months. The influenza and pneumonia vaccines
should be obtained annuall y in the older adult because of their greater
susceptibilit y to respiratory tract infection. It is recommended that
older adults receive the influenza and pneumonia vaccines ann uall y
because they have a greater susceptibilit y to respiratory tract infection.
PTS: 1 DIF: A REF: Chapter 34, 649 OBJ: Knowledge
TOP: Nursing Process: Assessment MSC: NC LEX test plan
designation: Reduction of Risk Potential/Techniques of Physical
Assessment
3. A pregnant client is seen by the nurse in the antenatal clinic. On
inspection, the nurse expects that this clients breasts will have:
, A. Softer tissue
B. Flatter nipples
C. Darkened areola
D. Diminished superficial veins
ANS: C
Normal changes of the breasts during pregnancy include the areola
becoming darker and the diameter increasing. Breast tissue becomes
softer during menopause, not pregnancy. Nipples become flatter in
older adulthood. Superficial veins become more prominent during
pregnancy.
PTS: 1 DIF: A REF: 612 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Reduction of Risk Potential/Techniques of Physical Assessment
4. At a medical clinic, a client with vascular insufficiency is seen frequentl y.
The nurse will give the client additional instruction about her condition if
the client:
A. Walks regularl y
B. Wears knee-length stockings
C. Elevates the feet when sitting
D. Alternates periods of sitting and standing
ANS: B
The client with risk or evidence of vascular insufficie ncy should not
wear tight clothing over the lower body or legs, such as knee -length
stockings. Walking regularl y is recommended for the client with
, vascular insufficiency. The client with vascular insufficiency should
elevate his or her feet when sitting. The client with vascular
insufficiency should avoid sitting or standing for long periods.
PTS: 1 DIF: A REF: 605 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Reduction of Risk Potential/Techniques of Physical Ass essment
5. During the physical examination, the nurse should assess the clients
glands by using the:
A. Dorsum of the hand
B. Pads of the fingers
C. Palmar surface of the hand
D. Fingertip grasp of the tissue
ANS: B
To assess the clients glands, the nurse should use t he pads of the
fingers and palpate gentl y. The dorsum of the hand may be used to
detect skin temperature, not to assess the clients glands. The palmar
surface of the hand is not used to assess the clients glands. The nurse
should not use a fingertip grasp of the tissue when assessing a clients
glands.
PTS: 1 DIF: A REF: 589 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Reduction of Risk Potential/Techniques of Physical Assessment
