,SET 1 (50 Questions) – Health Assessment V2
1. A nurse is performing a general survey on a 78-year-old client.
Which finding is considered an expected age-related change?
A) Increased tactile fremitus
B) Decreased vibration sense in the lower extremities
C) Positive Babinski reflex
D) Orthostatic blood pressure increase of 15 mm Hg
Rationale: Mild decrease in vibration sense in the lower extremities
is common with aging due to peripheral nerve changes.
2. When assessing a client’s radial pulse, the nurse notes an irregular
rhythm with no discernible pattern. What should the nurse do next?
A) Document as normal sinus arrhythmia
B) Palpate the apical pulse for one full minute
C) Recheck the radial pulse in 30 minutes
D) Notify the healthcare provider immediately
Rationale: An irregularly irregular rhythm (e.g., atrial fibrillation)
requires apical pulse assessment to detect a pulse deficit.
3. A client has a blood pressure of 162/94 mm Hg in the right arm
and 118/72 mm Hg in the left arm. What does this suggest?
A) Normal interarm difference
B) Right arm hypertension
C) Possible aortic dissection or subclavian stenosis
D) Incorrect cuff size on the left arm
,*Rationale: A systolic difference >15-20 mm Hg between arms is
abnormal and may indicate aortic dissection or subclavian artery
stenosis.*
4. The nurse assesses a client’s pupils. One pupil is dilated and
nonreactive to light, while the other constricts normally. This finding
suggests:
A) Physiologic anisocoria
B) Cranial nerve III compression
C) Horner syndrome
D) Glaucoma
Rationale: A dilated, fixed pupil (mydriasis) with a normal
contralateral pupil indicates oculomotor nerve compression, a
neurologic emergency.
5. A client’s oxygen saturation is 89% on room air. The client has no
respiratory distress. What is the nurse’s priority?
A) Apply a non-rebreather mask at 15 L/min
B) Apply oxygen at 2 L/min via nasal cannula
C) Obtain an arterial blood gas
D) Reposition the client to Trendelenburg
*Rationale: Mild hypoxemia (SpO2 <90%) warrants low-flow
oxygen; higher concentrations may be unnecessary and harmful in
some clients.*
, 6. During auscultation of the lungs, the nurse hears fine, crackling
sounds at the lung bases that do not clear with coughing. These are
best described as:
A) Atelectatic crackles
B) Fine crackles (consistent with pulmonary fibrosis)
C) Rhonchi
D) Wheezes
Rationale: Persistent fine crackles at the bases suggest interstitial
lung disease, such as pulmonary fibrosis.
7. A client with dark skin has a newonset of jaundice. Where should
the nurse best assess for this finding?
A) Palms of the hands
B) Hard palate and sclera
C) Dorsum of the feet
D) Abdomen
Rationale: Jaundice is most reliably assessed in the sclera and hard
palate because these areas have high elastin content that binds
bilirubin.
8. The nurse is testing cranial nerve V (trigeminal). Which assessment
technique is correct?
A) Ask the client to smile and frown
B) Have the client identify a familiar scent
C) Lightly touch the client’s forehead, cheek, and chin with a cotton
1. A nurse is performing a general survey on a 78-year-old client.
Which finding is considered an expected age-related change?
A) Increased tactile fremitus
B) Decreased vibration sense in the lower extremities
C) Positive Babinski reflex
D) Orthostatic blood pressure increase of 15 mm Hg
Rationale: Mild decrease in vibration sense in the lower extremities
is common with aging due to peripheral nerve changes.
2. When assessing a client’s radial pulse, the nurse notes an irregular
rhythm with no discernible pattern. What should the nurse do next?
A) Document as normal sinus arrhythmia
B) Palpate the apical pulse for one full minute
C) Recheck the radial pulse in 30 minutes
D) Notify the healthcare provider immediately
Rationale: An irregularly irregular rhythm (e.g., atrial fibrillation)
requires apical pulse assessment to detect a pulse deficit.
3. A client has a blood pressure of 162/94 mm Hg in the right arm
and 118/72 mm Hg in the left arm. What does this suggest?
A) Normal interarm difference
B) Right arm hypertension
C) Possible aortic dissection or subclavian stenosis
D) Incorrect cuff size on the left arm
,*Rationale: A systolic difference >15-20 mm Hg between arms is
abnormal and may indicate aortic dissection or subclavian artery
stenosis.*
4. The nurse assesses a client’s pupils. One pupil is dilated and
nonreactive to light, while the other constricts normally. This finding
suggests:
A) Physiologic anisocoria
B) Cranial nerve III compression
C) Horner syndrome
D) Glaucoma
Rationale: A dilated, fixed pupil (mydriasis) with a normal
contralateral pupil indicates oculomotor nerve compression, a
neurologic emergency.
5. A client’s oxygen saturation is 89% on room air. The client has no
respiratory distress. What is the nurse’s priority?
A) Apply a non-rebreather mask at 15 L/min
B) Apply oxygen at 2 L/min via nasal cannula
C) Obtain an arterial blood gas
D) Reposition the client to Trendelenburg
*Rationale: Mild hypoxemia (SpO2 <90%) warrants low-flow
oxygen; higher concentrations may be unnecessary and harmful in
some clients.*
, 6. During auscultation of the lungs, the nurse hears fine, crackling
sounds at the lung bases that do not clear with coughing. These are
best described as:
A) Atelectatic crackles
B) Fine crackles (consistent with pulmonary fibrosis)
C) Rhonchi
D) Wheezes
Rationale: Persistent fine crackles at the bases suggest interstitial
lung disease, such as pulmonary fibrosis.
7. A client with dark skin has a newonset of jaundice. Where should
the nurse best assess for this finding?
A) Palms of the hands
B) Hard palate and sclera
C) Dorsum of the feet
D) Abdomen
Rationale: Jaundice is most reliably assessed in the sclera and hard
palate because these areas have high elastin content that binds
bilirubin.
8. The nurse is testing cranial nerve V (trigeminal). Which assessment
technique is correct?
A) Ask the client to smile and frown
B) Have the client identify a familiar scent
C) Lightly touch the client’s forehead, cheek, and chin with a cotton
