,SET A (Questions 1–50) – Health Assessment V2
1. A nurse is preparing to assess a client’s blood pressure. The client
reports a history of mastectomy on the left side. What should the
nurse do?
A) Use the left arm because the blood pressure will be more accurate
B) Use the right arm to avoid risk of lymphedema
C) Use the thigh to measure blood pressure
D) Use the left arm with a smaller cuff
Rationale: After mastectomy, especially with lymph node dissection,
blood pressure should not be taken on the ipsilateral arm to reduce
lymphedema risk.
2. During an abdominal assessment, the nurse notes a pulsatile mass
in the epigastric area. What is the priority action?
A) Auscultate for a bruit
B) Stop palpation and notify the healthcare provider
C) Measure the mass in centimeters
D) Palpate the mass to determine tenderness
Rationale: A pulsatile epigastric mass may indicate an abdominal
aortic aneurysm; deep palpation risks rupture.
3. The nurse is assessing a client’s orientation. The client can state
their name and location but cannot recall the current year. The nurse
documents this as:
A) Oriented ×1
,B) Oriented ×2
C) Oriented ×3
D) Disoriented
Rationale: Oriented ×2 means the client knows person and place;
time orientation is impaired.
4. A client has a positive Romberg test. Which condition does this
suggest?
A) Cerebellar dysfunction
B) Dorsal column (proprioceptive) dysfunction
C) Vestibular disorder
D) Motor cortex lesion
Rationale: Positive Romberg (swaying or falling with eyes closed)
indicates impaired proprioception, often from dorsal column
disease.
5. The nurse auscultates a client’s lungs and hears fine, crackling
sounds at the bases that do not clear with coughing. These are most
consistent with:
A) Atelectasis
B) Pulmonary fibrosis
C) Bronchitis
D) Asthma
Rationale: Persistent fine crackles at the lung bases suggest
interstitial lung disease such as pulmonary fibrosis.
, 6. A client with dark skin has a new onset of jaundice. The nurse
should best assess for jaundice by inspecting the:
A) Palms of the hands
B) Sclera and hard palate
C) Dorsum of the feet
D) Abdomen
Rationale: Jaundice is most reliably assessed in the sclera and hard
palate due to high elastin content that binds bilirubin.
7. The nurse is testing a client’s cranial nerve V (trigeminal). Which
technique is correct for the motor component?
A) Ask the client to smile
B) Ask the client to clench the jaw and palpate the masseter muscles
C) Ask the client to shrug shoulders
D) Ask the client to stick out the tongue
Rationale: CN V motor function is tested by jaw clenching
(masseter and temporalis muscles).
8. A client’s oxygen saturation is 89% on room air. The client is not
in 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 high Fowler’s
1. A nurse is preparing to assess a client’s blood pressure. The client
reports a history of mastectomy on the left side. What should the
nurse do?
A) Use the left arm because the blood pressure will be more accurate
B) Use the right arm to avoid risk of lymphedema
C) Use the thigh to measure blood pressure
D) Use the left arm with a smaller cuff
Rationale: After mastectomy, especially with lymph node dissection,
blood pressure should not be taken on the ipsilateral arm to reduce
lymphedema risk.
2. During an abdominal assessment, the nurse notes a pulsatile mass
in the epigastric area. What is the priority action?
A) Auscultate for a bruit
B) Stop palpation and notify the healthcare provider
C) Measure the mass in centimeters
D) Palpate the mass to determine tenderness
Rationale: A pulsatile epigastric mass may indicate an abdominal
aortic aneurysm; deep palpation risks rupture.
3. The nurse is assessing a client’s orientation. The client can state
their name and location but cannot recall the current year. The nurse
documents this as:
A) Oriented ×1
,B) Oriented ×2
C) Oriented ×3
D) Disoriented
Rationale: Oriented ×2 means the client knows person and place;
time orientation is impaired.
4. A client has a positive Romberg test. Which condition does this
suggest?
A) Cerebellar dysfunction
B) Dorsal column (proprioceptive) dysfunction
C) Vestibular disorder
D) Motor cortex lesion
Rationale: Positive Romberg (swaying or falling with eyes closed)
indicates impaired proprioception, often from dorsal column
disease.
5. The nurse auscultates a client’s lungs and hears fine, crackling
sounds at the bases that do not clear with coughing. These are most
consistent with:
A) Atelectasis
B) Pulmonary fibrosis
C) Bronchitis
D) Asthma
Rationale: Persistent fine crackles at the lung bases suggest
interstitial lung disease such as pulmonary fibrosis.
, 6. A client with dark skin has a new onset of jaundice. The nurse
should best assess for jaundice by inspecting the:
A) Palms of the hands
B) Sclera and hard palate
C) Dorsum of the feet
D) Abdomen
Rationale: Jaundice is most reliably assessed in the sclera and hard
palate due to high elastin content that binds bilirubin.
7. The nurse is testing a client’s cranial nerve V (trigeminal). Which
technique is correct for the motor component?
A) Ask the client to smile
B) Ask the client to clench the jaw and palpate the masseter muscles
C) Ask the client to shrug shoulders
D) Ask the client to stick out the tongue
Rationale: CN V motor function is tested by jaw clenching
(masseter and temporalis muscles).
8. A client’s oxygen saturation is 89% on room air. The client is not
in 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 high Fowler’s
