Exam 4: NR302 / NR 302 (2026/2027 Edition) Health Assessment I |Review with Questions and Answers| 100% Correct | A Grade -Chamberlain

Exam 4: NR302 / NR 302 (2026/2027 Edition) Health Assessment I |Review with Questions and Answers| 100% Correct | A Grade -Chamberlain Q. What are lymph nodes? A) A network of vessels that carry blood to the heart B) A network of vessels that carry blood away from the heart C) A network of vessels that collect and filtrate fluid produced by immune response D) Abnormal cancerous lumps which require immediate removal. ANSWER C Term for the space between the bones of the skull in a newborn where the sutures are not fully formed? Fontanelle Q. Which question is most important to ask during a health history of the head? A) "Do you have any problems hearing?" B) "When was your last food intake?" C) "Any unusually frequent or severe headaches?" D) "Do you have any ear piercings?" ANSWER C Q. Risk Factors for the Head and Neck ANSWER *Not using safety equipment such as helmets and seat belts *Alcohol or drug consumption Q. Risk Factors for the Nose, Mouth, and Throat ANSWER cigarette, vape, cigar, or chewing tobacco use lack of routine dental care not practicing proper hand hygiene and infection prevention practices poor nutritional intake Q. Inspecting and Palpating the Head ANSWER posture of the head (erect or slumped, midline, stable, or bobbing) symmetry of features and shape are normocephalic obvious masses, lumps, scars, or color variations signs of parasitic infestation (eyebrows, nape of neck, and hairline behind ears) Q. Inspecting and Palpating the Neck ANSWER *Symmetry and midline alignment of the trachea *scars that might indicate prior surgeries *visible lumps or areas of protrusion or swelling over the anterior aspect of the neck Q. Inspecting and Palpating the Lymph Nodes ANSWER Occasionally, a palpable lymph node can be felt, is usually less than 1 cm, soft, non-tender, and slightly movable. Q. The client has a headache. Which questions would the nurse ask? Select all that apply. A) "What did you do to cause the headache?" B) "Where do you feel the pain?" C) "Is the pain in one side or throbbing all over?" D) "When did the headache begin?" E) "Have you ever had this kind of headache before?" ANSWER B, C, D, E Q. The nurse is planning to assess the mouth of an adult client. What should be done first? A) Have the client cough. B) Place the client in a supine position. C) Ask the client to swish with mouthwash. D) Don gloves. ANSWER D Q. The nurse is demonstrating palpation of the sinuses to a group of nursing students. Which statement made by the students requires follow-up by the nurse? A) "The ethmoid sinuses of a client are usually very large and easily accessible for palpation." B) "The frontal sinuses are assessed by palpating the bony ridge above the eyes." C) "Complaints of tenderness during palpation by the client may indicate sinus infection." D) "The maxillary sinuses are assessed by palpating the bony ridge beneath the eye." ANSWER A Q. Which statement made by the client regarding head and neck care should be corrected by the nurse? A) "Bike helmets are required only for children." B) "If I notice a large lump on my neck, I should call a provider." C) "I should wear proper mouth protection when playing football." D) "I should floss and brush my teeth." ANSWER A Select the assessment data the nurse would expect to find in a client with hypothyroidism: Weakness, weight gain, Fatigue, dry skin, constipation, Goiter, Slow HR. Q. A client with hypothyroidism reports difficulty with activities of daily living and being "too tired to do anything." Which nursing diagnosis would be most appropriate when planning interventions for this client? A) Altered nutrition: More than body requirements related to excessive intake B) Depression related to fatigue C) Activity intolerance related to fatigue D) Fatigue related to role demands ANSWER C Hypothyroidism is usually caused by a low what? ANSWER Iodine Q. A client with hypothyroidism asked the nurse why the healthcare provider ordered levothyroxine for them. Which response provided by the nurse is correct? A)"Levothyroxine dissolves the goiter." B) "Levothyroxine decreases inflammation." C) "Levothyroxine increases thyroid-stimulating hormone (TSH) levels." D) "Levothyroxine replaces the missing hormones." ANSWER D Q. A nurse cares for a 25-year-old client who is diagnosed with Hashimoto's thyroiditis. The client asks, "What does this mean?" How should the nurse respond correctly? A) "It is a type of cancer that affects the thyroid." B) "This is a genetic disease that causes the thyroid to stop secreting thyroid-stimulating hormone (TSH)." C) "This is an autoimmune disease that damages the thyroid." D) "You will develop hyperthyroidism as you get older." ANSWER C Swelling around eye is called? Periorbital edema Q. A client is newly diagnosed with hypothyroidism. The nurse is providing education to the client about this disease process. Which statement made by the client indicates comprehension of the education about this condition? A) "Complications from hypothyroidism can lead to arrhythmias." B) "The only treatment for me is a thyroidectomy." C) "Untreated severe hypothyroidism can cause a coma." D) "If I stop using salt, I can cure my hypothyroidism." ANSWER C Q. A nurse is caring for four clients who all have hypothyroidism. Which of the clients should the nurse see first? A) A 82-year-old with dry skin B) A 72-year-old who has facial edema C) A 52-year-old with a sudden drop in blood pressure D) A 69-year-old with a high TSH ANSWER C Q. Which is part of the eye assessment? ANSWER Snellen, diagnostic positions test, and PERRLA are part of the eye assessment. Q. Risk factors for eye diseases and vision loss may include: ANSWER *family history of eye disease *advancing age *untreated strabismus *frequent or unprotected ultraviolet light exposure *increased intraocular pressure (glaucoma) *lifestyle behaviors (e.g., smoking, alcohol use) chronic diseases such as hypertension, diabetes mellitus, and renal dysfunction Q. Risk factors for hearing impairment may include: ANSWER *genetic predisposition for hearing loss *loud environments (e.g., high volume music, factory work, gun use) *chronic ear infections *cerumen buildup *advancing age Q. Which findings may contribute to hearing loss? Select all that apply. A) Loud noises B) Retinal changes C) Chronic infections D) Ultraviolet (UV) damage E) Cerumen buildup ANSWER A, C, E Q. Which pupil diameters are considered normal? Select all that apply. 2 3 4 5 6 7 8 9 ANS: 3, 4, 5. Q. Which tests are used for the hearing assessment? Whispered voice test, and turning fork test. Q. Which is a common age-related change in the ears? A) Coarse and stiff cilia B) Cerumen decreases C) Size of earlobes decrease D) Elasticity of pinna increases ANS: A To assess pupil accommodation, the nurse would instruct the client to focus on a distant object and then shift their gaze to a near object Q. A client with allergies reports their eyes hurt and itch. Their eyes are reddened and puffy. Which nursing diagnosis would be most appropriate when planning interventions for this client? A) Impaired self-concept related to inflammation B) Chronic pain related to changes of the eyes C) Acute pain related to inflammation D) Fatigue related to acute pain ANS: C A client with allergies asks the nurse what they can do to prevent seasonal allergies at home. Which responses provided by the nurse are correct? Select all that apply. A) "Use a HEPA air filtration system." B) "Always blow your nose three times a day." C) "Wash your clothes every day." D) "Keep doors and windows closed." E) "Bathe after being outside." ANS: A, D, E During a yearly physical exam, a 16-year-old is sneezing and tells the nurse that they do not want to go outside anymore. What potential symptoms suggest seasonal allergies? Select all that apply. A) Ear pressure B) Reddened eyes C) Fever D) Runny nose E) Increased respirations ANS:A, B, D During a yearly physical exam, a 16-year-old is sneezing and tells the nurse that they do not want to go outside anymore. Which assessment finding should the nurse expect for this client? A) Family history of chronic lung conditions B) Family history of allergies C) Chronic eye problems D) Family history of allergy onset in adulthood ANS: B) Family history of allergies. Which outcome would be appropriate for a client with allergic rhinitis? A) The client can identify their triggers. B) The client will deep breathe and cough after going outside. C) The client states they cannot go outside. D) The client will irrigate their eyes once daily. ANS: A) The client can identify their triggers. The client is reporting ear pressure. Which part of the ear would the nurse expect that, if congested, would be causing the pressure? A) Eustachian tube B) Tympanic cavity C) Tympanic membrane D) Malleus ANS: Eustachian Tube A symptom/sign is a(n) subjective/objective abnormal assessment finding detected on physical examination or through diagnostic testing. A symptom/sign is a(n) subjective/objective feeling a client has that is associated with a disorder. SIGN/ OBJECTIVE SYMPTOM/SUBJECTIVE Which are components of a health history? Select all that apply. Reason for seeking care Biographic data Medication reconciliation Review of systems Which question would be asked as part of the review of systems? "Do you have any difficulty with vision?" The examiner is documenting the reason for seeking care. Which statement is documented correctly? Client states, "I have pain in my right ankle." Which information is included in past history? Select all that apply. Immunizations Hospitalizations Childhood illnesses Which information should be included in a medication reconciliation? Select all that apply. Acetaminophen 500 mg as needed for pain Atenolol 50 mg for high blood pressure St. John's Wort 300 mg for depression Multivitamin 1 tablet The client states, "My last physical exam was last year." This would be documented under REVIEW OF SYSTEMS Which question would be asked as part of a developmental assessment? "When did your child get their first tooth?" The examiner would like to assess the quality of the client's pain. Which question should the examiner ask? "What does the pain feel like?" The client states they had their appendix removed 10 years ago. The examiner would document this under which portion of the health history? Past history During a clinic appointment, the examiner notes that a client with cancer looks fatigued and is wearing dirty clothes. The client has lost 20 pounds since their last visit. Which statements by the examiner therapeutically assess the client's functional ability? Select all that apply. "Tell me more about your support system." "Can you tell me how you are doing at home managing your daily activities?" "How is your lack of energy impacting what you want to do?" What would the examiner assess first? Complete a focused assessment of the back. The examiner is completing a health history on a client who presents with abdominal pain. Which is an example of biographic information that may be obtained during a health history? Current occupation An examiner is performing a health history on a client who is being admitted to the hospital. Which questions should be used to gather subjective data? Select all that apply. "Where are you working right now?" "Do you have a history of heart disease?" "How often do you forget to take a dose of your medication?" "How does the shortness of breath impact your life?" A client is struggling to complete the health history questionnaire because English is not their primary language. Which action should the examiner implement? Request an interpreter to assist the client. Match the following systems categories to the correct client statements. Click the item in the left column and then click the matching item in the right column; a line will appear between the two linking them together. General Overall Health State "I have gained 5 pounds in the last month." Health Promotion "My last electrocardiogram (ECG) was in 2015." Cardiovascular "I HAVE NO CHEST PAIN" Neurologic "I sometimes have headaches." Gastrointestinal "I have had no change in appetite." Respiratory "I do not have shortness of breath." Which is important health history information that can increase a client's risk of influenza? Select all that apply. Advanced age Occupation involving close physical contact with the public Pre-existing medical condition causing immunosuppression A client has a symptomatic, contagious, upper respiratory disease. Which health history question is most important to ask? Who lives in your house with you? A health history is a comprehensive record of a client's past and present health status. comprehensive focused client or an interpreter FRIENDS or FAMILY Drag the COVID assessment data the nurse should report to a provider to the right column. data: Temperature of 99.8 °F (37.7 °C) Signs of dehydration Rash Shortness of breath Body aches Chest pain Shortness of breath Cough runny nose reports to provider: signs of dehydration Confusion or dizziness SOB Chest pain In the scenario, which part of the health history was the most important in the primary care provider making the diagnosis? History of present illness A client with COVID asks why the nurse has to know where the client has traveled in the last 30 days. Which responses provided by the nurse are correct? Select all that apply. "I need to know if where you traveled is experiencing an outbreak." "Symptoms begin 2 to 14 days after you come into contact with the virus." "The questions help slow the spread of the virus." "These questions allow us to track where you could have gotten it from or who you exposed the virus to." Before placing a client on medication, it is important to verify other current medications or supplements the client may be taking. What is this process called? Medication reconciliation Which outcome would be appropriate for a client with COVID who has been sent home to self-isolate? The client will notify friends and family of the COVID diagnosis. The nurse recognizes which statement as an example of an open-ended question? "How do you typically deal with an asthma attack?" During an interview with a COVID positive client, the nurse wants to assess the client's background and health history. Which are examples of leading questions that a nurse should avoid? Select all that apply. "You didn't expose anyone to COVID, did you?" "You feel pretty good right now, right?" The nurse asks the client, "Have you ever used tobacco products?" The nurse recognizes that this question addresses the____section of the client's health history. functional assessment Which parts of the health history collect subjective information? Select all that apply. Family history Review of systems History of present illness Past health history The nurse knows that the primary purpose of obtaining a health history of a client is to achieve which of the following? Gathering pertinent data related to past and present health status A young Hispanic mother comes to the local clinic to be tested for COVID. The client speaks only Spanish and the nurse speaks only English. The nurse should ask a family member/ an interpreter/a priest/ a doctor for help. interpreter A nurse has four clients who have just had a health history done. Who should the nurse ask the provider to see first? A 30-year-old who complains of shortness of breath and has a history of asthma Which question asked by the nurse would be the most effective way to assess the intensity of pain? "How would you rate your pain on a scale from 0-10?" 6 vital signs - respirations - oxygen saturation - pulse - blood pressure - temperature - pain respirations - watch the rise and fall of the chest for a full 30 seconds - effort should be relaxed, regular, and automatic - if irregular - count for 1 minute normal respiration rate for neonate - 30-40 rpm normal respiration rate for 1 yo - 20-40 rpm normal respiration rate for 2 yo - 25-32 rpm normal respiration rate for 8-10 yo - 20-23 rpm normal respiration rate for 12-14 yo - 18-22 rpm normal respiration rate for 16 yo - 12-20 rpm normal respiration rate for adult - 10-20 rpm measurement of oxygen saturation - pulse oximeter a noninvasive method to assess arterial oxygen saturation (SPO2) - sensory attached to a person's finger or earlobe has diode that emits light and detector measures relative amount of light absorbed by oxyhemoglobin (HBO2) - compares ratio of light emitted to light absorbed and converts this ratio to percentage of oxygen saturation - because it only measures light absorption of pulsatile flow, result arterial oxygen saturation pulse - stroke volume: force of each heartbeat - periphery - use the pads of your 1st three fingers - rate - rhythm - force normal pulse rate - 60-100 bpm tachycardia pulse rate - 100 bpm bradycardia pulse rate - 60 bpm rhythm pulse rate - regular - irregular force pulse rate - full bounding - normal - weak, thready - absent full bounding pulse rate - 3+ normal pulse rate - 2+ weak, thready pulse rate - 1+ absent pulse rate - 0 blood pressure - the blood pressure is the force of blood pushing against the vessels systolic pressure (SBP): maximum pressure felt on artery during left ventricular contraction, or systole diastolic pressure: elastic recoil, or resting, pressure that blood exerts constantly between each contraction five factors that determine the blood pressure - cardiac output - peripheral vascular resistance - volume of circulating blood - viscosity - elasticity of vessel walls measuring BP - measured with stethoscope and aneroid sphygmomanometer multistep process to gain an accurate reading - korotkoff sounds: the sound you hear when taking the BP - BP reading can be categorized: normal: 120/80 prehypertension: 120-130/80-89 hypertension (stage 1): 140-159/90-99 HTN (stage II): 160/100 (or equal) normal blood pressure - 120/ 80 elevated blood pressure - 120-129/80 hypertension stage 1 - 130-139 / 80-89 hypertension stage 2 - 140 or higher/ 90 or higher hypertensive crisis - higher than 180 an/or higher than 120 temperature - a consistent temperature of 99F (37.2C) is required for normal cell function - range 96.4-99.1 F (35.8-37.3C) (normal oral temp) - know temperature reading in F & C 104F = 40C 98.6F = 37C 95F = 35 C - routes: oral, axillary, rectal, electronic, tympanic, temporal - hyperthermia (fever): 38C (100.4F) - hypothermia: 36C (96.8F) temperature is influenced by factors - sleep-wake cycles - menstruation cycles in women - exercise - age - variations in infants and elderly elderly mean temp: 36.2 C (97.2F) oral temperature: - most convenient; accurate - electronic place probe of tongue in posterior sublingual pocket usually red in 20-30s blue - tipped probes - oral route red - tipped probes - rectal - need to wait 10-15 minutes if pt ate/drank something hot/cold - be aware of how to take glass thermometer temperature, despite it being not commonly used rectal temperature - most accurate; most invasive - usually used when other routes are not practical (ex. comatose pt) - can cause discomfort place patient on left lateral decubitus position wear gloves, place cover on thermometer, apply lubricant to probe and insert 2-3 cm (1in.) wait until thermometer beeps. DO NOT let go of probe for infants less than 6, inset 1/2 inch tympanic membrane tempature - senses infrared emissions of eardrum - quick and efficient - looks like otoscope - place probe near ear canal and aim probe to eardrum - temperature given in 2-3 second temporal artery temperature - newer device; uses infrared emissions from temporal artery - more accurate than tympanic membrane thermometer (TMT) - slide probe across forehead and end behind the ear - temperature given within 6 seconds infants/children temperature - oral route should be used for children able to keep head still and mouth (~5-6 years) - rectal route used for infants when ill or when child unable to cooperate side-lying or supine with knees flexed to abdomen insert 1 in. 6 months; 1/2in. 6 months - tympanic/temporal route is useful for squirmy toddlers newborn pulse - 100-180 bpm 3 mo-2yrs pulse - 80-150 bpm - use apical pulse rate for 1 full min; radial pulse for kids 2 yrs 2-10 years pulse - 70-100 bpm infants/childrens respirations - watch infant's abdomen for respirations for 1 full minutes (as more diaphragmatic breathing) infants/childrens blood pressure - usually measured annually when children 3 yrs and older - measured more frequently for kids with medical conditions aging adults temperature - less likely to a have fever but greater risk for hypothermia due to changes in body's regulatory mechanism aging adult pulse - normal range: 50-95 bpm - may have irregular rhythm - radial artery may feel stiff, rigid, and tortous d/t increased stiffness in walls as a person ages aging adults respiration - decreased in vital capacity and inspiratory reserve volume aging adults blood pressure - aorta and major arteries may harden with age more pressure required to move blood against stiff aorta - increasing systolic pressure (may be hard to diagnose hypertension) skin structure - body's largest organ system covers 20 square feet of surface area in adults barrier from environmental stresses adapts to environmental influences - skin has two layers epidermis: outer highly differentiated layer basal cell layer forms new skin cells outer horny cell layer of dead keratinized cells dermis: inner supportive layer connective tissue or collagen elastic tissues - beneath these layers is a subcutaneous layer of adipose tissue function of the skin - protection from environment - prevents penetration - perception - temperature regulation - identification - communication - wound repair - absorption and excretion - production of vitamin D developmental competence: newborn infants - lanugo - vernix caseosa developmental competence: pregnant women - linea nigra - chloasma - striae gravidarum the aging adult - elasticity decreases - sweat and sebaceous glands decrease - senile purpura - skin breakdown - hair matrix culture and genetics - there is a genetic advantage for dark-skinned individuals against skin cancer due to melanin melanin protects the skin against harmful UV rays - increased likelihood of skin cancer in caucasians than in african american and hispanic populations - risk for melanoma increases with the following high exposure to UV radiation from sunlight or indoor tanning beds family history of melanoma presence of atypical or numerous greater than or equal to 50 moles - certain skin presentations associated with different ethnic groups keloids hypo/hyperpigmentation pseudofolliculitis melasma subjective questions for the exam - history - pigmentation changes - mole changes - excessive dryness, itching, or bruising - rash or lesions - medication - hair loss - nail condition - environmental or occupational hazards - self-care skin objective data - color - temperature - moisture - texture - thickness - edema - mobility and turgor - vascularity or bruising - lesions ABCDE skin assessment - promoting health and self-care teach skin self-examination using this rule to detect suspicious lesions - asymmetry - border - color - diameter - elevation and enlargment abnormal skin: pressure injury - stage 1 - stage 2 - stage 3 - stage 4 - unstageable - deep tissue injury nurses role in pressure injury prevention - assess risk for pressure injury development braden scale/skin assessment tools at risk populations (ex: geriatrics) critical thinking - interventions to reduce risk support surfaces to reduce intensity of pressure and shear turn and reposition (in and out of bed) maintain clean and dry skin proper nutrition (especially protein) protect heels prescribed wound dressing/gels abnormal skin: malignancy - there is a known link between ultraviolet radiation and skin cancer basal cell carcinoma squamous cell carcinoma malignant melanoma abnormal skin: vascular lesions - hemangiomas - telangiectases - purpuric lesions hair structure - hairs are threads of keratin shaft root (bulb matrix) - vellus hair - fine, thin, soft (covers most of body) - terminal hair - coarse, thick (scalp, eyebrows, axilla, pubis, face, and chest) - sebaceous glands - sweat glands: important for fluid balance and thermoregulation eccrine glands apocrine glands hair objective data - color - texture - distribution - lesions abnormal hair - alopecia - tinea capitis (scalp ringrowm) - seborrheic dermatitis (cradle cap) - folliculitis barbae (razor bumps) - pediculosis capitis (head lice) - furuncle or abscess nails objective data - shape - consistency - color - capillary refill abnormal nails - scabies - paronychia - beau line - clubbing - habit-tic dystrophy