NUR 2065 PHYSICAL ASSESSMENT FINAL EXAM REVIEW:
1. During an interview the nurse states, “you mentioned shortness of breath, tell me more
about that”. Which verbal skill is used with this statement?
• OPEN-ENDED QUESTIONS
2. Receiving is a part of the communication process. Which receiver is most likely to misinterpret
a message sent by a health care professional?
• A MAN WHOSE WIFE HAS JUST BEEN DIAGONSED WITH LUNG CANCER.
3. The nurse is preparing to conduct a health history. Which of these statements best describes
the purpose of a health history?
• TO PROVIDE A DATABASE OF SUBJECTIVE INFORMATIONABOUT THE PATIENT’S
PAST AND CURRENTL HEALTH
4. The nurse is taking a family history. Important diseases or problems to ask the patient
about specifically include:
• MENTAL ILLNESS
5. During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of
the questions. What could this be indicating?
• THE NURSE SHOULD SUSPECT ALCOHOL ABUSE AND CONTINUE WITH A
MORE THOROUGH SUBSTANCE ABUSE ASSESSMENT.
6. A patient has been in the intensive care unit for 10 days. He has just been moved to the
medical- surgical unit, and the admitting nurse is planning to perform a mental status
examination. During the tests of cognitive function, the nurse would expect that he:
• WILL BE ORIENDTED TO PLACE AND PERSON, BUT THAT PATIENT MAY NOT BE
CERTAIN OF THE DATE.
7. A 20-year-old construction worker has been brought into the emergency ... He has delirium as
a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse
should first assess the patient's:
• LEVEL OF CONSCIOUSNESS AND COGNITIVE ABILITIES
8. The nurse is assessing a patient who is admitted with possible delirium. Which of these
are manifestations of delirium? Select all that apply.
• DEVELOPS OVER A SHORT PERIOD
• PERSON IS EXHIBITING MEMORY IMPAIRMENT OF DEFICITS
• OCCURS AS A RESULT OF A MEDICAL CONDITION, SUCH AS SYSTEMATIC INFECTION
9. The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a
clock showing the time of 10:45, the patient drew a clock with the numbers out of order and
with an incorrect time. This result indicates which finding?
• COGNITIVE IMPAIRMENT
10. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of
the assessment, the nurse expects that this patient:
• MAY TAKE A LITTLE LONGER TO RESPOND, BUT HIS GENERAL KNOWLEDGE
AND ABILITIES SHOULD NOT HAVE DECLINED.
11. The nurse is preparing to conduct a mental status examination. Which statement is
true regarding the mental status examination?
• GATHERING MENTAL STATUS INFORMATION DURING THE HEALTH HISTORY
INTERVIEW IS USUALLY SUFFICIENT.
, 12. A woman brings her husband to the clinic for an examination. She is particularly worried
because after a recent fall, he seems to have lost a great deal of his memory of recent
events. Which statement reflects the nurse's best course of action?
• PERFORM A COMPLETE MENTAL STATUS EXAMINATION.
13. A woman who has just discovered that she is pregnant is in the clinic for her first obstetric
visit. She asks the nurse, "How many drinks a day is safe for my baby?" The nurse's best
response is:
• “NO AMOUNT OF ALCOHOL HAS BEEN DETERMINED TO BE SAFE
DURING PREGNANCY.”
14. The nurse is aware that intimate partner violence (IPV) screening should occur with
which situation?
• AS A ROUTINE PART OF EACH HEALTH CARE ENCOUNTER
15. Which term refers to a wound produced by the tearing or splitting of body tissue, usually
from blunt impact over a bony surface?
• LACERATION
16. A female patient has denied any abuse when answering the Abuse Assessment Screen, but
the nurse noticed some other conditions that are associated with IPV. Examples of such
conditions include:
• DEPRESSION
17. When performing a physical assessment, the first technique the nurse will always use is:
• INSPECTION
18. 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?
• HANDS ARE WASHED BEFORE AND AFTER EVERY PHYSICAL PATIENT ENCOUNTER
19. The nurse is providing instructions to newly hired graduates for the Mini-Mental
State Examination (MMSE). Which statement best describes this examination?
• THIS EXAMINATION IS A GOOD TOOL TO DETECT DELIRIUM AND DEMENTIA AND
TO DIFFERENTITATE THESE FROM PSYCHIATRIC MENTAL ILLNESS.
20. When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a
tripod position, leaning forward with arms braced on the chair. On the basis of this observation,
the nurse should:
• RECONGIZE THAT A TRIPOD POSTION IS OFTEN USED WHEN A PATIENT IS
HAVING RESPIRATORY DIFFICULITIES.
21. A 75-year-old man has a history of hypertension and was recently changed to a new
antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate
his blood pressure?
• ASSESS BLOOD PRESSURE AND PULSE IN THE SUPINE, SITTING, AND
STANDING POSITIONS.
22. The nurse has collected the following information on a patient: palpated blood pressure– 180
mm Hg; auscultated blood pressure–170/100 mm Hg; apical pulse–60 beats per minute;
radial pulse–70 beats per minute. How should the nurse record this patient's blood pressure?
• 70
1. During an interview the nurse states, “you mentioned shortness of breath, tell me more
about that”. Which verbal skill is used with this statement?
• OPEN-ENDED QUESTIONS
2. Receiving is a part of the communication process. Which receiver is most likely to misinterpret
a message sent by a health care professional?
• A MAN WHOSE WIFE HAS JUST BEEN DIAGONSED WITH LUNG CANCER.
3. The nurse is preparing to conduct a health history. Which of these statements best describes
the purpose of a health history?
• TO PROVIDE A DATABASE OF SUBJECTIVE INFORMATIONABOUT THE PATIENT’S
PAST AND CURRENTL HEALTH
4. The nurse is taking a family history. Important diseases or problems to ask the patient
about specifically include:
• MENTAL ILLNESS
5. During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of
the questions. What could this be indicating?
• THE NURSE SHOULD SUSPECT ALCOHOL ABUSE AND CONTINUE WITH A
MORE THOROUGH SUBSTANCE ABUSE ASSESSMENT.
6. A patient has been in the intensive care unit for 10 days. He has just been moved to the
medical- surgical unit, and the admitting nurse is planning to perform a mental status
examination. During the tests of cognitive function, the nurse would expect that he:
• WILL BE ORIENDTED TO PLACE AND PERSON, BUT THAT PATIENT MAY NOT BE
CERTAIN OF THE DATE.
7. A 20-year-old construction worker has been brought into the emergency ... He has delirium as
a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse
should first assess the patient's:
• LEVEL OF CONSCIOUSNESS AND COGNITIVE ABILITIES
8. The nurse is assessing a patient who is admitted with possible delirium. Which of these
are manifestations of delirium? Select all that apply.
• DEVELOPS OVER A SHORT PERIOD
• PERSON IS EXHIBITING MEMORY IMPAIRMENT OF DEFICITS
• OCCURS AS A RESULT OF A MEDICAL CONDITION, SUCH AS SYSTEMATIC INFECTION
9. The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a
clock showing the time of 10:45, the patient drew a clock with the numbers out of order and
with an incorrect time. This result indicates which finding?
• COGNITIVE IMPAIRMENT
10. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of
the assessment, the nurse expects that this patient:
• MAY TAKE A LITTLE LONGER TO RESPOND, BUT HIS GENERAL KNOWLEDGE
AND ABILITIES SHOULD NOT HAVE DECLINED.
11. The nurse is preparing to conduct a mental status examination. Which statement is
true regarding the mental status examination?
• GATHERING MENTAL STATUS INFORMATION DURING THE HEALTH HISTORY
INTERVIEW IS USUALLY SUFFICIENT.
, 12. A woman brings her husband to the clinic for an examination. She is particularly worried
because after a recent fall, he seems to have lost a great deal of his memory of recent
events. Which statement reflects the nurse's best course of action?
• PERFORM A COMPLETE MENTAL STATUS EXAMINATION.
13. A woman who has just discovered that she is pregnant is in the clinic for her first obstetric
visit. She asks the nurse, "How many drinks a day is safe for my baby?" The nurse's best
response is:
• “NO AMOUNT OF ALCOHOL HAS BEEN DETERMINED TO BE SAFE
DURING PREGNANCY.”
14. The nurse is aware that intimate partner violence (IPV) screening should occur with
which situation?
• AS A ROUTINE PART OF EACH HEALTH CARE ENCOUNTER
15. Which term refers to a wound produced by the tearing or splitting of body tissue, usually
from blunt impact over a bony surface?
• LACERATION
16. A female patient has denied any abuse when answering the Abuse Assessment Screen, but
the nurse noticed some other conditions that are associated with IPV. Examples of such
conditions include:
• DEPRESSION
17. When performing a physical assessment, the first technique the nurse will always use is:
• INSPECTION
18. 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?
• HANDS ARE WASHED BEFORE AND AFTER EVERY PHYSICAL PATIENT ENCOUNTER
19. The nurse is providing instructions to newly hired graduates for the Mini-Mental
State Examination (MMSE). Which statement best describes this examination?
• THIS EXAMINATION IS A GOOD TOOL TO DETECT DELIRIUM AND DEMENTIA AND
TO DIFFERENTITATE THESE FROM PSYCHIATRIC MENTAL ILLNESS.
20. When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a
tripod position, leaning forward with arms braced on the chair. On the basis of this observation,
the nurse should:
• RECONGIZE THAT A TRIPOD POSTION IS OFTEN USED WHEN A PATIENT IS
HAVING RESPIRATORY DIFFICULITIES.
21. A 75-year-old man has a history of hypertension and was recently changed to a new
antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate
his blood pressure?
• ASSESS BLOOD PRESSURE AND PULSE IN THE SUPINE, SITTING, AND
STANDING POSITIONS.
22. The nurse has collected the following information on a patient: palpated blood pressure– 180
mm Hg; auscultated blood pressure–170/100 mm Hg; apical pulse–60 beats per minute;
radial pulse–70 beats per minute. How should the nurse record this patient's blood pressure?
• 70
