NURS 190 Midterm Physical Assessment Kim Hein with Answers Graded A+

NURS 190 Midterm Physical Assessment Quiz Questions & Answers 1. The nurse is performing a comprehensive skin assessment. Which of the following pieces of equipment is appropriate to use during the skin assessment? (2 Points) doppler Wood's lamp Reflex hammer Goniometer 2. Which of the following is an expected finding in a healthy client on assessment of Stensen's ducts? (2 Points) red glow is present midline and symmetric saliva is present redness is present 3. Which of the following signs or symptoms does the nurse recognize in a client with hypothyroidism? (Select all that apply) (2 Points) Fatigue intolerance to cold increased cardiac output constipation 4. The client has a new diagnosis of right sided heart failure. The nurse understands a client with right sided heart failure may have edema and jugular vein distension. (2 Points) True False 5. The nurse performs the Romberg test to assess for: (2 Points) balance hearing vision loss cranial nerve 6 dysfunction 6. Which of the following techniques will the nurse perform to assess for signs of breast abnormalities? (2 Points) inspection, palpation, and auscultation inspection and palpation inspection, palpation, and percussion palpation and auscultation 7. The nurse is caring for a client with obesity. The nurse places the client in which of the following positions to best hear heart sounds? supine prone sitting upright lef t lateral 8. State at which location(s) the S1 sound (lub) is heard loudest on cardiac auscultation. State why the S1 is loudest at these locations. (Write 1-2 sentences). If you are you are at the proper location, you will hear the sound the loudest. (2 Points) 9. The nurse palpates an enlarged lymph node at the back of the ear, over the mastoid bone. The nurse documents this location as: (2 Points) posterior auricular submental posterior occular occipital 10. The older adult client is admitted with new onset pain and pressure to their eyes. On inspection, the sclera is red and the pupil is an irregular shape to the left eye. The nurse should further assess for: (2 Points) macular degeneration cataracts presbyopia Glaucoma BOOK REF. PG 253 11. The client is seen in the urgent care center with a suspected fungal infection to the fingernails. The nails are thick, yellow, and lifting off the nail bed. The nurse documents this finding as: (2 Points) clubbing Onycholysis BOOK REF PG. 203 beau's lines splinter hemmorage 12. The nurse assesses the client's radial pulses and documents these findings: 68 beats per minute, regular, 2+, symmetrical. The physician asks the nurse, "What was the client's pulse amplitude?" The best response of the nurse: (2 Points) "68 beats per minute" "regular" "2+" BOOK REF PG 404 "symmetrical" 13. The nurse is performing a cardiac auscultation and hears a harsh, blowing sound that is very loud at the 4th ICS, left sternal border. No thrill is present. The nurse understands this murmur is graded as: (2 Points) grade 4 grade 2 grade 3 grade 5 14. Which of the following clients is most at risk for developing a deep-vein thrombosis? (2 Points) A 30 year old client with is 1 week post delivery of a baby A 60 year old client who is on anticoagulant medications A 45 year old client on oral contraceptives and smokes A 40 year old female with underwent laser eye surgery 15. The nurse is performing an otoscope exam on a child in the outpatient clinic. Which of the following safety measures should the nurse observe when performing this exam? (2 Points) Position the dorsal surface of the hand on the child's head Look in the right eye with the nurse's right eye Pull the pinna up and back Look in the right ear while holding the scope in the left hand 16. Which of the following terms best describes a complete inspiratory phase and expiratory phase of breathing? (2 Points) Cardiac cycle Eupnea pneumothorax respiratory cycle 17. The client reports during the interview that they see a physician for medical care and say a nightly prayer to improve health. The nurse documents this data as which of the following? (2 Points) family history health beliefs health patterns medical history 18. The nurse is required to clean equipment, such as the stethoscope, before and after each use with a patient. (2 Points) True False 19. The nurse performing a skin assessment of a client notes the client has vascular skin lesions that are flat, bright red in color, with tiny vessels that radiate out from the center of the lesion. The nurse concludes the lesions are which of the following? (2 Points) petechiae venous stars spider angiomas port wine stain 20. The nurse notices the client has on torn clothing and is walking with a walker when entering the examination room. Which one of the following components should also be included in the general survey? (2 Points) biographical data health patterns mental status medical history 21. When assessing a client with peripheral arterial disease, the nurse assesses the client for which of the following signs and symptoms that would be consistent with arterial insufficiency? (2 Points) brownish discoloration to the skin on the ankles normal skin temperature peripheral edema leg pain while walking REF BOOK PG 398 & PG 413 22. Capillary refill is an indication of arterial status (2 Points) False True 23. The nurse assesses the posterior tibial pulse at this location: (2 Points) benind the knee directly above the antecubital area on top of the foot, between the great toe and first toe between the ankle and Achilles tendon 24. The client is seen by the nurse in the urgent care center with complaints of a headache in the frontal lobes. On collection of history, the nurse learns the client had a "bad cold" about two weeks ago. Which of the following should the nurse perform for a comprehensive sinus assessment? (2 Points) palpation, direct percussion, transillumination inspection, palpation, percussion, and auscultationte palpation, direct percussion, auscultation inspection and palpation 25. The nurse is caring for a client with end stage emphysema and plans to perform a respiratory auscultation. Which of the following is the best position for this client during the exam? (2 Points) supine prone sitting upright 26. The nurse is performing an assessment of the client's head and neck. Which of the following findings in the assessment warrants further follow up? (2 Points) midline trachea symmetric facial features non-palpable cervical lymph node crepitus on TMJ evaluation 27. The nurse is performing an ear assessment on a client. Findings: Redness, swelling, and drainage on inspection of the auricle and ear canal. Tympanic membrane is flat, grey, no white patches present. The nurse suspects: (2 Points) Otitis externa Scaring on the tympanic membrane Tophi Otitis media 28. The nurse is asking the client when the migraine headache started. The nurse is assessing in OLDCART: (2 Points) characteristics location relieving factors onset 29. This type of percussion produces a flat sound over bone such as the ribs: (2 Points) Blunt Direct Indirect Light 30. The nurse plans to complete an assessment of the head and neck lymph nodes. The nurse plans to: (2 Points) use strong pressure to the jaw and neck use a slow, gentle circular motion using fingerpads REF VIDEO palpate with the tips of the fingers to all locations auscultate with the bell of the stethoscope 31. The nurse is asking the client to describe how much and what type of exercise they participate in weekly. The nurse is assessing: (2 Points) biographical data social history health patterns general survey 32. The nurse performs palpation during a respiratory assessment of the client's thorax for: (select all that apply) (2 Points) masses vesicular sounds respiratory expansion crepitus tenderness 33. The nurse understands the importance of collecting subjective data first in a health assessment. Which of the following are included in subjective data collection? (Select all that apply) (2 Points) asking family history asking the client how much they weigh asking the client social history measuring a client's height 34. Type in your name and student ID number to confirm you are following all the WCU testing guidelines. 35. Which client with advanced breast cancer is asking the nurse to explain "peau d'orange." The nurse responds: (2 Points) This is a nipple discharge of serous fluid