HEALTH ASSESSMENT 3 QUESTIONS
AND ANSWERS A GRADED
When the nurse assesses a 78 year old patient with pneumonia, what is the priority
assessment?
A. Breath Sounds
B. Airway patency
C. Respiratory rate
D. Percussion Sounds Correct Answer: B. Airway patency
Rationale: consider the ABCs. Airway always assumes priority
A 45 year old man has been admitted to the hospital with suspicion of PE. Which
of the following symptoms should the nurse report to the primary health
practitioner IMMEDIATELY?
A. chest pain
B. shortness of breath
C. respirations of 20 breaths per minute
D. productive speach Correct Answer: A. Chest pain
Rationale: chest pain is assumed to be heart pain and must be evaluated
immediately. Ischemic heart pain such as with a MI must be ruled out before
considering other diagnosis
A 62 year old woman comes to the clinic with an exacerbation of asthma. Which
of the following findings indicate worsening status of her asthma?
A. increased wheezing
B. sustained rhonchi
C. Decreased respirations
D. Oxygen saturation 94% Correct Answer: A increased wheezing
Rationale: wheezing is associated with the airway inflammation and narrowing that
accompany asthma. Bronchial rhonchi indicate secretions in the airway such as
pneumonia and are not expected with asthma. Increased respirations are expected
with decreased oxygen. Pulse ox less than 92% is cause for concern.
A 3 year old boy is brought to the emergency department for stridor, nasal flaring,
intercostal and supraclavicular retractions, and respiratory rate of 40
breaths/minute. What type of situation is this?
A. Stable
B. Acute
C. Urgent
,D. Emergency Correct Answer: D. Emergency
Rationale: stridor indicates upper airway obstruction and is considered an
emergency. Because it is accompanied in this case by retractions and tachypnea, a
rapid response may be indicated.
A 92 year old woman with a history of COPD presents with increasing shortness of
breath, decreased lung sounds in the bases, increased ankle edema, and 5 lb weight
gain in 1 week. What is the most likely problem?
A. Impaired gas exchange
B. Ineffective airway clearene
C. Activity intolerance
D. excess fluid volume Correct Answer: D. Excess fluid volume
Rationale: patients with COPD often retain fluid because of the increased work
load on the heart that the disease imposes. Fluid accumulates in the bases and
peripheral parts of the lungs leading to increased shortness of breath and weight
gain
Which of the following factors is the most significant risk factor for COPD?
A. increased age
B. immune suppression
C. tobacco smoking
D. occupational exposure Correct Answer: C. tobacco smoking
Rationale: smoking is the most common cause of COPD. It is the risk that should
be assessed, assistance with smoking cessation should be offered
When the nurse assesses a client with respiratory symptoms, which of the
following complaints should be evaluated first?
A. Chest soreness
B. dyspnea
C. Cough
D. sputum Correct Answer: B. Dyspnea
Rationale: shortness of breath is observed durng the initial contact with the patient.
These data assist in determining the acuity of the problem. Chest tenderness with
palpitations will be assessed during history. Sputum and lung sounds are assessed
during the initial physical assessment
When assessing a patient with atelectasis what assessment findings are expected?
Choose all that apply.
A. Shortness of breath
B. Decreased breath sounds
, C. Decreased oxygen saturation
D. Increased tactile fremitus
E. Hyperresonance Correct Answer: A, B, C, D
Rationale: with atelectasis, the lung tissue has collapsed which leads to less tissue
for oxygenation. Consequently, the oxygen saturation is low , breath sounds are
decreased, and the patient is short of breath. Because of the tissue is consolidated,
tactile fremitus is increased. The percussion sound might be dull, not
hyperresonant, as a result of consolidation
Which assessment findings would indicate that inhaled bronchodilators have been
effective?
A. Expiratory wheezing, O2 saturation of 94% pallor
B. vesicular breath sounds, o2 sat of 96% pink
C. bronchial breath sounds, O2 sat of 100% erythema
D. crackles, o2 sat 90% circumoral cyanosis Correct Answer: B. vesicular breath
sounds, O2 sat 96% pink
Rationale: if bronchodilators are effective, assessment findings would indicate
adequate gas exchange. abnormal findings include wheezing, low O2 sat, pallor,
bronchial breath sounds, erythema, crackles, and cyanosis
The nurse auscultates bronchovesicular breath sounds in the second ICS near the
sternum. The nurse interprets this as:
A. a normal finding over the trachea
B. A normal finding over the bronchi
C. an abnormal finding over the lung
D. an abnormal finding over the trachea Correct Answer: B. a normal finding over
the bronchi
Rationale: the trachea bifurcates at the second intercostal space and
bronchovesicular sounds are expected. Bronchial sounds are auscultated over the
trachea, vesicular sounds are heard over the lung fields
Which of the following statements describes the cardiovascular system most
accurately?
A. It is a double pump circulating blood out the the lungs and body
B. It has a heart with 6 chambers, great vessels, and valves
C. It includes the concept of precontractility, postcontractility, and load
D. It functions with a conduction system that starts in the ventricles Correct
Answer: A. It is a double pump circulating blood out to the lungs and body
Rationale: the heart is a double pump with 4 chambers, 4 valves, and a conduction
system that has a pacemaker originating in the atrium (SA node). Concepts of
AND ANSWERS A GRADED
When the nurse assesses a 78 year old patient with pneumonia, what is the priority
assessment?
A. Breath Sounds
B. Airway patency
C. Respiratory rate
D. Percussion Sounds Correct Answer: B. Airway patency
Rationale: consider the ABCs. Airway always assumes priority
A 45 year old man has been admitted to the hospital with suspicion of PE. Which
of the following symptoms should the nurse report to the primary health
practitioner IMMEDIATELY?
A. chest pain
B. shortness of breath
C. respirations of 20 breaths per minute
D. productive speach Correct Answer: A. Chest pain
Rationale: chest pain is assumed to be heart pain and must be evaluated
immediately. Ischemic heart pain such as with a MI must be ruled out before
considering other diagnosis
A 62 year old woman comes to the clinic with an exacerbation of asthma. Which
of the following findings indicate worsening status of her asthma?
A. increased wheezing
B. sustained rhonchi
C. Decreased respirations
D. Oxygen saturation 94% Correct Answer: A increased wheezing
Rationale: wheezing is associated with the airway inflammation and narrowing that
accompany asthma. Bronchial rhonchi indicate secretions in the airway such as
pneumonia and are not expected with asthma. Increased respirations are expected
with decreased oxygen. Pulse ox less than 92% is cause for concern.
A 3 year old boy is brought to the emergency department for stridor, nasal flaring,
intercostal and supraclavicular retractions, and respiratory rate of 40
breaths/minute. What type of situation is this?
A. Stable
B. Acute
C. Urgent
,D. Emergency Correct Answer: D. Emergency
Rationale: stridor indicates upper airway obstruction and is considered an
emergency. Because it is accompanied in this case by retractions and tachypnea, a
rapid response may be indicated.
A 92 year old woman with a history of COPD presents with increasing shortness of
breath, decreased lung sounds in the bases, increased ankle edema, and 5 lb weight
gain in 1 week. What is the most likely problem?
A. Impaired gas exchange
B. Ineffective airway clearene
C. Activity intolerance
D. excess fluid volume Correct Answer: D. Excess fluid volume
Rationale: patients with COPD often retain fluid because of the increased work
load on the heart that the disease imposes. Fluid accumulates in the bases and
peripheral parts of the lungs leading to increased shortness of breath and weight
gain
Which of the following factors is the most significant risk factor for COPD?
A. increased age
B. immune suppression
C. tobacco smoking
D. occupational exposure Correct Answer: C. tobacco smoking
Rationale: smoking is the most common cause of COPD. It is the risk that should
be assessed, assistance with smoking cessation should be offered
When the nurse assesses a client with respiratory symptoms, which of the
following complaints should be evaluated first?
A. Chest soreness
B. dyspnea
C. Cough
D. sputum Correct Answer: B. Dyspnea
Rationale: shortness of breath is observed durng the initial contact with the patient.
These data assist in determining the acuity of the problem. Chest tenderness with
palpitations will be assessed during history. Sputum and lung sounds are assessed
during the initial physical assessment
When assessing a patient with atelectasis what assessment findings are expected?
Choose all that apply.
A. Shortness of breath
B. Decreased breath sounds
, C. Decreased oxygen saturation
D. Increased tactile fremitus
E. Hyperresonance Correct Answer: A, B, C, D
Rationale: with atelectasis, the lung tissue has collapsed which leads to less tissue
for oxygenation. Consequently, the oxygen saturation is low , breath sounds are
decreased, and the patient is short of breath. Because of the tissue is consolidated,
tactile fremitus is increased. The percussion sound might be dull, not
hyperresonant, as a result of consolidation
Which assessment findings would indicate that inhaled bronchodilators have been
effective?
A. Expiratory wheezing, O2 saturation of 94% pallor
B. vesicular breath sounds, o2 sat of 96% pink
C. bronchial breath sounds, O2 sat of 100% erythema
D. crackles, o2 sat 90% circumoral cyanosis Correct Answer: B. vesicular breath
sounds, O2 sat 96% pink
Rationale: if bronchodilators are effective, assessment findings would indicate
adequate gas exchange. abnormal findings include wheezing, low O2 sat, pallor,
bronchial breath sounds, erythema, crackles, and cyanosis
The nurse auscultates bronchovesicular breath sounds in the second ICS near the
sternum. The nurse interprets this as:
A. a normal finding over the trachea
B. A normal finding over the bronchi
C. an abnormal finding over the lung
D. an abnormal finding over the trachea Correct Answer: B. a normal finding over
the bronchi
Rationale: the trachea bifurcates at the second intercostal space and
bronchovesicular sounds are expected. Bronchial sounds are auscultated over the
trachea, vesicular sounds are heard over the lung fields
Which of the following statements describes the cardiovascular system most
accurately?
A. It is a double pump circulating blood out the the lungs and body
B. It has a heart with 6 chambers, great vessels, and valves
C. It includes the concept of precontractility, postcontractility, and load
D. It functions with a conduction system that starts in the ventricles Correct
Answer: A. It is a double pump circulating blood out to the lungs and body
Rationale: the heart is a double pump with 4 chambers, 4 valves, and a conduction
system that has a pacemaker originating in the atrium (SA node). Concepts of
