Health Assessment Quiz Evolve Updated 2023/2024 Correct Questions and Answers

A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client? A) Level of consciousness. B) Gait characteristics. C) Presence of trauma. D) Bladder control ability. (ANS- A) Level of consciousness The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? A) Press the tongue down one side at a time with a tongue depressor. B) Ask the client to open the mouth and say "ah." C) Listen for hoarseness after asking the client to speak. D) Palpate the neck and ask the client to swallow. (ANS- A) Press the tongue down one side at a time with a tongue depressor. Which findings can the nurse determine by palpating a client's skin? (Select all that apply.) A) Pruritus. B) Diaphoresis. C) Pallor. D) Jaundice. E) Scaling. (ANS- B) Diaphoresis. E) Scaling. The nurse is completing a physical assessment of a client who feel from a tree. The client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which assessment technique should the nurse implement when evaluating the client's spleen? A) Elevate head of bed 30 degrees to percuss the spleen. B) Palpate the splenic borders before percussing. C) Percuss the splenic area as the client takes a deep breath. D) Place client in a Trendelenburg position to isolate the spleen. (ANS- C) Percuss the splenic area as the client takes a deep breath Which information should the nurse obtain to identify the client's self-perception of health status? A) Vital signs. B) Health history. C) Informed consent. D) Genetic predisposition. (ANS- B) Health history. Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? A) Ask closed-ended questions with the assistance of the interpreter. B) Maintain eye contact with the client while listening to the translation. C) Instruct interpreter to answer questions from interpreter's point of view. D) Protect the client's privacy by asking a limited number of questions. (ANS- B) Maintain eye contact with the client while listening to the translation. When performing range of motion exercises on the joints of an older adult client, the nurse notes that joint range is greater with passive ranging than with active ranging. A goniometer indicates that this difference is as much as 15% in some joints. How should this finding be documented? A) Normal. B) Expected in older adults. C) Minor deviation. D) Abnormal. (ANS- D) Abnormal. A nurse is completing a nutritional assessment with a client. What is the easiest method for the nurse to use to get information about the client's nutritional intake? A) 24-hour dietary recall B) Food diary. C) Intake and output record. D) Lab information (albumin, pre-albumin). (ANS- A) 24-hour dietary recall A client is in the clinic and is reporting lower abdominal pain and constipation. Which information is of greatest concern to the nurse when obtaining the health history from this client? A) Administration of rubeola vaccine at age 7. B) Removal of gallbladder 5 years ago. C) Family history of colon cancer on mother's side. D) Family history of hypertension on father's side. (ANS- C) Family history of colon cancer on mother's side The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest? A) The left leg internally rotates. B) The left leg rises off of the table. C) The left leg remains on the table. D) The left leg externally rotates. (ANS- C) The left leg remains on the table. A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this procedure? A) Lying. B) Sitting. C) Leaning. D) Standing. (ANS- A) Lying The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse place the stethoscope diaphragm to listen for this condition? A) 2nd intercostal space along the right sternal border. B) 2nd intercostal space along the left sternal border. C) 3rd intercostal space on the right midclavicular line. D) 5th intercostal space on the left midclavicular line. (ANS- A) 2nd intercostal space along the right sternal border. A client reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation? A) Current alcohol and tobacco use. B) A 24-hour dietary recall. C) Use of vitamin and iron supplements. D) Daily pattern of oral hygiene practices. (ANS- C) Use of vitamin and iron supplements The nurse enters an examination room to conduct a routine health assessment on an adolescent female client, who is accompanied by her mother. Which action by the nurse is likely to facilitate accurate responses to personal and social history questions? A) Include the mother in the interviewing process. B) Request that the mother leave the exam room. C) Allow the client to broach discussion of any sensitive topics. D) Use highly structured and directed questions to explore sensitive topics. (ANS- B) Request that the mother leave the exam room. A male executive is seen in the primary care clinic for a physical examination. While obtaining the client's health history, the nurse inquires about his drug and alcohol use. The executive denies drug use, but reports that he has "two glasses of wine" per night. Which response is best for the nurse to provide? A) "You alcohol intake should be reduced by 8 ounces daily." B) "Does your use of alcohol concern any of your family members?" C) "What effect do you think your use of alcohol may have on you?" D) "The amount of alcohol you are drinking concerns me." (ANS- C) "What effect do you think your use of alcohol may have on you?" When assessing facial nerve function of a 96-year-old, the nurse asks the client to smile in an exaggerated manner. Which finding is most important for the nurse to further asses? A) Only one side of the mouth moves when smiling. B) The client's teeth have a yellowed appearance. C) The client smiles broadly but appears anxious. D) The client asks the nurse to repeat the directions. (ANS- A) Only one side of the mouth moves when smiling The nurse performs a series of cranial nerve tests on a client with a head injury. Which test should the nurse use to assess damage to the first cranial nerve? A) Ask the client to count down from 100 by 7s for as long as possible. B) Occlude one nostril and have the client identify various odors. C) Have the client follow the tip of a moving penlight with the eyes. D) Tell the client to walk heel to toe in a straight line for nine steps. (ANS- B) Occlude one nostril and have the client identify various odors. The nurse is interviewing a client who reports having a persistent, productive cough during the winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis? A) Phlegm production and wheezing. B) Smoking history. C) Hemoptysis. D) Night sweats. (ANS- A) Phlegm production and wheezing. A client is in the clinic for a routine health examination. The nurse notices the client appears underweight. Which question is most important for the nurse to ask when completing the health history of this client? A) What types of food do you like or dislike? B) Have you experienced sudden weight loss? C) Do you use dietary supplements every day? D) Can you recall the last 24 hours of food intake? (ANS- B) Have you experienced sudden weight loss? The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema. During the health assessment, the nurse should implement which technique to determine evidence of hepatomegaly? A) Tap the liver's boundaries lightly with a percussion hammer to produce a sound. B) Push gently using fingers of both hands to determine the boundaries of the liver. C) Use a bouncing motion to tap the middle finger placed within boundaries of the liver. D) Cup hands and clap with alternating contact with the skin over regions of the liver. (ANS- C) Use a bouncing motion to tap the middle finger placed within boundaries of the liver.