Holistic Assessment Exam Questions With 100% Correct
Solutions.
A nurse is assessing a patient for possible fluid overload. Which assessment
finding is most consistent with this diagnosis
-Boggy eyeball
-Moist, plump tongue
-Distended neck veins w/ head elevated at 45 degrees
-venous filling of 3 second
Distended neck veins w/ head elevated at 45 degrees
The nurse is preparing to perform a physical examination on a female patient who
has been transferred to the medical unit from the emergency department. The
nurse should begin the collection of objective data with which examination?
-Head and neck examination.
-Palpation of lymph nodes.
-Vital signs.
-Breast examination
-Vital signs.
The nurse is assessing an older adult patient's mental status. Consistently, the
patient pauses after the nurse poses a question, but then provides a response
that is correct or appropriate. How should the nurse best interpret this
characteristic of the patient?
-The patient is displaying a sign of early Alzheimer disease.
-Slight delays in mental processing are normal in older adults.
-The patient may be trying to anticipate the nurse's desired response.
-The patient may be experiencing an early sign of delirium.
-Slight delays in mental processing are normal in older adults.
After teaching a group of students about the external and internal structures of
the eye, the instructor determines that the teaching was successful when the
students identify which of the following as external structures? SELECT ALL
THAT APPLY
-Lacrimal apparatus
-Conjunctiva
-Lens
-Iris
-Sclera
-Caruncle
-conjunctiva
-lens
-iris
,The nurse has completed the comprehensive health assessment of a patient who
has been admitted for the treatment of community-acquired pneumonia.
Following the completion of this assessment, the nurse periodically performs a
partial assessment primarily for which reason?
-Provide information for the client's record.
-Address areas previously omitted.
-To determine the need for crisis intervention.
-To reassess previously detected problems.
-To reassess previously detected problems.
A nurse is reviewing the four basic physical examination techniques and their
sequence prior to receiving a new patient from post-anesthetic recovery. The
nurse should plan to perform which technique first?
-Inspection
-Palpation
-Percussion
-Auscultation
-Inspection
The nurse collects vital signs on a hospital patient who has recently been
experiencing pain. Which finding would indicate the patient is currently
experiencing pain?
-Respiratory rate of 18 breaths/min.
-Temperature of 37.3°C (99.1°F).
-Heart rate of 110 beats/min.
-Blood pressure of 115/65 mm Hg
-Heart rate of 110 beats/min.
The nurse has identified abnormal findings when reviewing a young adult
patient's health history. Within Kohlberg theory of moral development, what
behavioral characteristic is the nurse most likely to observe?
-The patient is easily manipulated by others.
-The patient is unable to weigh options when presented with a dilemma.
-The patient has difficulty trusting others.
-The patient makes decisions without considering the impact on others.
-The patient makes decisions without considering the impact on others.
The nurse is percussing the area over the patient's lungs and hears a loud, low-
pitched, hollow sound. The nurse documents this finding as which of the
following?
-Tympany
-Dullness
-Flatness
-Resonance
-Resonance
, A nurse has received a report on a patient who will soon be admitted to the
medical unit from the emergency department. When preparing for the assessment
phase of the nursing process, what should the nurse do first?
-Validate important data.
-Collect subjective data.
-Document the data.
-Collect objective data.
-Collect subjective data.
During a Weber test, the patient reports lateralization of sound to the good ear.
The nurse interprets this as which the following?
-The poor ear is receiving sound vibrations by air.
-The good ear cannot receive sound vibrations.
-There is a sensorineural hearing impairment.
-There is a dysfunction of the middle ear.
-There is a sensorineural hearing impairment.
The nurse is preparing to test a patient's eyes for accommodation. The nurse
would have the patient focus on an object in which sequence for this test?
-Near, then far
-Lateral, then near
-Lateral, then far
-Far, then near
-Far, then near
An infant was removed from her home by social services because of the
dangerous and neglectful conditions that existed. According to Erikson, failure of
the infant to resolve the central crisis of infancy may lead to what personality
characteristics later in life?
-Suspicion and fear.
-Dependency and relational entanglement.
-Aggression and antagonism.
-Depression and introversion.
-Suspicion and fear.
Assessment of a patient who has suffered a recent stroke reveals that he is
unresponsive to all stimuli and his eyes remain closed. The nurse documents the
client's level of consciousness as which of the following?
-Obtunded
-Coma
-Stupor
-Lethargy
-Coma
A nurse is preparing to assess a patient who is new to the clinic. When beginning
the collection of the patient database, which of the following actions should the
Solutions.
A nurse is assessing a patient for possible fluid overload. Which assessment
finding is most consistent with this diagnosis
-Boggy eyeball
-Moist, plump tongue
-Distended neck veins w/ head elevated at 45 degrees
-venous filling of 3 second
Distended neck veins w/ head elevated at 45 degrees
The nurse is preparing to perform a physical examination on a female patient who
has been transferred to the medical unit from the emergency department. The
nurse should begin the collection of objective data with which examination?
-Head and neck examination.
-Palpation of lymph nodes.
-Vital signs.
-Breast examination
-Vital signs.
The nurse is assessing an older adult patient's mental status. Consistently, the
patient pauses after the nurse poses a question, but then provides a response
that is correct or appropriate. How should the nurse best interpret this
characteristic of the patient?
-The patient is displaying a sign of early Alzheimer disease.
-Slight delays in mental processing are normal in older adults.
-The patient may be trying to anticipate the nurse's desired response.
-The patient may be experiencing an early sign of delirium.
-Slight delays in mental processing are normal in older adults.
After teaching a group of students about the external and internal structures of
the eye, the instructor determines that the teaching was successful when the
students identify which of the following as external structures? SELECT ALL
THAT APPLY
-Lacrimal apparatus
-Conjunctiva
-Lens
-Iris
-Sclera
-Caruncle
-conjunctiva
-lens
-iris
,The nurse has completed the comprehensive health assessment of a patient who
has been admitted for the treatment of community-acquired pneumonia.
Following the completion of this assessment, the nurse periodically performs a
partial assessment primarily for which reason?
-Provide information for the client's record.
-Address areas previously omitted.
-To determine the need for crisis intervention.
-To reassess previously detected problems.
-To reassess previously detected problems.
A nurse is reviewing the four basic physical examination techniques and their
sequence prior to receiving a new patient from post-anesthetic recovery. The
nurse should plan to perform which technique first?
-Inspection
-Palpation
-Percussion
-Auscultation
-Inspection
The nurse collects vital signs on a hospital patient who has recently been
experiencing pain. Which finding would indicate the patient is currently
experiencing pain?
-Respiratory rate of 18 breaths/min.
-Temperature of 37.3°C (99.1°F).
-Heart rate of 110 beats/min.
-Blood pressure of 115/65 mm Hg
-Heart rate of 110 beats/min.
The nurse has identified abnormal findings when reviewing a young adult
patient's health history. Within Kohlberg theory of moral development, what
behavioral characteristic is the nurse most likely to observe?
-The patient is easily manipulated by others.
-The patient is unable to weigh options when presented with a dilemma.
-The patient has difficulty trusting others.
-The patient makes decisions without considering the impact on others.
-The patient makes decisions without considering the impact on others.
The nurse is percussing the area over the patient's lungs and hears a loud, low-
pitched, hollow sound. The nurse documents this finding as which of the
following?
-Tympany
-Dullness
-Flatness
-Resonance
-Resonance
, A nurse has received a report on a patient who will soon be admitted to the
medical unit from the emergency department. When preparing for the assessment
phase of the nursing process, what should the nurse do first?
-Validate important data.
-Collect subjective data.
-Document the data.
-Collect objective data.
-Collect subjective data.
During a Weber test, the patient reports lateralization of sound to the good ear.
The nurse interprets this as which the following?
-The poor ear is receiving sound vibrations by air.
-The good ear cannot receive sound vibrations.
-There is a sensorineural hearing impairment.
-There is a dysfunction of the middle ear.
-There is a sensorineural hearing impairment.
The nurse is preparing to test a patient's eyes for accommodation. The nurse
would have the patient focus on an object in which sequence for this test?
-Near, then far
-Lateral, then near
-Lateral, then far
-Far, then near
-Far, then near
An infant was removed from her home by social services because of the
dangerous and neglectful conditions that existed. According to Erikson, failure of
the infant to resolve the central crisis of infancy may lead to what personality
characteristics later in life?
-Suspicion and fear.
-Dependency and relational entanglement.
-Aggression and antagonism.
-Depression and introversion.
-Suspicion and fear.
Assessment of a patient who has suffered a recent stroke reveals that he is
unresponsive to all stimuli and his eyes remain closed. The nurse documents the
client's level of consciousness as which of the following?
-Obtunded
-Coma
-Stupor
-Lethargy
-Coma
A nurse is preparing to assess a patient who is new to the clinic. When beginning
the collection of the patient database, which of the following actions should the
