Health assessment test 2 questions with answers
1. 1. When assessing whispered pectoriloquy, the nurse should instruct a client to do which of
the following?
A) Softly repeat the words ione-two-three.i
B) Say the number ininety-nine.i
C) Cough each time the stethoscope is moved.
D) Say the letter iei until instructed to stop.: A
2. 2. When preparing to assess a client's thoracic cage, the nurse should locate which landmark when
determining where to begin the assessment of the ribs and intercostal spaces?
A) Scapula
B) Suprasternal notch
C) Sternal angle
D) Sternal border: C
3. 3. The nurse is assessing a client who has been admitted for the treatment of severe dehydration.
What might the nurse expect to hear when auscultating the lungs of a client
with this fluid volume deficit?
A) Friction rub
B) Decreased breath sounds
C) Sibilant wheeze
D) Stridor: A
4. 4. A client has sustained a brain stem injury and is being treated in the intensive care unit. Which
of the following would the nurse need to consider when assessing this client's respiratory status?
A) The client will have a loss of involuntary respiratory control.
B) The client will respond negatively to increased stimuli.
C) The client will have greatly increased respiratory effort.
D) The client will exhibit Cheyne-Stokes respirations.: A
,5. 5. During the health interview, a client tells the nurse that he ican't breathe all that welli at night
when he is lying down and that this significantly disrupts his sleep. The nurse should assess this
client further for which of the following health problems?
A) Pneumonia
B) Tuberculosis
C) Bronchitis
D) Heart failure: D
6. 6. A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment
prior to treatment. The nurse would be most concerned about which of the following assessment
findings related to the client's spu-
tum?
A) White or cream-colored
B) Yellowish and foul-smelling
C) Pink and frothy
D) Rust-tinged: C
7. 7. Upon entering the examination room, the nurse observes that the client is leaning forward with
his arms supporting his body weight. The nurse would recognize this as a tripod position and
suspect the presence of which of the following medical problems?
A) Pleural effusion
B) Heart failure
C) Chronic obstructive pulmonary disease
D) Pneumonia: C
8. 8. The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. The nurse
should document this as which of the following?
A) Limited expansion
B) Normal expansion
C) Hypoexpansion
D) Hyperexpansion: B
,9. 9. A client has a history of emphysema. During the respiratory assessment, the nurse percusses
the client's chest, expecting to find which of the follow- ing?
A) Hyperresonance
B) Dullness
C) Resonance
D) Tympany: A
10.10. While auscultating a client's lungs, the nurse notes the presence of adventitious sounds.
Which of the following actions should the nurse do first?
A) Refer the client for further medical evaluation.
B) Auscultate for egophony.
C) Perform bronchophony.
D) Have the client cough, then listen again.: D
11.11. The nurse is preparing to auscultate the client's thorax. Which of the following actions is
the priority during this component of assessment?
A) Listen at each site for at least one complete respiratory cycle.
B) Have the client breathe deeply through his or her nose.
C) Encourage the client to cough before auscultating each site.
D) Have the client hold the breath for a few seconds after auscultating each site.: A
12.12. An adult client has been diagnosed with bronchitis. Which of the following would the
nurse most likely hear on auscultation?
A) Sibilant wheezes
B) Fine crackles
C) Sonorous wheezes
D) Coarse crackles: C
13.13. The nurse is performing a respiratory assessment of a client who is palliative due to severe,
uncompensated heart failure. What type of respiratory pattern should the nurse anticipate?
A) Biot's
, B) Bradypnea
C) Kussmaul's
D) Cheyne-Stokes: D
14.14. The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of
the following should the nurse assess next?
A) Lateral aspect of the thorax
B) Lung volume
C) Hip levels
D) Spinal column: D
15.15. While auscultating a client's trachea, the nurse hears a high, harsh sound with short
inspiration and long expiration. The nurse would document which of the following?
A) Vesicular breath sounds
B) Bronchovesicular breath sounds
C) Adventitious breath sounds
D) Bronchial breath sounds: D
16.16. When percussing the scapula of a client, which of the following would the nurse expect to
hear?
A) Resonance
B) Dullness
C) Flatness
D) Hyperresonance: C
17.17. A group of students is reviewing the vertical reference lines of the thorax. They
demonstrate understanding when they identify which line as a reference line for the posterior
thorax?
A) Midaxillary line
B) Vertebral line
C) Right midclavicular line
1. 1. When assessing whispered pectoriloquy, the nurse should instruct a client to do which of
the following?
A) Softly repeat the words ione-two-three.i
B) Say the number ininety-nine.i
C) Cough each time the stethoscope is moved.
D) Say the letter iei until instructed to stop.: A
2. 2. When preparing to assess a client's thoracic cage, the nurse should locate which landmark when
determining where to begin the assessment of the ribs and intercostal spaces?
A) Scapula
B) Suprasternal notch
C) Sternal angle
D) Sternal border: C
3. 3. The nurse is assessing a client who has been admitted for the treatment of severe dehydration.
What might the nurse expect to hear when auscultating the lungs of a client
with this fluid volume deficit?
A) Friction rub
B) Decreased breath sounds
C) Sibilant wheeze
D) Stridor: A
4. 4. A client has sustained a brain stem injury and is being treated in the intensive care unit. Which
of the following would the nurse need to consider when assessing this client's respiratory status?
A) The client will have a loss of involuntary respiratory control.
B) The client will respond negatively to increased stimuli.
C) The client will have greatly increased respiratory effort.
D) The client will exhibit Cheyne-Stokes respirations.: A
,5. 5. During the health interview, a client tells the nurse that he ican't breathe all that welli at night
when he is lying down and that this significantly disrupts his sleep. The nurse should assess this
client further for which of the following health problems?
A) Pneumonia
B) Tuberculosis
C) Bronchitis
D) Heart failure: D
6. 6. A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment
prior to treatment. The nurse would be most concerned about which of the following assessment
findings related to the client's spu-
tum?
A) White or cream-colored
B) Yellowish and foul-smelling
C) Pink and frothy
D) Rust-tinged: C
7. 7. Upon entering the examination room, the nurse observes that the client is leaning forward with
his arms supporting his body weight. The nurse would recognize this as a tripod position and
suspect the presence of which of the following medical problems?
A) Pleural effusion
B) Heart failure
C) Chronic obstructive pulmonary disease
D) Pneumonia: C
8. 8. The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. The nurse
should document this as which of the following?
A) Limited expansion
B) Normal expansion
C) Hypoexpansion
D) Hyperexpansion: B
,9. 9. A client has a history of emphysema. During the respiratory assessment, the nurse percusses
the client's chest, expecting to find which of the follow- ing?
A) Hyperresonance
B) Dullness
C) Resonance
D) Tympany: A
10.10. While auscultating a client's lungs, the nurse notes the presence of adventitious sounds.
Which of the following actions should the nurse do first?
A) Refer the client for further medical evaluation.
B) Auscultate for egophony.
C) Perform bronchophony.
D) Have the client cough, then listen again.: D
11.11. The nurse is preparing to auscultate the client's thorax. Which of the following actions is
the priority during this component of assessment?
A) Listen at each site for at least one complete respiratory cycle.
B) Have the client breathe deeply through his or her nose.
C) Encourage the client to cough before auscultating each site.
D) Have the client hold the breath for a few seconds after auscultating each site.: A
12.12. An adult client has been diagnosed with bronchitis. Which of the following would the
nurse most likely hear on auscultation?
A) Sibilant wheezes
B) Fine crackles
C) Sonorous wheezes
D) Coarse crackles: C
13.13. The nurse is performing a respiratory assessment of a client who is palliative due to severe,
uncompensated heart failure. What type of respiratory pattern should the nurse anticipate?
A) Biot's
, B) Bradypnea
C) Kussmaul's
D) Cheyne-Stokes: D
14.14. The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of
the following should the nurse assess next?
A) Lateral aspect of the thorax
B) Lung volume
C) Hip levels
D) Spinal column: D
15.15. While auscultating a client's trachea, the nurse hears a high, harsh sound with short
inspiration and long expiration. The nurse would document which of the following?
A) Vesicular breath sounds
B) Bronchovesicular breath sounds
C) Adventitious breath sounds
D) Bronchial breath sounds: D
16.16. When percussing the scapula of a client, which of the following would the nurse expect to
hear?
A) Resonance
B) Dullness
C) Flatness
D) Hyperresonance: C
17.17. A group of students is reviewing the vertical reference lines of the thorax. They
demonstrate understanding when they identify which line as a reference line for the posterior
thorax?
A) Midaxillary line
B) Vertebral line
C) Right midclavicular line
