NCLEX Nursing Health Assessment
And Pain Exam
/. 1. Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would be
of greatest concern to the nurse when completing the nursing assessment of the
patient?
A. Alert and oriented to date, time, and place
B. Buccal cyanosis and capillary refill greater than 3 seconds
C. Clear breath sounds and nonproductive cough
D. Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3 - Answer-✅1.
Answer: B. Buccal cyanosis and capillary refill greater than 3 seconds
Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased
oxygen to the tissues, which requires immediate intervention. Alert and oriented, clear
breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and
leukocyte count of 5,300/mm3 are normal data.
/.2. During the nursing assessment, which data represent information concerning health
beliefs?
A. Family role and relationship patterns
B. Educational level and financial status
C. Promotive, preventive, and restorative health practices
D. Use of prescribed and over-the-counter medications - Answer-✅2. Answer: C.
Promotive, preventive, and restorative health practices
The health-beliefs assessment includes expectations of health care; promotive,
preventive, and restorative practices, such as breast self-examination, testicular
examination, and seat-belt use; and how the client perceives illness. Use of medications
provides information about the client's personal habits. Educational level, financial
status, and family role and relationship patterns represent information associated with
role and relationship patterns.
/.3. Nurse Patrick is acquiring information from a client in the emergency department.
Which is an example of biographic information that may be obtained during a health
history?
A. The chief complaint
B. Past health status
C. History immunizations
D. Location of an advance directive - Answer-✅3. Answer: D. Location of an advance
directive
, Biographic information may include name, address, gender, race, occupation, and
location of a living will or a durable power of attorney for health care. The chief
complaint, past health status, and history of immunizations are part of assessing the
client's health and illness patterns.
/.4. John Joseph was scheduled for a physical assessment. When percussing the
client's chest, the nurse would expect to find which assessment data as a normal sign
over his lungs?
A. Dullness
B. Resonance
C. Hyperresonance
D. Tympany - Answer-✅4. Answer: B. Resonance
Normally, when percussing a client's chest, percussion over the lungs reveals
resonance, a hollow or loud, low-pitched sound of long duration. Tympany is typically
heard on percussion over such areas as a gastric air bubble or the intestine. Dullness is
typically heard on percussion of solid organs, such as the liver or areas of consolidation.
Hyperresonance would be evidenced by percussion over areas of overinflation such as
an emphysematous lungs.
/.5. Matteo is diagnosed with dehydration and underwent series of tests. Which
laboratory result would warrant immediate intervention by the nurse?
A. Serum sodium level of 138 mEq/L
B. Serum potassium level of 3.1 mEq/L
C. Serum glucose level of 120 mg/dl
D. Serum creatinine level of 0.6 mg/100 ml - Answer-✅5. Answer: B. Serum potassium
level of 3.1 mEq/L
A normal potassium level is 3.5 to 5.5 mEq/L. A normal sodium level is 135 to 145
mEq/L, a normal nonfasting glucose level is 85 to 140 mg/dl, and a normal creatinine
level is 0.2 to 0.8 mg/100 ml.
/.6. During an otoscopic examination, which action should be avoided to prevent the
client from discomfort and injury?
A. Tipping the client's head away from the examiner and pulling the ear up and back
B. Inserting the otoscope inferiorly into the distal portion of the external canal
C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal
D. Bracing the examiner's hand against the client's head - Answer-✅6. Answer: C.
Inserting the otoscope superiorly into the proximal two-thirds of the external canal
In the superior position, the speculum of the otoscope is nearest the tympanic
membrane, and the most sensitive portion of the external canal is the proximal two-
And Pain Exam
/. 1. Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would be
of greatest concern to the nurse when completing the nursing assessment of the
patient?
A. Alert and oriented to date, time, and place
B. Buccal cyanosis and capillary refill greater than 3 seconds
C. Clear breath sounds and nonproductive cough
D. Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3 - Answer-✅1.
Answer: B. Buccal cyanosis and capillary refill greater than 3 seconds
Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased
oxygen to the tissues, which requires immediate intervention. Alert and oriented, clear
breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and
leukocyte count of 5,300/mm3 are normal data.
/.2. During the nursing assessment, which data represent information concerning health
beliefs?
A. Family role and relationship patterns
B. Educational level and financial status
C. Promotive, preventive, and restorative health practices
D. Use of prescribed and over-the-counter medications - Answer-✅2. Answer: C.
Promotive, preventive, and restorative health practices
The health-beliefs assessment includes expectations of health care; promotive,
preventive, and restorative practices, such as breast self-examination, testicular
examination, and seat-belt use; and how the client perceives illness. Use of medications
provides information about the client's personal habits. Educational level, financial
status, and family role and relationship patterns represent information associated with
role and relationship patterns.
/.3. Nurse Patrick is acquiring information from a client in the emergency department.
Which is an example of biographic information that may be obtained during a health
history?
A. The chief complaint
B. Past health status
C. History immunizations
D. Location of an advance directive - Answer-✅3. Answer: D. Location of an advance
directive
, Biographic information may include name, address, gender, race, occupation, and
location of a living will or a durable power of attorney for health care. The chief
complaint, past health status, and history of immunizations are part of assessing the
client's health and illness patterns.
/.4. John Joseph was scheduled for a physical assessment. When percussing the
client's chest, the nurse would expect to find which assessment data as a normal sign
over his lungs?
A. Dullness
B. Resonance
C. Hyperresonance
D. Tympany - Answer-✅4. Answer: B. Resonance
Normally, when percussing a client's chest, percussion over the lungs reveals
resonance, a hollow or loud, low-pitched sound of long duration. Tympany is typically
heard on percussion over such areas as a gastric air bubble or the intestine. Dullness is
typically heard on percussion of solid organs, such as the liver or areas of consolidation.
Hyperresonance would be evidenced by percussion over areas of overinflation such as
an emphysematous lungs.
/.5. Matteo is diagnosed with dehydration and underwent series of tests. Which
laboratory result would warrant immediate intervention by the nurse?
A. Serum sodium level of 138 mEq/L
B. Serum potassium level of 3.1 mEq/L
C. Serum glucose level of 120 mg/dl
D. Serum creatinine level of 0.6 mg/100 ml - Answer-✅5. Answer: B. Serum potassium
level of 3.1 mEq/L
A normal potassium level is 3.5 to 5.5 mEq/L. A normal sodium level is 135 to 145
mEq/L, a normal nonfasting glucose level is 85 to 140 mg/dl, and a normal creatinine
level is 0.2 to 0.8 mg/100 ml.
/.6. During an otoscopic examination, which action should be avoided to prevent the
client from discomfort and injury?
A. Tipping the client's head away from the examiner and pulling the ear up and back
B. Inserting the otoscope inferiorly into the distal portion of the external canal
C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal
D. Bracing the examiner's hand against the client's head - Answer-✅6. Answer: C.
Inserting the otoscope superiorly into the proximal two-thirds of the external canal
In the superior position, the speculum of the otoscope is nearest the tympanic
membrane, and the most sensitive portion of the external canal is the proximal two-
