NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank | Questions and
Answers with Rationale | Latest | Rasmussen College
The nurse is preparing to conduct a health history. Explain this to the patient. Correct Answer: Answer-
The purpose of a health history is to provide a database of subjective information about the patient's
past and current health history. You might say to the patient, "I will be asking you questions about your
past and present health." This information will help the provider along with the physical exam (objective
data) to develop a diagnosis or health status.
The nurse is evaluating the reliability of a patient's responses, which of these statements would be
correct? The patient: Correct Answer: Provided consistent information and therefore is reliable
A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's
best response? Correct Answer: "Can you point to where it hurts?"
A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be the
nurse's appropriate response to the woman's statement? Correct Answer: "How would you say the pain
affects your ability to do your daily activities?"
A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this
information? Correct Answer: "Describe what happens (or the reaction) to you when you take
Penicillin."
The nurse is taking a family history. Important diseases or problems about which the patient should be
specifically asked include: Correct Answer: Mental illness.
The review of systems provides the nurse with... Correct Answer: Information regarding health
promotion practices, the information helps to evaluate the past and present health state of each body
system, to obtain any data that may have been omitted in the section about present illness, and to
evaluate health promotion and teaching opportunities.
Which of these statements represents subjective data the nurse obtained from the patient regarding the
patient's skin? Correct Answer: Patient denies any color change.
The nurse is obtaining a history from a 30-year old male patient and is concerned about health
promotion activities. Which of these questions would be appropriate to use to assess health promotion
activities for this patient? Correct Answer: "Do you perform testicular self-examinations?"
Functional Assessment-- What information would you ask if the patient's leg was in a cast? Correct
Answer: A functional assessment includes the activities of daily living and the person's ability to take
care of their needs. This area will help to formulate a nursing diagnosis. This could be present to the
patient in a standardized form and will include data on the lifestyle and type of living environment.
(Page 57) self-esteem, activity/exercise, sleep/rest, nutrition/elimination, interpersonal
relationships/resources, spiritual resources, coping and stress management, personal habits,
environmental hazards, violence questions, and occupational health questions. If a patient had a cast on
their leg, appropriate questions would include how they transfer to bed, another chair, bathing
technique, coping with the situation, support during the situation.
,Regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason
why? Correct Answer: Alcohol can interact with all medications and make some diseases worse.
Describe a genogram. Correct Answer: Graphic family tree that uses symbols to depict the gender,
relationship, and age of immediate family. Usually 3 generations- parents, grandparents, siblings. Also
highlight the health of close family members and more details such as communicable disease,
environmental hazards (smoke), tobacco use, and alcohol use. Any additional information includes the
family history.
The nurse is obtaining health history on an 87-year-old woman. Which of the following areas of
questioning would be most useful at this time? Correct Answer: Current health promotion activities.
A 90-year-old patient tells the nurse that he cannot remember the names of the medication he is taking
or why he is taking them. An appropriate response from the nurse would be.. Correct Answer: Would
you have a family member bring in your medications please?
The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke.
Which of these questions would be most important to ask? Correct Answer: "Are you able to dress
yourself?"
A patient is describing his symptoms to the nurse. Which of these statements reflects a description of
the setting of his symptoms? Correct Answer: "This pain happens every time I sit down to use the
computer."
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the
breast is especially important. The reason why is... Correct Answer: This is the location for most breast
tumors.
In performing an assessment of a woman's elixir lymph system, the nurse should assess which of these
nodes? Correct Answer: Central, lateral, pectoral, and subscapular.
The breast has extensive lymphatic drainage, 75% of the drainage drains into the axillary nodes. There
are groups of axillary nodes central, pectoral and subscapular.
A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much". She states it
must be from a lack of exercise. What explanation should the nurse offer her? After menopause: Correct
Answer: The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in
sagging (flat and gabby) breasts.
In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of
the following describes the nurse's best course of action? Correct Answer: Explain that this is the result
of hormonal changes (testosterone) and recommend a visit to their provider.
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's
most appropriate response to this would be: Correct Answer: To seek more specific information about
the pain, such as: When did you first notice it? Is the pain localized or all over? Is it painful to touch? Is
the pain in relation to your menstrual cycle? Is the pain associated with activity or exercise?
,During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her
breast for approximately 2 weeks. In trying to find the cause of the rash, which questions would be
important for the nurse to ask? Correct Answer: Where did the rash first appear- on the nipple, areola,
or the surrounding skin? When did you first notice this?
During an annual physical examination, a 43-year-old patient states that she does not perform monthly
breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much
better job than I ever could to find a lump." The nurse should explain to her that: Correct Answer:
Breast self-exams may detect lumps that appear between mammograms
List risk factors for breast cancer Correct Answer: History of breast cancer - family history—first-degree
relative
Medications such as estrogen and progestin combined
Certain tumor suppressor genes called BRCA1 and BRCA2 (inherited mutation)
Age
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right
breast. Which of these statements is true about this finding? Correct Answer: Asymmetry isnot unusual,
but the nurse should verify that this change is not new
During the physical examination, the nurse notices that a female patient has an inverted left nipple.
Which statement regarding this is most accurate? Correct Answer: Whether the inversion is a recent
change should be determined.
The nurse is performing a breast examination. Which of these statements best describes the correct
procedure to use when screening for nipple and skin retraction during a breast examination? Have the
woman: Correct Answer: Slowly lift her arms above her head, and note any retraction or lag in
movement.
The nurse is palpating a female patient's breasts during an examination. Which of these positions is
most likely to make significant lumps more distinct during breast palpation? Correct Answer: Supine
with the arms raised over the head
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?
Correct Answer: The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period.
The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct Correct
Answer: "BSE on a monthly basis will help you become familiar with your own breasts and feel their
normal variations."
A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is
concerned about changes in her breasts that she has noticed over the past 5 years. She states that her
breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and
flabby." The nurse's best reply would be: Correct Answer: The decrease in hormones after menopause
causes atrophy of the glandular tissue in the breast and is a normal process of aging.
A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast
lump in her right breast for years. Recently, it has begun to change in consistency and is becoming
, harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was
nothing to worry about." The examination validates the presence of a mass in the right upper outer
quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, and non-tender, with
borders that are not well defined. The nurse replies: Correct Answer: Because of the change in
consistency of the lump, it should be further evaluated by the physician.
The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women
to perform BSEs is? Correct Answer: On the same day every month.
During a discussion about BSEs with a 30-year-old woman, what statement by the nurse is most
appropriate? Correct Answer: Examine your breast shortly after your menstrual period each month.
Peau d'orange- Correct Answer: Lymphatic obstruction causes edema, which thickens the skin and
exaggerates the hair follicles; this creates a pigskin or orange peel look. Could be an indication of cancer.
Dullness- Correct Answer: A high-pitched muffled thud sound obtained by percussing over relatively
dense organs such as liver or spleen, distended bladder, mass of adipose tissue
Tympany- Correct Answer: A high-pitchedmusical and drum like note obtained by percussing the
surface of a large air-containing space, such as the abdomen
Resonance- Correct Answer: A low-pitched, clear, hollow note obtained by percussing over normal lung
tissue
Hyperresonnance- Correct Answer: A low-booming note obtained by percussing over the adult lungs
that have increased air such as with a patient who has emphysema, present with distended abdomen
Which structure is located in the left lower quadrant of the abdomen? Correct Answer: Sigmoid colon
Aneurysm- Correct Answer: defect or sec formed by dilation in artery wall due to atherosclerosis,
trauma, or congenital defect (aortic aneurysm)
Dysphasia- Correct Answer: Difficulty swallowing
Anorexia- Correct Answer: Loss of appetite
Ascites Correct Answer: abnormal accumulation of serous fluid within the peritoneal cavity, associated
with heart failure, cirrhosis, cancer or portal hypertension
Bruit- Correct Answer: blowing, swoishing sound her through a stethoscope when an artery is partially
occluded
Hepatomegaly- Correct Answer: abnormally enlarged liver
Paralytic ileus- Correct Answer: complete absence of peristaltic movement that may follow abdominal
surgery or complete bowel obstruction
Peritonitis- Correct Answer: inflammation of the peritoneum
Answers with Rationale | Latest | Rasmussen College
The nurse is preparing to conduct a health history. Explain this to the patient. Correct Answer: Answer-
The purpose of a health history is to provide a database of subjective information about the patient's
past and current health history. You might say to the patient, "I will be asking you questions about your
past and present health." This information will help the provider along with the physical exam (objective
data) to develop a diagnosis or health status.
The nurse is evaluating the reliability of a patient's responses, which of these statements would be
correct? The patient: Correct Answer: Provided consistent information and therefore is reliable
A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's
best response? Correct Answer: "Can you point to where it hurts?"
A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be the
nurse's appropriate response to the woman's statement? Correct Answer: "How would you say the pain
affects your ability to do your daily activities?"
A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this
information? Correct Answer: "Describe what happens (or the reaction) to you when you take
Penicillin."
The nurse is taking a family history. Important diseases or problems about which the patient should be
specifically asked include: Correct Answer: Mental illness.
The review of systems provides the nurse with... Correct Answer: Information regarding health
promotion practices, the information helps to evaluate the past and present health state of each body
system, to obtain any data that may have been omitted in the section about present illness, and to
evaluate health promotion and teaching opportunities.
Which of these statements represents subjective data the nurse obtained from the patient regarding the
patient's skin? Correct Answer: Patient denies any color change.
The nurse is obtaining a history from a 30-year old male patient and is concerned about health
promotion activities. Which of these questions would be appropriate to use to assess health promotion
activities for this patient? Correct Answer: "Do you perform testicular self-examinations?"
Functional Assessment-- What information would you ask if the patient's leg was in a cast? Correct
Answer: A functional assessment includes the activities of daily living and the person's ability to take
care of their needs. This area will help to formulate a nursing diagnosis. This could be present to the
patient in a standardized form and will include data on the lifestyle and type of living environment.
(Page 57) self-esteem, activity/exercise, sleep/rest, nutrition/elimination, interpersonal
relationships/resources, spiritual resources, coping and stress management, personal habits,
environmental hazards, violence questions, and occupational health questions. If a patient had a cast on
their leg, appropriate questions would include how they transfer to bed, another chair, bathing
technique, coping with the situation, support during the situation.
,Regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason
why? Correct Answer: Alcohol can interact with all medications and make some diseases worse.
Describe a genogram. Correct Answer: Graphic family tree that uses symbols to depict the gender,
relationship, and age of immediate family. Usually 3 generations- parents, grandparents, siblings. Also
highlight the health of close family members and more details such as communicable disease,
environmental hazards (smoke), tobacco use, and alcohol use. Any additional information includes the
family history.
The nurse is obtaining health history on an 87-year-old woman. Which of the following areas of
questioning would be most useful at this time? Correct Answer: Current health promotion activities.
A 90-year-old patient tells the nurse that he cannot remember the names of the medication he is taking
or why he is taking them. An appropriate response from the nurse would be.. Correct Answer: Would
you have a family member bring in your medications please?
The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke.
Which of these questions would be most important to ask? Correct Answer: "Are you able to dress
yourself?"
A patient is describing his symptoms to the nurse. Which of these statements reflects a description of
the setting of his symptoms? Correct Answer: "This pain happens every time I sit down to use the
computer."
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the
breast is especially important. The reason why is... Correct Answer: This is the location for most breast
tumors.
In performing an assessment of a woman's elixir lymph system, the nurse should assess which of these
nodes? Correct Answer: Central, lateral, pectoral, and subscapular.
The breast has extensive lymphatic drainage, 75% of the drainage drains into the axillary nodes. There
are groups of axillary nodes central, pectoral and subscapular.
A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much". She states it
must be from a lack of exercise. What explanation should the nurse offer her? After menopause: Correct
Answer: The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in
sagging (flat and gabby) breasts.
In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of
the following describes the nurse's best course of action? Correct Answer: Explain that this is the result
of hormonal changes (testosterone) and recommend a visit to their provider.
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's
most appropriate response to this would be: Correct Answer: To seek more specific information about
the pain, such as: When did you first notice it? Is the pain localized or all over? Is it painful to touch? Is
the pain in relation to your menstrual cycle? Is the pain associated with activity or exercise?
,During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her
breast for approximately 2 weeks. In trying to find the cause of the rash, which questions would be
important for the nurse to ask? Correct Answer: Where did the rash first appear- on the nipple, areola,
or the surrounding skin? When did you first notice this?
During an annual physical examination, a 43-year-old patient states that she does not perform monthly
breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much
better job than I ever could to find a lump." The nurse should explain to her that: Correct Answer:
Breast self-exams may detect lumps that appear between mammograms
List risk factors for breast cancer Correct Answer: History of breast cancer - family history—first-degree
relative
Medications such as estrogen and progestin combined
Certain tumor suppressor genes called BRCA1 and BRCA2 (inherited mutation)
Age
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right
breast. Which of these statements is true about this finding? Correct Answer: Asymmetry isnot unusual,
but the nurse should verify that this change is not new
During the physical examination, the nurse notices that a female patient has an inverted left nipple.
Which statement regarding this is most accurate? Correct Answer: Whether the inversion is a recent
change should be determined.
The nurse is performing a breast examination. Which of these statements best describes the correct
procedure to use when screening for nipple and skin retraction during a breast examination? Have the
woman: Correct Answer: Slowly lift her arms above her head, and note any retraction or lag in
movement.
The nurse is palpating a female patient's breasts during an examination. Which of these positions is
most likely to make significant lumps more distinct during breast palpation? Correct Answer: Supine
with the arms raised over the head
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?
Correct Answer: The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period.
The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct Correct
Answer: "BSE on a monthly basis will help you become familiar with your own breasts and feel their
normal variations."
A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is
concerned about changes in her breasts that she has noticed over the past 5 years. She states that her
breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and
flabby." The nurse's best reply would be: Correct Answer: The decrease in hormones after menopause
causes atrophy of the glandular tissue in the breast and is a normal process of aging.
A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast
lump in her right breast for years. Recently, it has begun to change in consistency and is becoming
, harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was
nothing to worry about." The examination validates the presence of a mass in the right upper outer
quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, and non-tender, with
borders that are not well defined. The nurse replies: Correct Answer: Because of the change in
consistency of the lump, it should be further evaluated by the physician.
The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women
to perform BSEs is? Correct Answer: On the same day every month.
During a discussion about BSEs with a 30-year-old woman, what statement by the nurse is most
appropriate? Correct Answer: Examine your breast shortly after your menstrual period each month.
Peau d'orange- Correct Answer: Lymphatic obstruction causes edema, which thickens the skin and
exaggerates the hair follicles; this creates a pigskin or orange peel look. Could be an indication of cancer.
Dullness- Correct Answer: A high-pitched muffled thud sound obtained by percussing over relatively
dense organs such as liver or spleen, distended bladder, mass of adipose tissue
Tympany- Correct Answer: A high-pitchedmusical and drum like note obtained by percussing the
surface of a large air-containing space, such as the abdomen
Resonance- Correct Answer: A low-pitched, clear, hollow note obtained by percussing over normal lung
tissue
Hyperresonnance- Correct Answer: A low-booming note obtained by percussing over the adult lungs
that have increased air such as with a patient who has emphysema, present with distended abdomen
Which structure is located in the left lower quadrant of the abdomen? Correct Answer: Sigmoid colon
Aneurysm- Correct Answer: defect or sec formed by dilation in artery wall due to atherosclerosis,
trauma, or congenital defect (aortic aneurysm)
Dysphasia- Correct Answer: Difficulty swallowing
Anorexia- Correct Answer: Loss of appetite
Ascites Correct Answer: abnormal accumulation of serous fluid within the peritoneal cavity, associated
with heart failure, cirrhosis, cancer or portal hypertension
Bruit- Correct Answer: blowing, swoishing sound her through a stethoscope when an artery is partially
occluded
Hepatomegaly- Correct Answer: abnormally enlarged liver
Paralytic ileus- Correct Answer: complete absence of peristaltic movement that may follow abdominal
surgery or complete bowel obstruction
Peritonitis- Correct Answer: inflammation of the peritoneum
