Clinical Nursing Assessment
Question Bank
Course Introduction
Clinical Nursing Assessment focuses on the systematic process of collecting and analyzing health data to inform patient care in diverse clinical settings. This course equips students with the knowledge and skills necessary to perform comprehensive and focused health assessments, including patient interviews, physical examinations, and use of diagnostic tools. Emphasis is placed on developing clinical reasoning, effective communication, cultural competence, and evidence-based decision-making to identify patient needs, recognize deviations from normal health status, and formulate appropriate nursing interventions.
Recommended Textbook
Health Assessment for Nursing Practice 6th Edition by Wilson
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24 Chapters
634 Verified Questions
634 Flashcards
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Chapter 1: Introduction to Health Assessment
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14 Verified Questions
14 Flashcards
Source URL: https://quizplus.com/quiz/2458
Sample Questions
Q1) Which situation illustrates a screening assessment?
A) A patient visits an obstetric clinic for the first time and the nurse conducts a detailed history and physical examination.
B) A hospital sponsors a health fair at a local mall and provides cholesterol and blood pressure checks to mall patrons.
C) The nurse in an urgent care center checks the vital signs of a patient who is complaining of leg pain.
D) A patient newly diagnosed with diabetes mellitus comes to test his fasting blood glucose level.
Answer: B
Q2) For which person is an episodic or follow-up assessment indicated?
A) The person who had abdominal surgery yesterday
B) The person who is unaware of his high serum glucose levels
C) The person who is being admitted to a long-term care facility
D) The person who is beginning rehabilitation after a knee replacement
Answer: D
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3
Chapter 2: Obtaining a Health History
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) During an interview, a patient begins to cry and appears angry. Which response by the nurse is most therapeutic?
A) "This topic prompted an emotional response, tell me what you are feeling."
B) "This topic does not usually cause such an emotional response."
C) "Calm down and tell me what is wrong."
D) "I will leave you alone for a few minutes so you can pull yourself together."
Answer: A
Q2) While giving a history, a male patient describes several events out of order that occurred in different decades in his life. What technique does the nurse use to understand the timeline of these events?
A) State the order of events as understood and ask the patient to verify the order.
B) Draw conclusions about the order of events from data given.
C) Ask the patient to elaborate about these events.
D) Ask the patient to repeat what he said about these events.
Answer: A
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4
Chapter 3: Techniques and Equipment for Physical Assessment
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31 Verified Questions
31 Flashcards
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Sample Questions
Q1) When examining a patient, the nurse remembers to follow which principle of Standard Precautions?
A) Wear gloves throughout the entire examination of the patient.
B) Wear gloves when in contact with the patient's mucous membranes.
C) Wear gloves to reduce the need for handwashing.
D) Wear eye protection and a gown during the examination of the patient.
Answer: B
Q2) Using an ophthalmoscope, how does the nurse bring a patient's interior eye structures into focus?
A) Using the red filter
B) Adjusting the diopters
C) Dilating the patient's pupils
D) Using the wide-beam light
Answer: B
Q3) To test deep tendon reflexes, the nurse uses which instrument?
A) Goniometer
B) Calipers
C) Reflex hammer
D) Monofilament
Answer: C
Page 5
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Chapter 4: General Inspection and Measurement of Vital Signs
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18 Verified Questions
18 Flashcards
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Sample Questions
Q1) Which method of temperature measurement indirectly reflects inner core temperature? (Select all that apply.)
A) Axillary temperature
B) Oral temperature
C) Tympanic temperature
D) Rectal temperature
E) Temporal artery temperature
Q2) Which statement is correct regarding taking or interpreting axillary temperatures?
A) Axillary temperatures should not be used in patients less than 2 years of age.
B) Readings may be less accurate.
C) The thermometer is left in place for no more than 3 minutes.
D) The thermometer is placed in the axilla with the shoulder abducted.
Q3) Which body system does the nurse assess primarily by inspection?
A) Respiratory
B) Gastrointestinal
C) Skin
D) Cardiovascular
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Chapter 5: Cultural Assessment
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14 Verified Questions
14 Flashcards
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Sample Questions
Q1) Which question is most effective in assessing a patient's personal beliefs about health and illness?
A) "What or who do you believe controls your health?"
B) "Do you see your health care provider annually?"
C) "Do you have specific beliefs about health and illness?"
D) "Who makes the health decisions in your family?"
Q2) A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of persistent headaches. The patient tells the nurse that the medicines prescribed by the tribal healer have done "some good." What is the appropriate response of the nurse at this time?
A) "I advise you to stop taking those medicines from the tribal healer."
B) "Perhaps you should increase the frequency of the healer's medicines."
C) "Tell me about these medicines and how often you are using them."
D) "Could your headaches be caused by the healer's medicines?"
Q3) What are the characteristics of one's culture?
A) Color of skin and hair
B) System of beliefs and practices
C) Food preferences
D) Language and religion
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Page 7
Chapter 6: Pain Assessment
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15 Verified Questions
15 Flashcards
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Sample Questions
Q1) A patient with gout is complaining of severe, throbbing pain in the great toe. What type of pain is this patient experiencing?
A) Neuropathic pain
B) Somatic pain
C) Referred pain
D) Visceral pain
Q2) How do nurses assess a patient's pain?
A) By assessing physiologic changes of the patient
B) By understanding the sensory experience related to the amount of tissue damage
C) By the patient's medical diagnosis or surgical procedure
D) By asking the patient to rate the pain being experienced
Q3) The nurse notes in the patient's history that the patient has persistent, malignant pain. What is the meaning of this type of pain?
A) The pain has been present for at least 2 weeks.
B) The pain began after recent surgery and is associated with healing incisions.
C) The pain has been present for 6 or more months.
D) The pain has been present since surgery to remove cancer.
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Chapter 7: Mental Health Assessment
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17 Verified Questions
17 Flashcards
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Sample Questions
Q1) During conversation, the nurse observes that the patient is talking continuously and excitedly, and is switching rapidly from one topic to another with seemingly no relationship between topics. This behavior is often associated with which disorder?
A) Depression
B) Obsessive-compulsive disorder
C) Schizophrenia
D) Bipolar disorder
Q2) While assessing a man during a physical examination for work, the nurse suspects alcohol use. Which assessment tool is appropriate in this situation?
A) AUDIT screening tool
B) Rapid eye test
C) Mental status examination
D) HITS screening tool
Q3) What function do neurotransmitters have in mental health disorders?
A) Dopamine levels are increased in schizophrenia.
B) Increased levels of gamma aminobutyric acid (GABA) contribute to anxiety.
C) Serotonin is decreased in a state of anxiety.
D) Norepinephrine is increased in depression.
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Chapter 8: Nutritional Assessment
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22 Verified Questions
22 Flashcards
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Sample Questions
Q1) During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present?
A) Vitamin C
B) Vitamin B
C) Essential fatty acid
D) Protein
Q2) What is the desired body weight for a male who is 7 feet tall?
A) 178 lb
B) 225 lb
C) 250 lb
D) 275 lb
Q3) A woman's waist circumference is 32 inches and her hip circumference is 29 inches. Her waist-to-hip ratio is _____.
Q4) A nurse calculates a patient's body mass index (BMI) as 33. This measurement indicates which class of weight?
A) Overweight
B) Obesity class I
C) Obesity class II
D) Obesity class III
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Chapter 9: Skin, Hair, and Nails
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30 Verified Questions
30 Flashcards
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Sample Questions
Q1) A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure ulcer on the patient's left trochanter area that involves partial-thickness skin loss with damage to the subcutaneous tissue. The nurse reports this ulcer at what stage?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
Q2) During shift report, a nurse learns that a patient has a macular rash. As the nurse inspects the patient's skin, what finding will confirm the rash?
A) Elevated, firm, well-defined lesions less than 1 cm in diameter
B) Depressed, firm, or scaly, rough lesions greater than 1 cm in diameter
C) Elevated, fluid-filled lesions less than 1 cm in diameter
D) Flat, well-defined, small lesions less than 1 cm in diameter
Q3) How does the nurse recognize jaundice in a dark-skinned patient?
A) Inspect the conjunctiva for ashen-gray color.
B) Inspect the nail beds for a deeper brown or purple skin tone.
C) Inspect the palms and soles for yellowish-green color.
D) Inspect the oral mucous membrane for yellow color.
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Page 11
Chapter 10: Head, Eyes, Ears, Nose, and Throat
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75 Verified Questions
75 Flashcards
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Sample Questions
Q1) A nurse is assessing a patient who was hit at the base of the skull with a blunt instrument causing a skull fracture. What assessment finding does this nurse anticipate during the inspection?
A) Tinnitus, vertigo, and dizziness
B) Clear drainage from the ear and nose
C) Loss of hearing and smell
D) Purulent drainage from the ear and bloody drainage from the nose
Q2) A nurse reads in the history that a patient has a new onset of acute otitis media. Based on this information, how does the nurse expect this patient's tympanic membrane to appear?
A) Dull
B) Shiny
C) Red
D) Blue to deep red
Q3) A nurse suspects the patient has an infection of the maxillary sinuses. How can this suspicion be confirmed?
A) Using a flashlight to illuminate the floor of the mouth
B) Pressing gently with both thumbs into the eyebrow ridges
C) Applying firm pressure with the thumbs below the cheekbones
D) Standing behind the patient and asking him or her to slowly rotate the head
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Chapter 11: Lungs and Respiratory System
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) A patient has right lower lobe pneumonia, creating a consolidation in that lung. In assessing for vocal fremitus, the nurse found increased fremitus over the right lower lung. What finding does the nurse anticipate when assessing vocal resonance to confirm the consolidation?
A) Bronchophony reveals the patient's spoken "99" as clear and loud.
B) No sounds are expected since sounds cannot be transmitted through consolidation.
C) Egophony reveals indistinguishable sounds when the patient says "e-e-e."
D) Whispered pectoriloquy reveals a muffled sound when the patient says "1-2-3."
Q2) On inspection, a nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data does the nurse anticipate?
A) Increased vocal fremitus on palpation
B) Dull tones heard on percussion
C) Decreased breath sounds on auscultation
D) Complaint of sharp chest pain on inspiration
Q3) A patient tells the nurse that he has smoked 1 \(\frac{1}{2}\) packs of cigarettes a day for 14 years. The number of packs the nurse should record in the medical record is ___ pack-years.
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Chapter 12: Heart and Peripheral Vascular System
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this patient?
A) 1+ edema of the feet and ankles bilaterally
B) The circumference of the right leg is larger than the left leg
C) Patchy petechiae and purpura of the lower extremities
D) Cool feet with capillary refill of toes greater than 3 seconds
Q2) Which patient does the nurse identify as the one at greatest risk for hypertension?
A) Woman with coronary artery disease
B) Hispanic male
C) Obese male with diabetes mellitus
D) Postmenopausal woman
Q3) While assessing edema on a male patient's lower leg, the nurse notices that there is a slight imprint of his fingers where he palpated the patient's leg. How does the nurse document this finding?
A) No edema
B) 1+ edema
C) 2+ edema
D) 3+ edema
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Chapter 13: Abdomen and Gastrointestinal System
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38 Verified Questions
38 Flashcards
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Sample Questions
Q1) On inspection of a female patient's abdomen, the nurse asks the patient to raise her head without using her arms and notes a midline bulge. What is the appropriate response of the nurse at this time?
A) Ask the patient to hold her breath to see if the bulge reappears.
B) Auscultate the patient's abdomen for hypoactive bowel sounds.
C) Document this as a normal finding and continue the examination.
D) Perform light palpation of the abdomen.
Q2) A nurse notices abdominal distention when inspecting a patient's abdomen. What action does the nurse take next to gain further objective data?
A) Place a measuring tape around the superior iliac crests.
B) Assist the patient to turn on to the left side and then the right side.
C) Ask the patient to cough while lying supine.
D) Use the fingertips to sharply strike one side of the abdomen.
Q3) When inspecting a patient's abdomen, the nurse notes which finding as abnormal?
A) Protruding abdomen with skin that is lighter in color than the arms and legs
B) Marked, widely lateral pulsating mass to the left of the midline
C) Faint, fine vascular network
D) Small shadows created by changes in contour
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15
Chapter 14: Musculoskeletal System
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27 Verified Questions
27 Flashcards
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Sample Questions
Q1) Which movements does a nurse expect to find when assessing the hip range of motion of a healthy person? (Select all that apply.)
A) Pronation and supination
B) Flexion and extension
C) Internal and external rotation
D) Adduction and abduction
E) Hyperextension
Q2) When a nurse asks a patient to place the right arm behind the back, so that the back of the hand is touching the lower spine, the nurse is testing for which range of motion?
A) Pronation of the elbow
B) Hyperextension of the elbow
C) Internal rotation and adduction of the shoulder
D) External rotation and abduction of the shoulder
Q3) What movement from the patient does a nurse request to assess for hyperextension of the hip?
A) Raise one leg at a time while lying prone.
B) Raise one leg at a time while lying supine.
C) Move one leg at a time laterally, away from midline, while lying prone.
D) Move one leg at a time medially, toward midline, while lying supine.
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Page 16
Chapter 15: Neurologic System
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34 Verified Questions
34 Flashcards
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Sample Questions
Q1) A patient has a compression fracture of the cervical spine at C7 to C8 that is impairing deep tendon reflexes. Which response will the nurse expect from the affected deep tendon reflex?
A) Diminished to absent pronation of the arm
B) Diminished to absent flexion of the elbow
C) Diminished to absent extension of the elbow
D) Diminished to absent adduction of the upper arm
Q2) The nurse moves a wisp of cotton lightly across the anterior scalp, paranasal sinuses, and lower jaw to test the function of which cranial nerve?
A) CN IV (trochlear nerve)
B) CN V (trigeminal nerve)
C) CN VI (abducens nerve)
D) CN VII (facial nerve)
Q3) Which patient behavior indicates to the nurse that the patient's facial cranial nerve (CN VII) is intact?
A) The patient's eyes move to the left, right, up, down, and obliquely.
B) The patient moistens the lips with the tongue.
C) The sides of the mouth are symmetric when the patient smiles.
D) The patient's eyelids blink periodically.
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Page 17
Chapter 16: Breasts and Axillae
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24 Verified Questions
24 Flashcards
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Sample Questions
Q1) In teaching a patient about breast self-examination, why does the nurse emphasize palpation of the axillary areas?
A) Because deep muscles in that area can mask changes
B) Because some patients avoid this area because of tenderness
C) Because most lymph draining from the breast flows through this area
D) Because supporting ligaments in this area may present as tissue changes
Q2) Based on the history, a nurse determines that the patient with which finding requires further assessment?
A) Occasional discharge from nipples
B) Supernumerary nipples along the milk line
C) Rash in the axillae associated with change in deodorant
D) Mild breast swelling that fluctuates with the menstrual cycle
Q3) A nurse becomes suspicious that a patient may have breast cancer based on which abnormal finding?
A) An irregularly shaped hard mass in one breast
B) Bilateral, small, nontender nodes close to the surface
C) Multiple rubbery-feeling lumps with well-defined borders
D) A mobile, firm lump located in the upper outer quadrant of the left breast
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18
Chapter 17: Reproductive System and the Perineum
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40 Verified Questions
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Sample Questions
Q1) When does a nurse use transillumination of the scrotum?
A) When the patient has tortuosity of the veins along the spermatic cord
B) When the patient has an indirect hernia
C) When there is a mass or fluid in the epididymis
D) When there is twisting of the testicle and spermatic cord
Q2) Which assessment technique does a nurse use to assess the inguinal region and femoral area of a male patient as he is standing and straining?
A) Palpates the femoral artery
B) Palpates the inguinal lymph nodes
C) Observes for a bulge through the inguinal region
D) Observes for discoloration of the inguinal ring
Q3) A nurse expects to find which manifestations in the male patient who has both Chlamydia and gonorrhea?
A) Painful urination and purulent urethral discharge
B) A single, firm painless open sore on the shaft of the penis
C) Red superficial vesicles on the shaft of the penis
D) A single or a cluster of wartlike growth in the anal-rectal area
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19
Chapter 18: Developmental Assessment Throughout the Life Span
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Sample Questions
Q1) Which statement best illustrates Erikson's theory of development?
A) The main goal is to establish equilibrium between self and environment.
B) One progresses through stages that involve specific psychosocial tasks.
C) There are four distinct, sequential levels of cognitive development.
D) Cognitive development occurs from birth to around age 15.
Q2) Which behavior illustrates a developmental task for a "young-old" older adult?
A) Adapting to living alone
B) Adjusting to loss of physical strength, illness, and emotional stress
C) Managing leisure time
D) Accepting possible institutional living arrangements
Q3) A nurse is assessing a preschooler who is able to draw a three-part human figure, hop on one foot, and recognize three colors. The nurse recognizes these characteristics as consistent for what age?
A) 3 years old
B) 4 years old
C) 5 years old
D) 6 years old
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Chapter 19: Assessment of the Infant, Child, and Adolescent
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45 Verified Questions
45 Flashcards
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Sample Questions
Q1) What does the nurse teach to parents to prevent sudden infant death syndrome (SIDS)?
A) Place the baby on back to sleep.
B) Place the baby on side to sleep.
C) Not to feed the baby for 3 hours before sleep.
D) Place the baby on her stomach to sleep.
Q2) During the assessment of a newborn within hours after birth, a nurse determines which finding as abnormal?
A) Capillary refill time of less than 1 second
B) Apical pulse felt at the second intercostal space
C) Splitting of heart sounds
D) Cyanosis of the hands and feet
Q3) A nurse shines the light from the ophthalmoscope into the eyes of a newborn and observes a bright, round, red-orange glow seen through both pupils. How does the nurse document this finding?
A) An expected red reflex
B) Eyelid capillary hemangiomas
C) Bilateral conjunctivitis
D) Ophthalmia neonatorum
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Page 21
Chapter 20: Assessment of the Pregnant Patient
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30 Verified Questions
30 Flashcards
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Sample Questions
Q1) Which physiologic changes are associated with pregnancy? (Select all that apply.)
A) Increase in brittleness of fingernails
B) 1500 mL increase in blood volume
C) Periodic shortness of breath later in pregnancy
D) Edematous and bleeding gums
E) Painless vaginal bleeding
F) Waddling gait
Q2) The nurse correlates which clinical manifestation with the diagnosis of polyhydramnios?
A) Difficulty palpating fetal parts
B) Increased fetal movement
C) Weight gain of less than estimated by gestational age
D) Increase of 2 cm in fundal height in 1 week
Q3) In assessing a patient for modifiable risk factors, the nurse correlates which finding with a high-risk pregnancy?
A) 15-year-old mother
B) Low socioeconomic status
C) Previous birth of infant with isoimmunization
D) Weight less than 100 lb
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22
Chapter 21: Assessment of the Older Adult
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Sample Questions
Q1) In collecting a history from an older adult, which information does the nurse consider least essential for a patient of this age?
A) Past health history
B) Genogram
C) Functional abilities
D) Mental health
Q2) In assessing the external eyes of an older adult, a nurse documents which finding as abnormal?
A) Gray-white circle where the cornea and the sclera merge
B) Brown spots near the limbus in both eyes
C) Lack of luster of the eye and dry bulbar conjunctiva
D) Lower lid drops away from the globe
Q3) What finding does a nurse look for when assessing the skin of an older adult with solar lentigo?
A) Yellowish, thin papules with a central depression
B) Pigmented, raised, wartlike lesions on the face or trunk
C) Small, soft, pigmented tags of skin on the face and neck
D) Irregular, flat, deeply pigmented macules on sun-exposed areas
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Chapter 22: Conducting a Head-to-Toe Examination
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Sample Questions
Q1) When does the health assessment begin?
A) When the nurse first meets the patient
B) When the patient tells the nurse his name and age
C) When the nurse asks the patient the first health-related question
D) When the patient consents to have a health assessment performed
Q2) Which techniques does a nurse use routinely to collect data when assessing the abdomen of a patient? (Select all that apply.)
A) Testing for presence of abdominal reflexes
B) Inspecting skin for contour, scars, lesions, vascularity, and bulges
C) Percussing in all quadrants for tone
D) Lightly palpating for tenderness, guarding, and masses
E) Auscultating for bowel sounds, bruits, and venous hums
F) Deeply palpating for tenderness, guarding, and masses
Q3) Which assessments are routine examination techniques of the upper extremities?
A) Palpating the epitrochlear lymph nodes for size and tenderness
B) Palpating the arms for skin characteristics, symmetry, tenderness, and deformities
C) Testing the range of motion and muscle strength comparing one arm with the other
D) Testing triceps, biceps, and brachioradialis deep tendon reflexes bilaterally
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24
Chapter 23: Documenting the Comprehensive Health Assessment
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Sample Questions
Q1) What data do nurses document under the category general survey?
A) Mental health
B) Functional ability
C) Diet and nutrition
D) Orientation
Q2) A patient reports she has shortness of breath and peripheral edema. Under which category does the nurse document these data?
A) Review of systems
B) Present health status
C) Past health history
D) Functional ability
Q3) Which documentation by a nurse is most descriptive?
A) Heart sounds normal.
B) Few ectopic beats heard during auscultation.
C) S1 murmur is heard at second right sternal border.
D) Pulse within normal limits.
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Chapter 24: Adapting Health Assessment to the Hospitalized Patient
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Sample Questions
Q1) Which patient using respiratory equipment requires skin assessment? (Select all that apply.)
A) A patient using a nasal cannula
B) A patient with a tracheostomy
C) A patient using an incentive spirometer
D) A patient using a Ventimask
E) A patient with an IV
Q2) What data do nurses collect when assessing a patient's wound? (Select all that apply.)
A) Skin turgor
B) Width, length, and depth
C) Presence of pulsations
D) Wound color
E) Presence of edema
F) Drainage color
Q3) A nurse uses the Glasgow Coma Scale to assess which patient?
A) The patient who has a new onset of quadriplegia
B) The patient who has tonic-clonic seizures
C) The patient who requires stimuli for responses
D) The patient who has dementia
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