Health Assessment
Textbook Exam Questions
Course Introduction
Health Assessment is a foundational course designed to equip students with the knowledge and practical skills necessary to conduct comprehensive and focused evaluations of the health status of individuals across the lifespan. The course emphasizes the systematic collection and interpretation of data through health histories, physical examinations, and the use of diagnostic tools. Students learn to apply evidence-based techniques for assessing physical, psychological, social, and cultural factors that influence health, and to document findings accurately. Through theoretical instruction and hands-on practice, this course prepares students to identify normal and abnormal health patterns, support clinical decision-making, and establish the basis for effective care planning and intervention.
Recommended Textbook
Physical Examination and Health Assessment 3rd Canadian edition by Carolyn Jarvis
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1123 Verified Questions
1123 Flashcards
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Chapter 1: Evidence-Based Assessment
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Sample Questions
Q1) The nurse is reviewing data collected after an assessment.Of the data listed below, which would be considered related cues that would be clustered together during data analysis? (Select all that apply.)
A)Inspiratory wheezes noted in left lower lobes
B)Hypoactive bowel sounds
C)Nonproductive cough
D)Edema, +2, noted on left hand
E)Patient reports dyspnea upon exertion
F)Rate of respirations 16 breaths per minute
Answer: A, C, E, F
Q2) What step of the nursing process includes data collection through health history, physical examination, and interview?
A)Planning
B)Diagnosis
C)Evaluation
D)Assessment
Answer: D
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Chapter 2: Health Promotion in the Context of Health Assessment
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Sample Questions
Q1) The nurse is working with a population of refugees from Syria.What concerns might the nurse have regarding their health? (Select all that apply.)
A)The negative influence of low income on their health
B)The challenges of improved nutrition leading to obesity
C)Health disparities resulting in longer life expectancy
D)The challenges of accessing health care services leading to poor health outcomes
E)Health inequities resulting in higher instances of poor health
Answer: A, D, E
Q2) To implement primary prevention in practice.The nurse will: (Select all that apply.)
A)Promote routine childhood immunizations.
B)Provide teaching on heart failure management.
C)Encouraging the use of helmets when bicycling.
D)Recommend a mammography for the 55-year-old patient.
E)Discuss weight loss strategies for children diagnosed with obesity.
Answer: A, C
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Chapter 3: Cultural Competence: Cultural Care
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Sample Questions
Q1) Taking a critical cultural perspective when working with culturally diverse populations, the nurse is attentive to patients' culture and:
A)Significant cultural practices
B)The quality of patients' nutrition
C)The importance of patients' race
D)The influence of the social determinants of health
Answer: D
Q2) When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments.Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older White patient?
A)"Are you of the Christian faith?"
B)"Do you want to see a priest?"
C)"How often do you seek help from medical providers?"
D)"What cultural or spiritual beliefs are important to you?"
Answer: D
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Chapter 4: The Interview
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Questions
Q1) A woman is discussing the problems she is having with her 2-year-old son.She says, "He won't go to sleep at night, and during the day he has several fits.I get so upset when that happens." The nurse's best verbal response would be:
A)"Go on, I'm listening."
B)"Fits? Tell me what you mean by this."
C)"Yes, it can be upsetting when a child has a fit."
D)"Don't be upset when he has a fit; every 2-year-old has fits."
Q2) A 17-year-old woman, who is a lone parent, is describing how difficult it is to raise a 3-year-old child by herself.During the course of the interview, she states, "I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me!" Which of these responses by the nurse uses empathy?
A)"You feel alone."
B)"You can't believe he left you alone?"
C)"It must be so hard to face this all alone."
D)"I would be angry, too; raising a child alone is no picnic."
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6
Chapter 5: The Complete Health History
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Sample Questions
Q1) The nurse is incorporating a person's spiritual values into the health history.Which of these questions illustrates the "community" portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions?
A)"Do you believe in God?"
B)"Are you a part of any religious or spiritual group?"
C)"Do you consider yourself to be a religious or spiritual person?"
D)"How does your religious faith influence the way you think about your health?"
Q2) The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing.Which of these is an example of a symptom?
A)Chest pain
B)Clammy skin
C)Serum potassium level at 4.2 mEq/L
D)Body temperature of 100° F
Q3) The review of systems section provides the nurse with:
A)Physical findings related to each system
B)Information regarding health promotion practices
C)An opportunity to teach the patient medical terms
D)Information necessary for the nurse to diagnose the patient's medical problem
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Chapter 6: Mental Health Assessment
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Sample Questions
Q1) The nurse needs to determine if the 68-year-old patient is safe to continue living on his own in his own home.The nurse will complete a(n):
A)Risk assessment
B)Exercise log
C)Elimination routine
D)Functional assessment
Q2) To discourage stigmatization of patients with mental illness, the nurse educates nursing students that:
A)Reflection is not helpful in practice
B)Reality of mental illness is permanence
C)Recovery from mental illness is possible
D)Reducing stigma is not possible
Q3) During an interview, the patient's speech is garbled, and the thoughts shared are confused.What should the nurse do?
A)Nothing, because this is part of normal aging
B)Stop the interview and document that the patient is an alcoholic
C)Perform a mental status examination
D)Call the family to take the patient home
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Chapter 7: Substance Use and Health Assessment
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Sample Questions
Q1) The nurse is caring for a mother after the delivery of her infant.The mother had reported using an antidepressant through her pregnancy and is worried about her baby.The nurse should reassure the mother and:
A)Inform her that she should not have been taking antidepressants while pregnant.
B)Promote skin-to-skin contact and breastfeeding to support mother and baby.
C)Inform her that the baby will need medication to treat the withdrawal.
D)Remove the baby from her care.
Q2) The nurse is reviewing aspects of substance use in preparation for a seminar.Which of these statements illustrates the concept of tolerance to an illicit substance? The person:
A)Has a physiological dependence on a substance.
B)Requires an increased amount of the substance to produce the same effect.
C)Requires daily use of the substance to function and is unable to stop using it.
D)Experiences a syndrome of physiologic symptoms if the substance is not used.
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9
Chapter 8: Interpersonal Violence Assessments
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Sample Questions
Q1) During assessment of a 9-year-old patient, the nurse notes purple-blue bruises to both knees.The mother and patient separately inform the nurse that the patient got the bruises playing soccer the day before.From the colour of the bruises the nurse:
A)Is convinced the child is being abused.
B)Recognizes that the objective data validates the subjective data.
C)Questions when the bruises actually occurred.
D)Is unable to identify the time frame for when the bruises were attained.
Q2) The nurse is using the Danger Assessment (DA) tool to evaluate the risk for violence.Which of these statements best describes its use?
A)The DA tool is to be administered by law enforcement personnel.
B)The DA tool should be used in every assessment of suspected abuse.
C)The number of "yes" answers indicates the woman's understanding of her situation.
D)The higher the number of "yes" answers, the more serious is the danger of the woman's situation.
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Chapter 9: Assessment Techniques and the Clinical Setting
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Sample Questions
Q1) The nurse is reviewing percussion techniques with a newly graduated nurse.Which technique, if used by the new nurse, indicates that more review is needed?
A)Percussing once over each area
B)Quickly lifting the striking finger after each stroke
C)Striking with the fingertip, not the finger pad
D)Using the wrist, not the arm, to make the strikes
Q2) When examining an older adult, the nurse should use which technique?
A)Avoiding touching the patient too much
B)Attempting to perform the entire physical examination during one visit
C)Speaking loudly and slowly because most aging adults have hearing deficits
D)Arranging the sequence of the examination to allow as few position changes as possible
Q3) Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?
A)Palpation
B)Inspection
C)Percussion
D)Auscultation
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11
Chapter 10: General Survey, Measurement, Vital Signs
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Sample Questions
Q1) A patient is seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination?
A)Blood pressure readings are taken in both the arms and the thighs.
B)The patient is assisted to the lying position, and his blood pressure is taken.
C)His blood pressure is recorded in the lying, sitting, and standing positions.
D)His blood pressure is recorded in the lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.
Q2) The nurse notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff.The nurse should expect the reading to:
A)Yield a falsely low blood pressure.
B)Yield a falsely high blood pressure.
C)Be the same, regardless of cuff size.
D)Vary as a result of the technique of the person performing the assessment.
Q3) What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and pulse rate is 72 beats per minute?
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Page 12
Chapter 11: Pain Assessment
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Sample Questions
Q1) A patient has been admitted to the hospital with vertebral fractures related to osteoporosis.She is in extreme pain.This type of pain would be classified as:
A)Referred
B)Cutaneous
C)Visceral
D)Deep somatic
Q2) When assessing the intensity of a patient's pain, which question by the nurse is appropriate?
A)"What makes your pain better or worse?"
B)"How much pain do you have now?"
C)"How does pain limit your activities?"
D)"What does your pain feel like?"
Q3) When assessing a patient's pain, the nurse knows that the most reliable indicator of pain would be the:
A)Patient's vital signs.
B)Physical examination findings.
C)Results of a computed tomography (CT) scan.
D)Subjective report by the patient.
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13
Chapter 12: Nutritional Assessment
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Sample Questions
Q1) The nurse is assessing a patient who is obese for signs of metabolic syndrome.This condition is diagnosed when three or more certain risk factors are present.Which of these assessment findings are risk factors for metabolic syndrome? (Select all that apply.)
A)FPG level less than 5.5 mmol/L
B)FPG level greater than or equal to 6.1 mmol/L
C)BP reading of 140/90 mm Hg
D)BP reading of 110/80 mm Hg
E)Triglyceride level of 1.5 mmol/L
Q2) The nurse is performing a nutritional assessment on an 80-year-old patient.The nurse knows that physiological changes can directly affect the nutritional status of the older adult and include:
A)Slowed gastrointestinal motility.
B)Hyperstimulation of the salivary glands.
C)Increased sensitivity to spicy and aromatic foods.
D)Decreased gastrointestinal absorption causing esophageal reflux.
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Chapter 13: Skin, Hair, and Nails
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Sample Questions
Q1) The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry.This finding would be related to which factor in the older adult?
A)Increased vascularity of the skin
B)Increased numbers of sweat and sebaceous glands
C)An increase in elastin and a decrease in subcutaneous fat
D)An increased loss of elastin and a decrease in subcutaneous fat
Q2) The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth and that the lesions are raised approximately 1 to 3 mm.The nurse will assess the child for:
A)A pink, papular rash on the face and neck.
B)Pruritic vesicles over her trunk and neck.
C)Hyperpigmentation on the chest, abdomen, and back of the arms.
D)A red-purple, maculopapular, blotchy rash behind the ears and on the face.
Q3) The nurse is assessing for inflammation in a dark-skinned person.Which technique is the best?
A)Assessing the skin for cyanosis and swelling
B)Assessing the oral mucosa for generalized erythema
C)Palpating the skin for edema and increased warmth
D)Palpating for tenderness and local areas of ecchymosis
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Page 15
Chapter 14: Head, Face, and Neck, Including Regional Lymphatics
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Sample Questions
Q1) A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger.During assessment, the nurse suspects a noncancerous finding as the lump:
A)Is singular and firm.
B)Consists of multiple nodules.
C)Disappears when the patient smiles.
D)Is hard and fixed to the surrounding structures.
Q2) When examining children affected with Down's syndrome (trisomy 21), the nurse looks for the possible presence of:
A)Misshapen ears.
B)Long, thin neck.
C)Thin tongue sticking out.
D)Narrow and raised nasal bridge.
Q3) The nurse notices that a patient's palpebral fissures are unequal.On examination, the nurse may find that damage has occurred to which cranial nerve (CN)?
A)III
B)V
C)VII
D)VIII
Page 16
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Chapter 15: Eyes
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Sample Questions
Q1) A patient's vision is recorded as 20/30 when the Snellen eye chart is used.The nurse interprets these results to indicate that:
A)At 30 feet the patient can read the entire chart.
B)The patient can read at 20 feet what a person with normal vision can read at 30 feet.
C)The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.
D)The patient can read from 30 feet what a person with normal vision can read from 20 feet.
Q2) A 60-year-old man with suspected ptosis of one eye is at the clinic for an eye examination.The nurse confirms ptosis by:
A)Performing the confrontation test.
B)Assessing the patient's near vision.
C)Observing the distance between the palpebral fissures.
D)Performing the corneal light test, and looking for symmetry of the light reflex.
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Chapter 16: Ears
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Sample Questions
Q1) The nurse is preparing to perform an otoscopic examination on a 2-year-old child.Which one of these reflects the correct procedure?
A)Pulling the pinna down
B)Pulling the pinna up and back
C)Slightly tilting the child's head toward the examiner
D)Instructing the child to touch his chin to his chest
Q2) During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall.What does this finding suggest?
A)Malignancy
B)Viral infection
C)Blood in the middle ear
D)Yeast or fungal infection
Q3) A patient has been shown to have a sensorineural hearing loss.During the assessment, it would be important for the nurse to:
A)Speak loudly so the patient can hear the questions.
B)Assess for middle ear infection as a possible cause.
C)Ask the patient about current medications.
D)Look for the source of the obstruction in the external ear.
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18
Chapter 17: Nose, Mouth, and Throat
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Sample Questions
Q1) The nurse is using an otoscope to assess the nasal cavity.Which of these techniques is correct?
A)Inserting the speculum at least 3 cm into the vestibule
B)Avoiding touching the nasal septum with the speculum
C)Gently displacing the nose to the side that is being examined
D)Keeping the speculum tip medial to avoid touching the floor of the nares
Q2) The nurse is assessing a 3-year-old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odour is noted from the left naris, and no drainage is observed from the right naris.The child is afebrile with no other symptoms.What should the nurse do next?
A)Refer to the physician for an antibiotic order
B)Have the mother bring the child back in 1 week
C)Perform an otoscopic examination of the left nares
D)Tell the mother that this drainage is normal for a child of this age
Q3) The tissue that connects the tongue to the floor of the mouth is the:
A)Uvula.
B)Palate.
C)Papillae.
D)Frenulum.
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Page 19
Chapter 18: Breasts and Regional Lymphatics
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Sample Questions
Q1) In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important.The reason for this is that the upper outer quadrant is:
A)The largest quadrant of the breast.
B)The location of most breast tumours.
C)Where most of the suspensory ligaments attach.
D)More prone to injury and calcifications than other locations in the breast.
Q2) 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:
A)"Don't worry about the pain; breast cancer is not painful."
B)"I would like some more information about the pain in your left breast."
C)"Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct."
D)"Breast pain is almost always the result of benign breast disease."
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Chapter 19: Thorax and Lungs
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Sample Questions
Q1) An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard.The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes.The nurse interprets that these assessment findings are consistent with:
A)Asthma.
B)Atelectasis.
C)Lobar pneumonia.
D)Heart failure.
Q2) A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-coloured sputum, low-grade afternoon fevers, and night sweats for the past 2 months.The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:
A)Bronchitis.
B)Pneumonia.
C)Tuberculosis.
D)Pulmonary edema.
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Chapter 20: Heart and Neck Vessels
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Sample Questions
Q1) When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
A)Mitral and tricuspid
B)Tricuspid and aortic
C)Aortic and pulmonic
D)Mitral and pulmonic
Q2) The nurse is assessing a patient's pulses and notices a difference between the patient's apical pulse and radial pulse.The apical pulse is 118 beats per minute, and the radial pulse is 105 beats per minute.What is the pulse deficit?
Q3) During the cardiac auscultation, the nurse hears a sound immediately occurring after S at the second left intercostal space.To further assess this sound, what should the nurse do?
A)Have the patient turn to the left side while the nurse listens with the bell of the stethoscope.
B)Ask the patient to hold his or her breath while the nurse listens again.
C)No further assessment is needed because the nurse knows this sound is S3.
D)Watch the patient's respirations while listening for the effect of breathing on the sound.
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Chapter 21: Peripheral Vascular System and Lymphatic System
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Sample Questions
Q1) When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+.What should the nurse do next?
A)Document the finding
B)Auscultate the site for a bruit
C)Check for calf pain
D)Check capillary refill in the toes
Q2) The nurse is reviewing an assessment of a patient's peripheral pulses and notes previous documentation of radial pulses to be "2+." The nurse recognizes that this reading indicates what type of pulse?
A)Bounding
B)Normal
C)Weak
D)Absent
Q3) During assessment of a patient with emphysema, the nurse examines the patient's fingers from the side to detect:
A)Pitting edema
B)Early clubbing
C)Symmetry of the fingers
D)Insufficient capillary refill
23
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Chapter 22: Abdomen
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Sample Questions
Q1) The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen.Which statement by the new graduate shows correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
A)"We need to determine the areas of tenderness before using percussion and palpation."
B)"Auscultation prior prevents distortion of bowel sounds that might occur after percussion and palpation."
C)"Auscultation allows the patient more time to relax and thus be more comfortable with the physical examination."
D)"Auscultation prevents distortion of vascular sounds, such as bruits and hums, which might occur after percussion and palpation."
Q2) A patient is suspected of having cholecystitis, or inflammation of the gallbladder.The nurse should conduct which of these techniques to assess for this condition?
A)Obturator test
B)Test for inspiratory arrest
C)Assess for rebound tenderness
D)Iliopsoas muscle test
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Page 24
Chapter 23: Anus, Rectum, and Prostate
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Sample Questions
Q1) Which statement concerning the anal canal is true? The anal canal:
A)Is approximately 2 cm long in the adult
B)Slants backward toward the sacrum
C)Contains hair and sebaceous glands
D)Is the outlet for the gastrointestinal tract
Q2) During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx.The nurse recognizes that this lesion is likely a:
A)Rectal polyp
B)Pruritus ani
C)Carcinoma
D)Pilonidal cyst
Q3) A patient who is visiting the clinic complains of having "stomach pains for 2 weeks" and describes his stools as being "sticky looking and black" for approximately the past 10 days.He denies taking any medications.The nurse is aware that these symptoms are mostly indicative of:
A)Excessive fat caused by malabsorption
B)Increased iron intake, resulting from a change in diet
C)Occult blood, resulting from gastrointestinal bleeding
D)Absent bile pigment from liver problems
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Chapter 24: Musculoskeletal System
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Sample Questions
Q1) A mother brings her newborn baby boy in for a checkup; she tells the nurse that he does not seem to be moving his right arm as much as his left arm and that he seems to have pain when she lifts him up by holding him under the arms.The nurse suspects a fractured clavicle and would observe for:
A)Negative Allis test
B)Positive Ortolani sign
C)Limited ROM during the Moro reflex
D)Limited ROM during the LaSègue test
Q2) The nurse is assessing a patient who sprained his ankle playing soccer.The nurse explains that the fibrous bands which usually connect the medial and lateral malleolus and strengthen that joint have been stretched beyond their limits.The nurse identifies these bands as:
A)Bursa
B)Tendons
C)Cartilage
D)Ligaments
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Chapter 25: Neurological System
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Sample Questions
Q1) In a person with an upper motor neuron lesion after a cerebrovascular accident, which of these physical assessment findings should the nurse expect?
A)Hyper-reflexia
B)Fasciculations
C)Loss of muscle tone and flaccidity
D)Atrophy and wasting of the muscles
Q2) In the assessment of a 1-month-old infant, the nurse notices lack of response to noise or stimulation.The mother reports that in the past week he has been sleeping all the time, and when he is awake all he does is cry.The nurse hears that the infant's cries are very high pitched and shrill.What should be the nurse's appropriate response to these findings?
A)Refer the infant for further testing
B)Talk with the mother about eating habits
C)Do nothing; these are expected findings for an infant this age
D)Tell the mother to bring the baby back in 1 week for a recheck
Q3) During the assessment of DTRs, the nurse finds that a patient's responses are bilaterally normal.What number is used to indicate normal DTRs when the documenting this finding? __________+
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Chapter 26: Male Genitourinary System
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Sample Questions
Q1) A male patient with possible fertility problems asks the nurse where sperm is produced.The nurse knows that sperm production occurs in the: A)Testes
B)Prostate
C)Epididymis
D)Vas deferens
Q2) A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination.He is experiencing:
A)Dysuria
B)Nocturia
C)Polyuria
D)Hematuria
Q3) During a physical examination, the nurse finds that a male patient's foreskin is fixed and tight and will not retract over the glans.The nurse recognizes that this condition is: A)Phimosis
B)Epispadias
C)Urethral stricture
D)Peyronie's disease
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Chapter 27: Female Genitourinary System
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Q1) A 46-year-old woman is in the clinic for her annual gynecological examination.She voices her concern about ovarian cancer because her mother and sister had died as a result of it.Which statement regarding ovarian cancer does the nurse know to be correct?
A)Ovarian cancer rarely has any symptoms.
B)The Pap test detects the presence of ovarian cancer.
C)Women at high risk for ovarian cancer should undergo screening with annual transvaginal ultrasonography.
D)Women over age 40 years should have a thorough pelvic examination every 3 years.
Q2) During a speculum inspection of the vagina of a 25-year-old female who has never been pregnant, what would the nurse expect to see at the end of the vaginal canal?
A)Cervix with a smooth, small os
B)Pear-shaped uterus
C)Oval-shaped ovaries
D)Cervix with an irregular, enlarged os
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Chapter
Child, and Adolescent
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Sample Questions
Q1) Which of these is included when the nurses assesses the general appearance of the patient?
A)Height
B)Weight
C)Skin colour
D)Vital signs
Q2) During a complete health assessment, how would the nurse test the patient's hearing?
A)Observing how the patient participates in normal conversation
B)Using the whispered voice test
C)Using the Weber and Rinne tests
D)Testing with an audiometer
Q3) The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles.This finding indicates:
A)Lymphedema
B)Raynaud's disease
C)Arterial insufficiency
D)Venous insufficiency
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Chapter 29: Bedside Assessment of the Hospitalized Patient
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Sample Questions
Q1) At the beginning of rounds when entering the room, what should the nurse do first?
A)Check the intravenous (IV) infusion site for swelling or redness
B)Check the infusion pump settings for accuracy
C)Make eye contact with the patient, and introduce himself or herself as the patient's nurse
D)Offer the patient something to drink
Q2) During an assessment of a hospitalized patient, the nurse pinches a fold of skin under the clavicle or on the forearm to test the:
A)Mobility and turgor
B)Patient's response to pain
C)Percentage of the patient's fat-to-muscle ratio
D)Presence of edema
Q3) When assessing the neurological system of a hospitalized patient during morning rounds, the nurse should include which of these during the assessment?
A)Blood pressure
B)Patient's rating of pain on a scale of 1 to 10
C)Patient's ability to communicate
D)Patient's personal hygiene level
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Chapter 30: The Pregnant Woman
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Sample Questions
Q1) During auscultation of FHTs, the nurse determines that the heart rate is 136 beats per minute.The nurse's next action should be to:
A)Document the results, which are within normal range
B)Take the maternal pulse to verify these findings as the uterine soufflé
C)Have the patient change positions and count the FHTs again
D)Immediately notify the physician for possible fetal distress
Q2) The nurse auscultates a functional systolic murmur, grade II/IV, on a woman in week 30 of her pregnancy.The remainder of her physical assessment is within normal limits.The nurse would:
A)Consider this finding abnormal, and refer her for additional consultation
B)Ask the woman to run briefly in place and then assess for an increase in intensity of the murmur
C)Know that this finding is normal and is a result of the increase in blood volume during pregnancy
D)Ask the woman to restrict her activities and return to the clinic in 1 week for re-evaluation
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Chapter 31: Functional Assessment of the Older Adult
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Sample Questions
Q1) The nurse is preparing to perform a functional assessment with an older patient and knows that a good approach would be to:
A)Observe the patient's ability to perform the tasks
B)Ask the patient's wife how he does when performing tasks
C)Review the medical record for information on the patient's abilities
D)Ask the patient's physician for information on the patient's abilities
Q2) The nurse is preparing to use the Lawton IADL instrument as part of an assessment.Which statement about the Lawton IADL instrument is true?
A)The nurse uses direct observation to implement this tool.
B)The Lawton IADL instrument is designed as a self-report measure of performance rather than ability.
C)This instrument is not useful in the acute hospital setting.
D)This tool is best used for those residing in an institutional setting.
Q3) When beginning to assess a person's spirituality, which question by the nurse would be most appropriate?
A)"Do you believe in God?"
B)"How does your spirituality relate to your health care decisions?"
C)"What religious faith do you follow?"
D)"Do you believe in the power of prayer?"
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