Patient Assessment Techniques
Exam Answer Key
Course Introduction
This course provides students with foundational knowledge and practical skills in patient assessment procedures critical to effective healthcare delivery. Emphasizing both subjective and objective methods, the course covers health history taking, vital sign measurement, inspection, palpation, percussion, and auscultation across body systems. Students will learn to systematically evaluate patients physical, emotional, and psychosocial status, enabling accurate identification of health problems and formulation of care plans. Hands-on activities and case studies reinforce the application of assessment techniques in a variety of clinical scenarios.
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) For which person is a shift 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: A
Q2) A community organization sponsors a health fair to increase awareness of colon cancer. At the health fair, colorectal cancer screening kits are distributed, and health care professionals answer questions, take blood pressure, and distribute literature. What level of health prevention is being implemented by this community organization?
A) Primary
B) Secondary
C) Tertiary
D) Risk factor
Answer: B
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Chapter 2: Obtaining a Health History
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) A male patient is very talkative and shares much information that is not relevant to his history or the reason for his admission. Which action by the nurse improves data collection in this situation?
A) Terminate the interview.
B) Use closed-ended questions.
C) Ask the patient to stay on the subject.
D) Ask another nurse to complete the interview.
Answer: B
Q2) A nurse is interviewing a male patient who reports he has not had a tetanus immunization in about 15 years because he had a "bad reaction" to the last tetanus immunization. What is the most appropriate response by the nurse in this case?
A) Notify the health care provider that this immunization cannot be given.
B) Document that the patient is allergic to the tetanus vaccine.
C) Give the vaccine after explaining that adverse reactions are rare.
D) Ask the patient to describe the "bad reaction" to the vaccine in more detail.
Answer: D
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Chapter 3: Techniques and Equipment for Physical Assessment
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31 Verified Questions
31 Flashcards
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Sample Questions
Q1) What part of the stethoscope do nurses use to auscultate the chest?
A) Press the bell firmly against the skin to hear sounds and vibrations.
B) The bell of the stethoscope is used to hear breath sounds.
C) The diaphragm of the stethoscope is used to hear heart sounds.
D) Either the bell or the diaphragm is used to auscultate the chest.
Answer: C
Q2) A nurse is preparing to assess a patient's ability to detect vibrations. Which piece of equipment is appropriate for this assessment?
A) Reflex hammer
B) Tuning fork
C) Goniometer
D) Monofilament
Answer: B
Q3) When does a nurse use a Pederson or Graves speculum for examination of a patient?
A) To inspect the external ear
B) To assess the vaginal canal
C) To inspect nasal passages
D) To assess the oropharynx
Answer: B
Page 5
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Chapter 4: General Inspection and Measurement of Vital Signs
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18 Flashcards
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Sample Questions
Q1) Nurses understand that a patient's diastolic pressure represents which physiologic function?
A) The pressure needed to open the aortic and pulmonic valves
B) The pressure in blood vessels when the ventricles contract
C) The pressure of the blood returning to the heart from the venous system
D) The pressure in blood vessels when the ventricles are relaxed
Q2) According to research findings, which site is preferred for measuring blood pressure when the nurse is unable to use the patient's upper arms?
A) Ankle
B) Thigh
C) Calf
D) Wrist
Q3) The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation?
A) The measurement at 6 AM
B) The measurement at 12 PM
C) The measurement at 6 PM
D) The measurement at 12 AM
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Chapter 5: Cultural Assessment
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14 Verified Questions
14 Flashcards
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Sample Questions
Q1) A Hispanic patient tells an African-American nurse, "You are African-American and can't possibly understand how a person like me feels." What is an appropriate response by the nurse at this time?
A) Find a nurse who is not African-American to interview the patient.
B) Ask the patient, "Why do you think that, since we just met?"
C) Note that the patient is very defensive about being racially different.
D) Encourage the patient to describe what he means by his statement.
Q2) A nurse is caring for a woman who has given birth to a healthy baby. The woman's husband and mother are in the room, and more family members are in the lobby. Which comment by the nurse demonstrates culturally competent care?
A) "We need to take your baby to the nursery now for a physical examination."
B) "Are there any ceremonies or other practices that are important to you at this time?"
C) "We can only allow immediate family in the room with you at this time."
D) "Because breastfeeding is the best way to feed your baby, we'll bring your baby to you when she is hungry."
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Chapter 6: Pain Assessment
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15 Verified Questions
15 Flashcards
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Sample Questions
Q1) A patient who had an amputation of his lower leg comes to the clinic with a complaint of pain. He asks, "How I can be feeling pain in my foot-my foot is gone?" What is the appropriate response from the nurse?
A) "After your amputation, pain perception increases."
B) "Amputating your leg caused abnormal processing of sensory input by the peripheral nervous system."
C) "Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there."
D) "When sensory nerves enter the spinal cord, they stimulate nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located."
Q2) A patient with a partial small bowel obstruction describes the pain as "cramping, off-and-on pain that spreads over my stomach." What type of pain is this patient experiencing?
A) Referred pain
B) Phantom pain
C) Somatic pain
D) Visceral pain
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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 a sports physical for a 16-year-old girl, the nurse asks which question to collect data about drug use?
A) "Many teenagers have tried street drugs. Have you tried these drugs?"
B) "Tell me which street drugs your friends have offered to you?"
C) "Do most of your friends drink alcohol or do street drugs?"
D) "Your high school has a reputation for drug use. Do you use drugs?"
Q2) A nurse screens every adult and adolescent patient for alcohol consumption. Which patient drinks more than recommended?
A) The man who reports drinking three beers and one shot of whiskey each day
B) The woman who reports drinking two glasses of wine and two vodka martinis each day
C) The older adult man who reports drinking one glass of sherry before going to bed each night
D) The woman who reports drinking one glass of wine with dinner each day.
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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Page 9
Chapter 8: Nutritional Assessment
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22 Verified Questions
22 Flashcards
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Sample Questions
Q1) 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
Q2) Which patient may require additional nutritional assessment?
A) A male patient with a blood glucose level of 100 mg/dl
B) A pregnant patient with a hemoglobin level of 10.5 g/dl
C) A female patient with a prealbumin level of 25 mg/dl
D) A male patient with a serum triglyceride level of 100 mg/dl
Q3) A nurse is asking questions about the present health status of a young woman who has lost weight recently. Which question is most appropriate when inquiring about present health status?
A) "What concerns have you had in the past regarding your weight?"
B) "Do you have anorexia?"
C) "Describe the recent changes in your weight."
D) "Do you have a family history of eating disorders?"
Q4) A woman's waist circumference is 32 inches and her hip circumference is 29 inches. Her waist-to-hip ratio is _____.
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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 patient asks the nurse if it is possible to grow new skin. What is the nurse's most appropriate response?
A) "Even if new skin growth is required, the melanocytes do not regenerate."
B) "The avascular epidermis sheds slowly and is replaced completely every 4 weeks."
C) "The outer layer of skin remains the same over the lifetime except for repairing injuries."
D) "Epidermal regeneration is impossible because it is avascular."
Q2) A patient is visiting an urgent care center after being hit in the back with a baseball. Upon examination, the nurse notes a flat, nonblanchable spot 2.25 cm wide that is reddish-purple in color. How does the nurse document this lesion?
A) As an angioma
B) As purpura
C) As petechiae
D) As ecchymosis
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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 observes a student using the whisper test to screen a patient with hearing loss. Which behavior by the student requires a corrective comment from the nurse?
A) Instructing the patient to cover the ear not being tested
B) Standing beside the patient on the side of the ear being tested
C) Shielding the mouth to prevent the patient from reading lips
D) Whispering one or two syllable words and ask the patient to repeat what is heard
Q2) Which cranial nerve is assessed by using the Snellen visual acuity chart?
A) Optic cranial nerve (CN II)
B) Oculomotor cranial nerve (CN III)
C) Abducens cranial nerve (CN IV)
D) Trochlear cranial nerve (CN VI)
Q3) During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo?
A) "I felt faint, like I was going to pass out."
B) "I just could not keep my balance when I sat up."
C) "It seemed that the room was spinning around."
D) "I was afraid that I was going to lose consciousness."
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Page 12
Chapter 11: Lungs and Respiratory System
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) On inspection, the nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. What other findings does this nurse expect during the examination? (Select all that apply.)
A) Inspiratory wheezing found on auscultation
B) Hyperresonance heard on percussion
C) Decreased breath sounds heard on auscultation
D) Deceased diaphragmatic excursion on percussion
E) A sharp, abrupt pain reported when the patient breathes deeply
F) Decreased to absent vibration on vocal fremitus
Q2) In reviewing the patient's record, the nurse notes that the patient has air in the subcutaneous tissue. The nurse validates that this patient has crepitus with which finding?
A) Asymmetric expansion of the chest wall on inhalation
B) Increased transmission of vocal vibrations on auscultation
C) Crackling sensation under the skin of the chest on palpation
D) Coarse grating sounds heard over the mediastinum 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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Page 13
Chapter 12: Heart and Peripheral Vascular System
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) While taking a history, a nurse learns that a patient had rheumatic heart disease as a child. Based on this information, what abnormal data might this nurse expect to find during an examination?
A) An extra beat just before the S2 heart sound heard during auscultation
B) A raspy machine-like or blowing sound heard during auscultation
C) A prominent thrust of the heart against the chest wall felt on palpation
D) A visible indentation of pericardial tissue noted during inspection
Q2) How does a nurse accurately palpate carotid pulses?
A) Two fingers of each hand are placed firmly over the right and left temples at the same time.
B) One finger is placed gently in the space between the biceps and triceps muscles.
C) Two fingers are placed at the thumb side of the forearm at the wrist.
D) One finger is placed along the right and then the left medial sternocleidomastoid muscle.
Q3) How is the first heart sound (S1) created?
A) Pulmonic and tricuspid valves close.
B) Mitral and aortic valves close.
C) Aortic and pulmonic valves close.
D) Mitral and tricuspid valves close.
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Page 14
Chapter 13: Abdomen and Gastrointestinal System
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38 Verified Questions
38 Flashcards
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Sample Questions
Q1) A patient reports having frequent heartburn. Which question does the nurse ask in response to this information?
A) "Has your abdomen been distended when you feel the heartburn?"
B) "What have you eaten in the last 24 hours?"
C) "Is there a history of heart disease in your family?"
D) "How long after eating do you have heartburn?"
Q2) Alcoholism increases the risk of cancers of the gastrointestinal tract. Which cancer risk is increased in patients with alcoholism? (Select all that apply.)
A) Esophageal cancer
B) Stomach cancer
C) Pancreatic cancer
D) Liver cancer
E) Colon cancer
F) Bladder cancer
Q3) What instructions does the nurse give a patient before palpating the abdomen?
A) Bend the knees.
B) Take a deep breath and hold it.
C) Take a deep breath and cough.
D) Place the hands over the head.
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Page 15
Chapter 14: Musculoskeletal System
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27 Verified Questions
27 Flashcards
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Sample Questions
Q1) Which description of pain from the patient makes a nurse suspect the patient's pain is originating from a muscle?
A) "Crampy"
B) "Dull and deep"
C) "Boring and intense"
D) "Sharp upon movement"
Q2) The nurse asks the patient to rest the left arm on a table and to move the lower arm so that the palm of the hand is up and then down. What motion is the nurse testing?
A) Adduction and abduction of the wrist
B) Supination and pronation of the wrist
C) Adduction and abduction of the elbow
D) Supination and pronation of the elbow
Q3) When a nurse asks a patient to place the right arm behind the head, the nurse is testing for which range of motion?
A) Flexion of the elbow
B) Hyperextension of the shoulder
C) Internal rotation and adduction of the shoulder
D) External rotation and abduction of the shoulder
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Chapter 15: Neurologic System
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34 Verified Questions
34 Flashcards
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Sample Questions
Q1) Which manifestations does a nurse correlate with a patient with suspected meningitis? (Select all that apply.)
A) Ptosis
B) Loss of balance when standing with feet together and the eyes closed
C) Confusion, agitation, and irritability
D) Severe headache
E) Stiff neck
F) Lethargy
Q2) A nurse holds the patient's relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. What is the expected response for this deep tendon reflex?
A) Extension of the left elbow
B) Pronation of the left forearm
C) Supination of the left arm
D) Flexion of the left elbow
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Chapter 16: Breasts and Axillae
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Sample Questions
Q1) The nurse notices dimpling of the skin surrounding a palpable mass in the right breast of a female patient. What is the most appropriate action for the nurse to take next?
A) Record this as an expected finding.
B) Palpate the area of dimpling for pain.
C) Palpate the borders of the area of dimpling for irregularity.
D) Tell the patient that dimpling indicates the mass is benign.
Q2) A patient comes to the clinic complaining of a new onset of nipple discharge. After inspection of the breast and discharge, what action of the nurse has the highest priority?
A) Palpating both breasts comparing amount of discharge
B) Asking the patient about breast pain
C) Asking the patient to raise her arms and comparing the movement of the breasts
D) Obtaining a specimen of the discharge for cytology
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Chapter 17: Reproductive System and the Perineum
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40 Verified Questions
40 Flashcards
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Sample Questions
Q1) The nurse documents which finding as expected on inspection of the anus?
A) Skin tone darker and coarser than that of the surrounding skin
B) Sphincter lightly closed when the patient is relaxed
C) Large amount of stiff, curling hair surrounding the anus
D) Slight protrusion under the skin when the patient strains or bears down
Q2) 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
Q3) While giving a history, a patient reports having a weak urinary stream and feeling that his bladder is not empty after urination. Based on these data, what finding does the nurse anticipate upon examination?
A) An enlarged prostate gland palpated on the anterior wall of the rectum
B) An indirect hernia palpated through the inguinal ring when the patient coughs
C) The foreskin of the penis cannot be returned to position after retraction behind the glans
D) A nodular prostate gland palpated on the posterior wall of the rectum
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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) During middle adulthood, which immunization may be recommended?
A) PPV (pneumococcal pneumonia vaccine)
B) Hepatitis B virus vaccine, third dose
C) Human papillomavirus (HPV)
D) Td (tetanus and diphtheria toxoids)
Q3) Which characteristics are expected during an assessment of a normal toddler?
A) Half of adult height achieved by age two, potbelly, and sway back
B) Thirty-two erupted teeth by age 2, tripled birth weight by age 30 months
C) Desire for autonomy coupled with sufficient judgment to ensure safety
D) Head circumference greater than chest circumference, high frustration tolerance
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20
Chapter 19: Assessment of the Infant, Child, and Adolescent
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Sample Questions
Q1) When assessing an infant, the nurse recognizes which finding requires immediate attention?
A) Cheyne-Stokes type of respiratory pattern
B) 1:1 anteroposterior to lateral chest diameter
C) Stridor and nasal flaring
D) Bronchovesicular lung sounds in the periphery
Q2) A nurse refers which child for further assessment?
A) A 2-year-old who has a jugular venous hum after playing
B) A 4-year-old who has a resting heart rate of 100
C) A 5-year-old who positions herself in a squat after running a few feet
D) A 7-year-old who has a strong femoral pulse readily detected on palpation
Q3) Which disorder, if any, does a nurse screen for when examining a healthy adolescent?
A) Muscle weakness.
B) Limited joint range of motion.
C) Curvature of the spine.
D) No screening is needed when the adolescent is healthy.
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21
Chapter 20: Assessment of the Pregnant Patient
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30 Verified Questions
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Sample Questions
Q1) A pregnant patient presents to the clinic with a 3 lb/week weight gain for 2 successive weeks. The nurse is most concerned that this patient is demonstrating signs of which condition?
A) Gestational diabetes mellitus
B) Preeclampsia
C) Placenta enlargement
D) Multiple gestations
Q2) To perform Leopold maneuvers, the nurse uses which assessment technique?
A) Percussing over the symphysis pubis
B) Auscultating all four abdominal quadrants
C) Palpating the fundus
D) Measuring from symphysis pubis to the umbilicus
Q3) A pregnant woman who drinks alcoholic beverages while pregnant increases the risk for which disorder?
A) Low infant birth weight
B) Birth defects
C) Abruptio placentae
D) Gestational diabetes mellitus
Q4) If a patient's last menstrual period was May 13, her estimated date of birth is
22
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Chapter 21: Assessment of the Older Adult
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Sample Questions
Q1) 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
Q2) In assessing the nails of an older adult, which finding does a nurse expect to find?
A) Transverse ridges
B) Thick, brittle, and yellow nails
C) Thin, brittle nails
D) Lateral edges turned upward
Q3) Which finding on cardiovascular assessment of an older adult patient warrants further evaluation?
A) Occasional ectopic beats heard on auscultation of the heart
B) Murmur heard over the mitral valve
C) Systolic pressure of 156 in the right arm and 188 in the left arm
D) Persistent S4 sound in a patient with a history of decreased ventricular function
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Chapter 22: Conducting a Head-to-Toe Examination
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Sample Questions
Q1) Which data does a nurse collect during the general survey when meeting a patient for the first time? (Select all that apply.)
A) Gait
B) Muscle strength
C) Heart sounds
D) Hearing and speech abilities
E) Mood or affect
F) Position of the trachea
Q2) Which techniques does a nurse use routinely to collect data when assessing a patient's anterior thorax? (Select all that apply.)
A) Palpation of the thorax for fremitus
B) Inspection of the skin for color, intactness, lesions, and scars
C) Auscultation of breath sounds bilaterally
D) Auscultation of heart sounds for rate, rhythm, frequency, and S1 and S2
E) Palpation of the anterior chest wall for thoracic expansion
F) Inspection of respiratory movement for symmetry and ease of respiration
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Chapter 23: Documenting the Comprehensive Health Assessment
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Sample Questions
Q1) Which data do nurses document under the category of past health history?
A) Chronic diseases
B) Immunizations received
C) Allergies to medications or food
D) Causes of death of the patient's parents
Q2) 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.
Q3) Which data do nurses document under the category of personal and psychosocial health history? (Select all that apply.)
A) Allergies to medications or food
B) Diet and foods eaten on a regular basis
C) Type of employment
D) Address and date of birth
E) Activities that promote health
F) Use of tobacco and alcohol
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Chapter 24: Adapting Health Assessment to the Hospitalized Patient
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Sample Questions
Q1) Which tube interferes with hearing lung sounds during auscultation? (Select all that apply.)
A) Gastrostomy tube
B) Chest tube
C) Nasogastric tube
D) Tracheostomy tube
E) Oral endotracheal tube
Q2) 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
Q3) How does a nurse assess perfusion to the foot when a patient has a cast from the left middle calf to the toes?
A) Palpate the popliteal pulse of the left leg.
B) Palpate the posterior tibial pulse of the left leg.
C) Assess movement and sensation of the left toes.
D) Assess the capillary refill of the left toes.
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