Health Assessment Final Test Bank EXAM 2024-2025 QUESTIONS AND
CORRECT VERIFIED ANSWERS /100% PASS SOLUTION / ALREADY
GRADED A+
A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation?
a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed.
b. The dermatome served by this nerve will no longer experience any sensation.
c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the
severed nerve.
d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have
no sensory component. - answer>>c. The adjacent spinal nerves will continue to carry sensations for the
dermatome served by the severed nerve.
Rationale: A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord
segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic
insurance; that is, if one nerve is severed, then most of the sensations can be transmitted by the spinal
nerve above and the spinal nerve below the severed nerve.
After completing an initial assessment of a patient, the nurse has charted that his respirations are
eupneic and his pulse is 58 beats per minute. These types of data would be:
a. Objective
b. Reflective
c. Subjective
d. Introspective - answer>>a. Objective
Rationale: Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. Subjective data is what the person says
about him or herself during history taking. The terms reflective and introspective are not used to
describe data.
A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would
be:
a. Objective
b. Reflective
c. Subjective
,d. Introspective - answer>>c. Subjective
Rationale: Subjective data are what the person says about him or herself during history taking.
Objective data are what the health professional observes by inspecting, percussing, palpating, and
auscultating during the physical examination. The terms reflective and introspective are not used to
describe data.
When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next
action should be to:
a. Immediately notify the patients physician
b. Document the sound exactly as it was heard
c. Validate the data by asking a coworker to listen to the breath sounds
d. Assess again in 20 minutes to note whether the sound is still present - answer>>c. Validate the
data by asking a coworker to listen to the breath sounds
Rationale: When unsure of a sound heard while listening to a patients breath sounds, the nurse
validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks
an expert to listen.
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other
injuries. During the assessment what would the nurse expect to find when testing the patients deep
tendon reflexes?
a. Reflexes will be normal.
b. Reflexes cannot be elicited.
c. All reflexes will be diminished but present.
d. Some reflexes will be present, depending on the area of injury. - answer>>a. Reflexes will be
normal.
Rationale: A reflex is a defense mechanism of the nervous system. It operates below the level of
conscious control and permits a quick reaction to potentially painful or damaging situations.
,A 70-year-old woman tells the nurse that every time she gets up in the morning or after shes been
sitting, she gets really dizzy and feels like she is going to fall over. The nurses best response would be:
a. Have you been extremely tired lately?
b. You probably just need to drink more liquids.
c. I'll refer you for a complete neurologic examination.
d. You need to get up slowly when you've been lying down or sitting. - answer>>d. You need to get
up slowly when you've been lying down or sitting.
Rationale: Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this
decrease causes dizziness and a loss of balance with a position change. These individuals need to be
taught to get up slowly. The other responses are incorrect.
While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the
infants ability to suck and grasp the mothers finger. What is the nurse assessing?
a. Reflexes
b. Intelligence
c. CNs
d. Cerebral cortex function - answer>>a. Reflexes
Rationale: Questions regarding reflexes include such questions as, What have you noticed about the
infants behavior, Are the infants sucking and swallowing seem coordinated, and Does the infant grasp
your finger? The other responses are incorrect.
In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and
that he has noticed a tremor in his hands that affects his ability to hold things. With this information,
what response should the nurse make?
a. Does your family know you are drinking every day?
, b. Does the tremor change when you drink alcohol?
c. Well do some tests to see what is causing the tremor.
d. You really shouldn't drink so much alcohol; it may be causing your tremor. - answer>>b. Does
the tremor change when you drink alcohol?
Rationale: Senile tremor is relieved by alcohol, although not a recommended treatment. The nurse
should assess whether the person is abusing alcohol in an effort to relieve the tremor.
A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the
past week. The nurse should perform which type of neurologic examination?
a. Glasgow Coma Scale
b. Neurologic recheck examination
c. Screening neurologic examination
d. Complete neurologic examination - answer>>d. Complete neurologic examination
Rationale: The nurse should perform a complete neurologic examination on an individual who has
neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of
neurologic dysfunction. The Glasgow Coma Scale is used to define a persons level of consciousness.
The neurologic recheck examination is appropriate for those who are demonstrating neurologic
deficits. The screening neurologic examination is performed on seemingly well individuals who have
no significant subjective findings from the health history.
During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or
frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse
presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?
a. Motor component of CN IV
b. Motor component of CN VII
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