NR 302 Health Assessment Final Exam
______ is exhibiting an accurate understanding of the other person's feelings within a
communication context. - ANS-empathy
"Positive consensual light reflex" means... - ANS-simultaneous constriction
A 24 hour recall of dietary intake is used as: - ANS-a questionnaire of everything eaten in last
day
A 30 year old woman reports having persistent intense pain in her right arm related to trauma
from a car accident 5 months ago. She states that the slightest touch or clothing exacerbates
the pain. This report suggest: - ANS-Complex regional pain I
A barrel-shaped chest is characterized by: - ANS-equal anteroposterior transverse diameter and
ribs being horizontal
A configuration of individual lesions arranged in circles or arcs, like ringworm, is: - ANS-annular
lesions
A genogram is used for which reasons? - ANS-family history
A major characteristic of dementia is: - ANS-impairment of short and long term memory
A murmur heard after S1 and before S2 is classified as: - ANS-systolic, possibly benign
A nasal polyp is distinguished from the nasal turbinates by 3 things - ANS-moveable, pale/gray,
nontender
A patient asks the nurse "May I ask you a question?" This is an example of - ANS-a closed
question
A patient has recently received health insurance and would like to know how often to see his
provider. How do you respond? - ANS-Your visits may very, depending on your level of wellness
A patient is in the emergency department with nausea and vomiting. Which would you include in
the database? - ANS-A diet and GI history
A patient is requesting pain medication and says pain is 9/10, but is up and smiling. How should
you proceed? - ANS-Use therapeutic communication to determine patients pain scale goal and
history of chronic pain
,A patient presents with acute pain of the abdomen. After the initial exam, how would you
proceed? - ANS-give pain meds as ordered
A patient says she is very nervous and nauseated, and she feels as if she will vomit. This is
what type of data? - ANS-Subjective
A pregnant woman explains that she does not intend to stop drinking bc her friends didnt and
their kids are fine. How should you respond? - ANS-No amount of alcohol has been determined
to be safe for a pregnant woman so i ask you to stop completely
A risk factor for melanoma is: - ANS-skin that freckles or burns before tanning
A throbbing, unilateral pain associated with nausea, vomiting, and photophobia is characteristic
of:
A. cluster headache
B. subarachnoid hemorrhage
C. migraine headache
D. tension headache - ANS-migraine headache
ABCDE of skin cancer - ANS-Asymmetry
Border
Color
Diameter
Elevation
Abdomen / Genitourinary- bedside - ANS-Abdomen•Assess contour of abdomen: flat,
rounded.•Listen to bowel sounds in all four quadrants.•Check any tube placement for drainage
and insertion site integrity.•Inquire whether passing flatus or stool.•Be aware of dietary orders.
•Genitourinary•Inquire whether voiding regularly.•Check urine for color, clarity.•If Foley catheter
is in place: check color, quantity, clarity, and amount .•If urine output is below expected value,
perform a bladder scan according to agency protocol.
Abdomen: infant - ANS-Inspect
ØShape of abdomen and skin condition
ØUmbilicus, count cord vessels, condition of cord or stump, detection of hernia
ØSkin turgor
Palpate
ØLight palpation to note muscle tone, liver, spleen tip, and bladder
ØDeep palpation to note kidneys and potential masses
ØFemoral arteries and inguinal lymph nodes
Percuss all quadrants
Abnormal finding of jugular venous pressure - ANS-patient elevated to 45 degrees , Internal
jugular vein pulsation at 4 cm above sternal angle
, Acculturation - ANS-process of social and psychological exchanges with encounters between
persons of different cultures, resulting in changes in either group
Acrocyanosis - ANS-bluish color around the lips, hands and fingernails, feet and toenails.
Activity- bedside - ANS-Note activity order—If patient is on bed rest, HOB should be
elevated.Note if SCDs are ordered and follow protocol.If ambulatory, assist patient to sitting
level and move to chairNote any assistance needed and ability to transfer.Assess need for
ambulatory aid or equipment.Complete any standardized scales per protocol to quantify fall
risk.Initiate or continue appropriate plan of care and follow core measures as needed.Complete
documentation.
Ad hoc interpreter - ANS-using a patient's family member, friend, or child as interpreter for a
patient with limited English proficiency (LEP)
african american with flat, 3cm, nontender, gray/white lesion on bucal mucosa -
ANS-leukodema, normal
Although a full mental status examination may not be required for every patient, the health care
provider must address the four main components during a health history and physical
examination. The four components are:
A) memory, attention, thought content, and perceptions.
B) language, orientation, attention, and abstract reasoning.
C) appearance, behavior, cognition, and thought processes.
D) mood, affect, consciousness, and orientation. - ANS-appearance, behavior, cognition, and
thought processes
An 18 month old is brought into the clinic for a health screening. To assess height of child use: -
ANS-horizontal measuring board
An area of thin shiny skin with decreased visibility of normal skin markings is most likely: -
ANS-atrophy
angle of nail is less than 160 and spongy, indicates- - ANS-congenital heart disease and COPD
Annoyed, easily provoked - ANS-irritability
Apex - ANS-3 to 4cm above inner third of clavicles
apprehensive from the anticipation of an unknown source of danger - ANS-anxiety
Assessing a patient's skin turgor is done to assess which clinical finding? - ANS-dehydration
