NR-304 ExamHealth Assessment II -
Chamberlain
1. A patient presents with swelling in the legs and ankles. What is the most likely
cause of this symptom?
A) Dehydration
B) Venous insufficiency
C) Hypertension
D) Hyperglycemia
Answer: B) Venous insufficiency
2. During a physical examination, a nurse observes that the patient's skin is warm,
dry, and intact. What should the nurse consider as the most relevant assessment?
A) Check for signs of infection
B) Assess for dehydration
C) Evaluate for hypothermia
D) Monitor for skin breakdown
Answer: B) Assess for dehydration
3. What is the most appropriate technique to assess for jugular venous pressure
(JVP) in a patient?
A) Have the patient lie flat and measure the vertical height of the pulsation from the
sternal angle.
B) Place the patient in a sitting position and measure the pulsation at the level of the
clavicles.
C) Ask the patient to stand and observe the pulsation in the carotid artery.
D) Measure the pulsation of the jugular vein while the patient is supine and the head
elevated at a 30-degree angle.
Answer: D) Measure the pulsation of the jugular vein while the patient is supine and
the head elevated at a 30-degree angle.
,4. When auscultating the lungs, the nurse hears wheezes. What does this finding
suggest?
A) Fluid accumulation in the lungs
B) Airway obstruction or narrowing
C) Presence of a pleural friction rub
D) Normal airflow through the bronchi
Answer: B) Airway obstruction or narrowing
5. A patient reports sudden, severe headache, nausea, and vomiting. The nurse
suspects possible subarachnoid hemorrhage. What should be the priority action?
A) Administer pain medication
B) Perform a neurological assessment
C) Obtain a CT scan of the brain
D) Initiate intravenous fluids
Answer: B) Perform a neurological assessment
6. In assessing a patient's abdomen, the nurse finds that the abdomen is distended
and tympanic. What could this finding indicate?
A) Constipation
B) Ascites
C) Bowel obstruction
D) Liver enlargement
Answer: C) Bowel obstruction
7. A patient has a history of chronic obstructive pulmonary disease (COPD) and
presents with increased shortness of breath. What is the most appropriate initial
intervention?
A) Administer supplemental oxygen
B) Start a bronchodilator therapy
C) Perform chest physiotherapy
D) Obtain a chest X-ray
Answer: A) Administer supplemental oxygen
,8. During a cardiac examination, the nurse detects a third heart sound (S3). What is
this finding indicative of in a patient with heart failure?
A) Normal physiological finding
B) Increased cardiac output
C) Possible heart failure or volume overload
D) Mitral valve regurgitation
Answer: C) Possible heart failure or volume overload
9. When assessing a patient’s neurological status, which of the following is the most
appropriate way to test cranial nerve function?
A) Observe the patient’s gait
B) Check for sensation in the extremities
C) Test for pupil reaction to light
D) Measure blood pressure
Answer: C) Test for pupil reaction to light
10. In evaluating a patient’s musculoskeletal system, the nurse notes decreased
range of motion in the shoulder joint. What should be the next step in the
assessment?
A) Measure the circumference of the shoulder
B) Assess for signs of joint inflammation
C) Compare range of motion with the opposite shoulder
D) Check for muscle strength in the arm
Answer: C) Compare range of motion with the opposite shoulder
11. A patient is experiencing difficulty swallowing and a sensation of food sticking in
the chest. What should the nurse suspect?
A) Gastroesophageal reflux disease (GERD)
B) Esophageal stricture
C) Peptic ulcer disease
D) Gastritis
, Answer: B) Esophageal stricture
12. When assessing a patient's extremities for edema, what measurement technique
is most accurate?
A) Visual inspection of the legs
B) Palpation for pitting edema
C) Measurement of leg circumference at the same site
D) Assessment of skin temperature
Answer: C) Measurement of leg circumference at the same site
13. What is the most appropriate nursing action when a patient exhibits signs of a
deep vein thrombosis (DVT)?
A) Encourage the patient to ambulate frequently
B) Apply heat to the affected area
C) Elevate the affected leg and avoid massaging it
D) Administer anticoagulants as prescribed
Answer: C) Elevate the affected leg and avoid massaging it
14. When assessing a patient’s cardiac function, which finding would most likely
indicate right-sided heart failure?
A) Dyspnea on exertion
B) Pulmonary crackles
C) Jugular vein distention
D) Decreased blood pressure
Answer: C) Jugular vein distention
15. A patient with a history of diabetes mellitus is experiencing numbness and
tingling in the feet. What should the nurse assess next?
A) Peripheral pulses
B) Blood glucose levels
C) Skin temperature
D) Capillary refill time
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