Health Assessment Exam 1 NCLEX
A nurse precepting a student nurse asks, "What's the most important step in the critical-
thinking process?"
a. Clustering subjective and objective data
b. Analyzing health data
c. Using evidence-based assessment techniques
d. Prioritizing health concerns - answerc. Using evidence-based assessment techniques
Evidence-based techniques are supported by research showing effectiveness of the
technique that provides the safest and most current techniques to promote the health of
patients. Clustering subjective and objective data is a step in the critical-thinking
process, but is not the most important step. Analyzing health data is a step in the
critical-thinking process, but is not the most important step. Prioritizing health concerns
is a step in the critical-thinking process, but is not the most important step.
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up
appointment. On assessment, the nurse might expect to see which assessment finding?
- answerclubbing of the nails
A flat macular hemorrhage is called a(n):
A. purpura.
B. ecchymosis.
C. petechiae.
D. hemangioma. - answerpurpura
Describe Direct percussion - answerStrike body surface with 1 or 2 fingers.
Which of the following statements regarding language barriers and health care is true?
A. There is a law that addresses language barriers and health care.
B. Limited English proficiency is associated with a higher quality of care.
C. English proficiency is associated with a lower quality of care.
D. Patients with language barriers have a decreased risk of nonadherence to
medication regimens. - answerA. There is a law that addresses language barriers and
health car
Assessment of self-esteem and self-concept is part of the functional assessment. Areas
covered under self-esteem and self-concept include:
A. education, financial status, and value-belief system.
B. exercise and activity, leisure activities, and level of independence.
C. family role, interpersonal relations, social support, and time spent alone.
,D. stressors, coping mechanisms, and change in past year. - answerA. education,
financial status, and value-belief system.
The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is
aware that this means that the patient's trachea is: - answerpushed to the unaffected
side.
Parents or caretakers accompany children to the health care setting. Starting at ___
years of age, the interviewer asks the child directly about his or her presenting
symptoms.
A. 5
B. 7
C. 9
D. 11 - answer7
Normal Temp (Infant) Temp: - answer97.5 - 99.0 F
When taking the health history, the patient complains of pruritus. What is a common
cause of this symptom?
A. Excessive bruising
B. Hyperpigmentation
C. Melasma
D. Drug reactions - answerD. Drug reactions
pruritus: uncomfortable itchy feeling
What is Nystagmus? - answerinvoluntary eye movement
Order of physical assessment - answerfirst inspect, then palpate, then percussion, then
ausculatation
The nurse is preparing to assess a patient's abdomen by palpation. How should the
nurse proceed? - answerStart with light palpation to detect surface characteristics and
to accustom the patient to being touched.
The examiner notices a fine tremor when the patient sticks out his or her tongue. What
disorder is consistent with this finding?
A Hyperthyroidism
B Diabetic ketoacidosis
C Halitosis
D Alcoholism - answerA Hyperthyroidism
A patient is admitted to the emergency department after a motor vehicle accident. The
trachea is deviated to the left side. This finding is characteristic of:
A right pneumothorax.
B aortic arch aneurysm.
,C right pleural adhesion.
D right-sided atelectasis. - answerA right pneumothorax.
The use of euphemisms to avoid reality or to hide feelings is known as:
A. distancing language.
B. sympathetic language.
C. avoidance language.
D. ethnocentric language. - answerC. avoidance language.
Physical appearance includes statements that compare appearance with:
A. mood and affect.
B. stated age.
C. gait.
D. nutrition. - answerB. stated age.
An example of subjective data is:
a. decreased range of motion.
b. crepitation in the left knee joint.
c. arthritis
d. left knee has been swollen and hot for the past 3 days. - answerd. left knee has been
swollen and hot for the past 3 days.
Subjective data is what the patient says about himself or herself during history taking.
Objective data is what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. Range of motion is
assessed by inspection. Objective data is what the health professional observes by
inspecting, percussing, palpating, and auscultating during the physical examination.
Crepitation is assessed by palpating. Arthritis is a medical diagnosis.
An example of objective data is
a. a report of impaired mobility from left knee pain as evidenced by an inability to walk,
swelling, and pain on passive range of motion.
b. a complaint of left knee pain.
c. crepitation in the left knee joint
d. left knee has been swollen and hot for the past 3 days. - answerc. crepitation in the
left knee joint.
felt on palpation
Which of the following actions/behaviors in the critical-thinking process are important for
the novice nurse to remember? (Select all that apply.)
a. Disregard initial cues
b. Approach assessment with a nonjudgmental attitude
c. Cluster associated assessment data
d. Perform assessment in whatever manner works for you
e. Avoid making assumptions - answerb, c, e
, you want to cluster all the infromation so you have a general view of the signs and
symtpoms
Define first level priority, second, third - answerFirst-level priority problems are problems
that are emergent, life-threatening, and immediate. Impaired gas exchange is an
emergent and immediate problem. Third-level priority problems are problems that are
important to the patient's health but can be addressed after more urgent health
problems are addressed. Ineffective self-health management is an example of a third-
level priority. Second-level priority problems are problems that are next in urgency;
these problems require prompt intervention to forestall further deterioration. Risk for
infection is an example of a second-level priority. Third-level priority problems are
problems that are important to the patient's health but can be addressed after more
urgent health problems are addressed. Wellness diagnoses are third-level priority
problems.
When preparing the physical setting for an interview, the interviewer should
a.stand next to the patient to convey a professional demeanor.
b. conduct the interview at eye level and at a distance of 4 to 5 feet.
c. reduce noise by turning the volume on the television or radio down.
d. set the room temperature between 64° F and 66° F. - answerb
Both the interviewer and the patient should be at eye level at a distance of 4 to 5 feet.
The room temperature should be set at a comfortable level; a temperature between 64°
F and 66° F is too cool. Turn off the television or radio and any unnecessary equipment
to reduce noise. The interviewer and the patient should be comfortably seated; standing
communicates haste and assumes superiority.
INCORRECT
Nonverbal communication is the primary form of communication for which group of
individuals?
a. older adults
b. infants
c. preschoolers
d. adolescents - answerb
Nonverbal communication is the primary communication method for infants.
Preschoolers' communication is direct, concrete, literal, and set in the present.
Adolescents should be treated with respect; the nurse should use open, honest,
professional communication. Older adults may need special considerations r/t physical
limitations (e.g., adjusted pace to avoid fatigue, impaired hearing).
The most appropriate introduction to use to start an interview with an older adult patient
is
a. "Mr. Jones, I want to ask you some questions about your health so that we can plan
your care."
A nurse precepting a student nurse asks, "What's the most important step in the critical-
thinking process?"
a. Clustering subjective and objective data
b. Analyzing health data
c. Using evidence-based assessment techniques
d. Prioritizing health concerns - answerc. Using evidence-based assessment techniques
Evidence-based techniques are supported by research showing effectiveness of the
technique that provides the safest and most current techniques to promote the health of
patients. Clustering subjective and objective data is a step in the critical-thinking
process, but is not the most important step. Analyzing health data is a step in the
critical-thinking process, but is not the most important step. Prioritizing health concerns
is a step in the critical-thinking process, but is not the most important step.
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up
appointment. On assessment, the nurse might expect to see which assessment finding?
- answerclubbing of the nails
A flat macular hemorrhage is called a(n):
A. purpura.
B. ecchymosis.
C. petechiae.
D. hemangioma. - answerpurpura
Describe Direct percussion - answerStrike body surface with 1 or 2 fingers.
Which of the following statements regarding language barriers and health care is true?
A. There is a law that addresses language barriers and health care.
B. Limited English proficiency is associated with a higher quality of care.
C. English proficiency is associated with a lower quality of care.
D. Patients with language barriers have a decreased risk of nonadherence to
medication regimens. - answerA. There is a law that addresses language barriers and
health car
Assessment of self-esteem and self-concept is part of the functional assessment. Areas
covered under self-esteem and self-concept include:
A. education, financial status, and value-belief system.
B. exercise and activity, leisure activities, and level of independence.
C. family role, interpersonal relations, social support, and time spent alone.
,D. stressors, coping mechanisms, and change in past year. - answerA. education,
financial status, and value-belief system.
The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is
aware that this means that the patient's trachea is: - answerpushed to the unaffected
side.
Parents or caretakers accompany children to the health care setting. Starting at ___
years of age, the interviewer asks the child directly about his or her presenting
symptoms.
A. 5
B. 7
C. 9
D. 11 - answer7
Normal Temp (Infant) Temp: - answer97.5 - 99.0 F
When taking the health history, the patient complains of pruritus. What is a common
cause of this symptom?
A. Excessive bruising
B. Hyperpigmentation
C. Melasma
D. Drug reactions - answerD. Drug reactions
pruritus: uncomfortable itchy feeling
What is Nystagmus? - answerinvoluntary eye movement
Order of physical assessment - answerfirst inspect, then palpate, then percussion, then
ausculatation
The nurse is preparing to assess a patient's abdomen by palpation. How should the
nurse proceed? - answerStart with light palpation to detect surface characteristics and
to accustom the patient to being touched.
The examiner notices a fine tremor when the patient sticks out his or her tongue. What
disorder is consistent with this finding?
A Hyperthyroidism
B Diabetic ketoacidosis
C Halitosis
D Alcoholism - answerA Hyperthyroidism
A patient is admitted to the emergency department after a motor vehicle accident. The
trachea is deviated to the left side. This finding is characteristic of:
A right pneumothorax.
B aortic arch aneurysm.
,C right pleural adhesion.
D right-sided atelectasis. - answerA right pneumothorax.
The use of euphemisms to avoid reality or to hide feelings is known as:
A. distancing language.
B. sympathetic language.
C. avoidance language.
D. ethnocentric language. - answerC. avoidance language.
Physical appearance includes statements that compare appearance with:
A. mood and affect.
B. stated age.
C. gait.
D. nutrition. - answerB. stated age.
An example of subjective data is:
a. decreased range of motion.
b. crepitation in the left knee joint.
c. arthritis
d. left knee has been swollen and hot for the past 3 days. - answerd. left knee has been
swollen and hot for the past 3 days.
Subjective data is what the patient says about himself or herself during history taking.
Objective data is what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. Range of motion is
assessed by inspection. Objective data is what the health professional observes by
inspecting, percussing, palpating, and auscultating during the physical examination.
Crepitation is assessed by palpating. Arthritis is a medical diagnosis.
An example of objective data is
a. a report of impaired mobility from left knee pain as evidenced by an inability to walk,
swelling, and pain on passive range of motion.
b. a complaint of left knee pain.
c. crepitation in the left knee joint
d. left knee has been swollen and hot for the past 3 days. - answerc. crepitation in the
left knee joint.
felt on palpation
Which of the following actions/behaviors in the critical-thinking process are important for
the novice nurse to remember? (Select all that apply.)
a. Disregard initial cues
b. Approach assessment with a nonjudgmental attitude
c. Cluster associated assessment data
d. Perform assessment in whatever manner works for you
e. Avoid making assumptions - answerb, c, e
, you want to cluster all the infromation so you have a general view of the signs and
symtpoms
Define first level priority, second, third - answerFirst-level priority problems are problems
that are emergent, life-threatening, and immediate. Impaired gas exchange is an
emergent and immediate problem. Third-level priority problems are problems that are
important to the patient's health but can be addressed after more urgent health
problems are addressed. Ineffective self-health management is an example of a third-
level priority. Second-level priority problems are problems that are next in urgency;
these problems require prompt intervention to forestall further deterioration. Risk for
infection is an example of a second-level priority. Third-level priority problems are
problems that are important to the patient's health but can be addressed after more
urgent health problems are addressed. Wellness diagnoses are third-level priority
problems.
When preparing the physical setting for an interview, the interviewer should
a.stand next to the patient to convey a professional demeanor.
b. conduct the interview at eye level and at a distance of 4 to 5 feet.
c. reduce noise by turning the volume on the television or radio down.
d. set the room temperature between 64° F and 66° F. - answerb
Both the interviewer and the patient should be at eye level at a distance of 4 to 5 feet.
The room temperature should be set at a comfortable level; a temperature between 64°
F and 66° F is too cool. Turn off the television or radio and any unnecessary equipment
to reduce noise. The interviewer and the patient should be comfortably seated; standing
communicates haste and assumes superiority.
INCORRECT
Nonverbal communication is the primary form of communication for which group of
individuals?
a. older adults
b. infants
c. preschoolers
d. adolescents - answerb
Nonverbal communication is the primary communication method for infants.
Preschoolers' communication is direct, concrete, literal, and set in the present.
Adolescents should be treated with respect; the nurse should use open, honest,
professional communication. Older adults may need special considerations r/t physical
limitations (e.g., adjusted pace to avoid fatigue, impaired hearing).
The most appropriate introduction to use to start an interview with an older adult patient
is
a. "Mr. Jones, I want to ask you some questions about your health so that we can plan
your care."
