Basic Physical Assessment
Physical assessment is an important step in the nursing process it is considered the foundation of the nursing process. With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans, therefore, creating wrong interventions and evaluation. Take the quiz below to see how much you know about basic physical assessment.
- 1.A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel.The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing.Based on these findings, the nurse suspects injury to which lobe of thebrain?
- A.
Frontal
- B.
Occipital
- C.
Parietal
- D.
Temporal
- 2.A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?
- A.
Pustules
- B.
Papules
- C.
Plaque
- D.
Vesicles
- 3.A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?
- A.
Place a tongue blade on the front of the tongue and ask the client to say "ah."
- B.
Place a tongue blade lightly on the posterior aspect of the pharynx.
- C.
Place a tongue blade on the middle of the tongue and ask the client to cough.
- D.
Place a tongue blade on the uvula.
- 4.A nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?
- A.
A rub occurs only during expiration and produces a light, popping, musical noise.
- B.
A rub occurs only during inspiration and the nurse may hear it anywhere.
- C.
A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.
- D.
A rub occurs only during inspiration and clears with coughing.
- 5.During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides which type of data?
- A.
Subjective
- B.
Objective
- C.
Secondary source
- D.
Medical
- 6.A nurse is taking a client's blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure?
- A.
Have the client lie down while she takes his blood pressure.
- B.
Inflate the cuff to at least 200 mm Hg.
- C.
Take blood pressure readings in both of the client's arms.
- D.
Inflate the cuff at least another 30 mm Hg after she can't palpate the radial pulse.
- 7.When palpating the bladder of an adult client, a nurse should identify which finding as normal?
- A.
A soft, smooth bladder
- B.
A hard, rough bladder
- C.
A nonpalpable bladder
- D.
A palpable bladder located 3″ to 5″ (7.5 to 12.7 cm) above the symphysis pubis
- 8.A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?
- A.
Confusion
- B.
Pale, warm, dry skin
- C.
Heart rate of 110 beats/minute
- D.
Urine output of 30 ml/hour
- 9.A nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity?
- A.
Collects data
- B.
Formulates nursing diagnoses
- C.
Develops a care plan
- D.
Writes client outcomes
- 10.A nurse correctly identifies which items as belonging to the dorsal cavity?
- A.
Mediastinum
- B.
Mouth
- C.
Vertebral canal
- D.
Reproductive organs
- 11.A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3–, 24 mEq/L. What do these values indicate?
- A.
Metabolic acidosis
- B.
Metabolic alkalosis
- C.
Respiratory acidosis
- D.
Respiratory alkalosis
- 12.When obtaining a client's history, a nurse develops a genogram. What is the purpose of developing a genogram?
- A.
To identify genetic and familial health problems
- B.
To identify previously undetected diseases and disorders
- C.
To identify the client's reason for seeking care
- D.
To identify the client's chronic health problems
- 13.A nurse conducts a test for Romberg's sign. What is the correct procedure for this test?
- A.
Have the client stand with feet together and arms at his sides and try to balance. Have the client first do this with his eyes open and then with his eyes closed.
- B.
Instruct the client to walk across the room on his heels and to return walking on his toes.
- C.
Ask the client to touch the thumb of one hand to each finger on that hand and then do the same thing using the other hand.
- D.
Instruct the client to lie on his back and slowly slide his heel down the shin of the opposite leg, from the knee to the ankle.
- 14.The ear canal of an infant or young child:
- A.
Slants upward.
- B.
Slants downward.
- C.
Is horizontal.
- D.
Slants backward.
- 15.A nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?
- A.
38.9° C
- B.
39° C
- C.
40.1° C
- D.
47° C
- 16.A nurse is conducting a physical assessment on an obese 17-year-old who has asked for information about gastric bypass surgery. Which statement best describes informed consent as it applies to this situation?
- A.
Providing the adolescent with information about the procedure implies informed consent.
- B.
The nurse should inform the adolescent that he may sign a consent form for the surgical procedure if a parent cosigns the form.
- C.
The nurse should inform the adolescent that, in most states, only parents may give consent for a minor's medical care.
- D.
The nurse may provide the adolescent's legal guardian with information regarding the procedure.
- 17.A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
- A.
Coma or seizures.
- B.
Sunken eyeballs and poor skin turgor.
- C.
Increased heart rate with hypotension.
- D.
Thirst or irritability.
- 18.A nurse is palpating a client's pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing?
- A.
Brachial
- B.
Femoral
- C.
Posterior tibial
- D.
Dorsalis pedis
- 19.A nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain more information about the client's rash? Select all that apply.
- A.
When did the rash start?
- B.
Are you allergic to any medications, foods, or pollen?
- C.
How old are you?
- D.
What have you been using to treat the rash?
- E.
Have you recently traveled outside the country?
- F.
Do you smoke cigarettes or drink alcohol?
- 20.A nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?
- A.
The bell detects high-pitched sounds best.
- B.
The diaphragm detects high-pitched sounds best.
- C.
The bell detects thrills best.
- D.
The diaphragm detects low-pitched sounds best.
- 21.A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by:
- A.
Shortening it.
- B.
Speaking in a loud voice.
- C.
Addressing the client by his first name.
- D.
Allowing extra time for the assessment.
- 22.A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?
- A.
Assess the client's level of pain and administer prescribed analgesics.
- B.
Assess the client's level of anxiety and provide emotional support.
- C.
Prepare the client for pulmonary artery catheterization.
- D.
Ensure that the client's family is kept informed of his status.
- 23.A nurse is teaching a client who will soon be discharged how to change a sterile dressing on his right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?
- A.
Infection
- B.
Dehiscence
- C.
Hemorrhage
- D.
Evisceration
- 24.Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:
- A.
Pallor and coolness of the left foot.
- B.
A decrease in the left pedal pulse.
- C.
Loss of hair on the lower portion of the left leg.
- D.
Left calf circumference 1" (2.5 cm) larger than the right.
- 25.A mother comes to the clinic with her 5-year-old son who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This rating means they're:
- A.
Barely visible outside the tonsillar pillar.
- B.
Midway between the tonsillar pillar and the uvula.
- C.
Touching the uvula.
- D.
Touching each other.
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