Physical Assessment, Part II, 50 Questions

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Physical Assessment, Part II, 50 Questions

From Foundations of Nursing by Christensen Kockrow, pages 93 through 120.


Questions and Answers
  • 1. 
    The consumption of alcohol, tobacco, caffeine, or herbal products are important in health history and which are part of what?
    • A. 

      Illegal activity

    • B. 

      Habits and lifestyle patterns

    • C. 

      Fun and pleasure

    • D. 

      Rest and recreation

  • 2. 
    Which of the following are true regarding cultural sensitivity
    • A. 

      All members of one cultural group behave in exactly the same manner

    • B. 

      As a nurse, it is important to identify and examine our own cultural and ethnic beliefs

    • C. 

      Cultural and ethnic diversity have no impact in health care

    • D. 

      Patient's response to signs and symptoms are independent of their cultural values

  • 3. 
    We know that the nurse knows the right time to do a physical assessment when she says:
    • A. 

      "I will do it as soon as possible"

    • B. 

      "I think the next shift will have to do it"

    • C. 

      "After I give the medication"

    • D. 

      "Maybe later, when I am done with others"

  • 4. 
    The difference between a "head to toe" assessment and a "focused assessment"
    • A. 

      Head to toe is systemic while focused concentrates on regional parts

    • B. 

      Head to toe is completed when the patient is admitted; focused concentrates on a particular part of a body

    • C. 

      Head to toe is done on every shift while focused is done when the person is admitted

    • D. 

      Both RN's and LPN's should do head to toe assessments as well as focused assessments

  • 5. 
    The nurse tells a 75 year old patient that she will have to do a "head to toe" assessment on him. The patient asks, "what is that"? Her best answer would be ...
    • A. 

      I will need to determine the etiology of any pathologic symptoms you might have.

    • B. 

      Oh nothing, it is just something that we do.

    • C. 

      It is a way for us to know how we are going to take care of you later

    • D. 

      Maybe you can tell me how you got here.

  • 6. 
    A person who is just being admitted complains of pain on his right foot. What is the proper way to provide this patient a proper physical assessment?  
    • A. 

      Do a focused assessment on the foot first and do the complete physical assessment later

    • B. 

      If a complete physical assessment is necessary, it is best to assess any painful areas last.

    • C. 

      Focus on the pain and provide comfort before anything else.

    • D. 

      Since the patient is a new admit, concentrate on the general physical assesment only

  • 7. 
    In the interview portion of the physical assessment, since we are not actually touching the patient, there is no need to wash our hands. 
    • A. 

      True

    • B. 

      False

  • 8. 
    Before the beginning of a physical examination, to make the patient more comfortable, what should be done first
    • A. 

      Give patient a warm blanket

    • B. 

      Ask if patient wants a glass of water

    • C. 

      Offer patient to empty his/her bladder

    • D. 

      Provide a small

  • 9. 
    When performing a head-to-toe assessment, we normally begin with a neurologic assessment . What is the next? 
    • A. 

      Skin, hair, head and neck including eyes, ear, nose and mouth

    • B. 

      Chest, back, arm, abdomen

    • C. 

      Perineal area, legs and feet

    • D. 

      Eyes and ears alone

  • 10. 
    Which of the following are included in the neurologic assessment?
    • A. 

      Motor function

    • B. 

      Range of motion

    • C. 

      Level of consiousness

    • D. 

      Pupillary response

  • 11. 
    In the mnemonic used for assessments, what does PS stand for in ABC in and out, PS? 
    • A. 

      Painful sensation

    • B. 

      Problem and solution

    • C. 

      Pain and safety

    • D. 

      Pernicious stimulation

  • 12. 
    PERRLA refers to 
    • A. 

      Motor function

    • B. 

      Order of assessment

    • C. 

      Level of consciousness

    • D. 

      Pupillary response

  • 13. 
    A neurologic examination pertaining to the sensations of body movements and awareness of posture and cerebellar function
    • A. 

      Deep tendon reflexes

    • B. 

      Proprioception

    • C. 

      Cranial nerve assessment

    • D. 

      Pupillary reflex

  • 14. 
    Vital signs are reliable even when there is a central nervous system deficit. 
    • A. 

      True

    • B. 

      False

  • 15. 
    What do the signs and symptoms of Cushing's triad include? They are typical of someone who had traumatic brain injury 
    • A. 

      Increase in systolic blood pressure

    • B. 

      Bradycardia

    • C. 

      Irregular breathing pattern

    • D. 

      Widening pulse pressure

  • 16. 
    Standardized objective measurement of the level of consiousness
    • A. 

      Glasgow Coma Scale

    • B. 

      PERRLA

    • C. 

      Rhomberg Test

    • D. 

      Motor function assessment

  • 17. 
    A patient has just been admitted. During physical assessment, it was observed that patient had decreased skin turgor  and dried  outer lips. What would be the most appropriate thing to offer this patient while the physical assessment is going on?
    • A. 

      A chair to sit on

    • B. 

      Medication

    • C. 

      Water

    • D. 

      Some snacks

  • 18. 
    A patient with increased turgor in his lower extremities manifested by smooth, taut, shiny skin that cannot be grasped or raised is most likely to have: 
    • A. 

      Enema

    • B. 

      Decubitus

    • C. 

      Edema

    • D. 

      Infection

  • 19. 
    Abnormal swishing sounds heard over organs, glands and arteries and results from an abnormality in an artery resulting from narrow or partially occluded artery such as those in atherosclerosis
    • A. 

      Thrill

    • B. 

      Crackles

    • C. 

      Bruits

    • D. 

      Wheezes

  • 20. 
    A vibrating sensation perceived when an artery is palpated and is not expected when examining a carotid pulse. 
    • A. 

      Bruit

    • B. 

      Thrill

    • C. 

      Crackles

    • D. 

      Rhonci

  • 21. 
    An abnormal cycle of respiration that begin with slow, shallow respiration that become rapid, then become slower and are followed by periods of apnea (20 seconds). Normally caused by hear failure, opioid overdose, renal failure, meningitis, and severe head ache. 
    • A. 

      Kussmaul

    • B. 

      Cheyne-stokes

    • C. 

      Botte's

    • D. 

      Whooping sneeze

  • 22. 
    Indicative of acute or chronic respiratory distress
    • A. 

      Height

    • B. 

      Posture

    • C. 

      Weight

    • D. 

      Hair loss

  • 23. 
    Teaching patients to perform breast self-exams is only directly related to females
    • A. 

      True

    • B. 

      False

  • 24. 
    When auscultating for lung sounds, which part of the stethoscope is designed to transmit the higher pitch of abnormal sounds 
    • A. 

      Ear piece

    • B. 

      Bell

    • C. 

      Diaphragm

    • D. 

      Tubes

  • 25. 
    When doing a respiratory assessment to a patient, which of the following is the most appropriate technique? 
    • A. 

      Use a stethoscope over the clothing of a patient who feels cold

    • B. 

      Instruct patient to breathe through his or her mouth quietly and more deeply and slowly than in a usual respiration

    • C. 

      Allow a patient with a slight lower back pain to lie supine on bed

    • D. 

      Listen to the heart sound at the same time that your are listening to the lung sounds

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