URDANETA CITY University

#1 San Vicente West, Urdaneta City, Pangasinan, 2428 Philippines

COLLEGE OF HEALTH SCIENCES

Final Term Periodical Exam

Academic Year 2019-2020: 2nd Semester
NCM 101 – HEALTH ASSESSMENT

Name: ________________________________________ Score: _________

Subject Code/Subject/Schedule: ____________________ Date: _________

DIRECTIONS: UNDERLINE the correct answer. You may use your resources to identify the right
answer.

Nutrition and Hydration

1.A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the
following assessment areas of the nutritional history will most likely impact the client's nutritional status?

a.Food preparation

b.Finances

c.Accessibility

d.Food preferences

2.A client has areas of petechiae and ecchymosis over the arms and legs. In which section of the Review
of Systems (ROS) of the nutritional health assessment would the nurse document this finding?

a.Cardiovascular

b.Skin, hair, and nails

c.Musculoskeletal

d.General survey

d.Reduce daily calorie intake by 100 calories each day.

3.A female client with a diagnosis of hypothyroidism asks the nurse why she has begun to gain body
weight. Which is the best explanation the nurse can provide?

a."Your metabolism is slowing down."

b."You are retaining fluid."

c."You could be making healthier food choices."

d."You should be exercising for longer periods of time."

4.A teenaged client is seen by the nurse for report of excessive thirst and weight loss despite high food
intake. Which health condition is most likely responsible for these symptoms?

a.diabetes mellitus

b.hypothyroidism
c.protein deficiency

d.anorexia

5.The nurse is conducting a nutrition history with a young adult with signs and symptoms of an eating
disorder. Which question exemplifies the most effective way for the nurse to ask about body image?

a."What would you change about your body, if you could?"

b."Do you gather around a table with other people for meals?"

c."How much do you exercise in one week?"

d."How many meals and snacks do you eat in one day?"

6.While conducting a physical examination, the nurse notices the client's mucous membranes are pale in
color. Which nutritional deficiency is most likely for this client?

a.Anemia

b.vitamin A

c.protein

d.vitamin C

7.The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is
most appropriate for the nurse to make given this finding?

a."Let's discuss your risk factors for heart disease."

b."You probably have a vitamin deficiency."

c."We should review the amount of protein in your diet."

d."Waist circumference can vary over the course of the day."

8.The nurse measures the height and body weight of a female client with high muscle mass. The client
weighs 175 pounds (79.4 kg) and is 68 inches (173 cm) tall. In which of these categories does the client's
body mass index (BMI) fit best?

a.Normal

b.Overweight

c.Underweight

d.Obese

9.It would be a priority for the nurse to provide counseling about nutrition and exercise for weight loss for
which client

a.a client with body mass index of 27 and blood pressure of 145/80 mm Hg

b.a client with body mass index of 18.5 and family history of heart disease

c.a client with a body mass index of 23 and high LDL cholesterol

d.a client with a body mass index of 25 and normal HDL cholesterol
10.A client is prescribed serial weight measurements every day.All the actions will the nurse take when
conducting these serial weights but one ?

a. Weigh the client at the same time in the morning.

b.Use the same scale to weigh the client.

c.Have the client wear the same clothing every day.

d.Weigh the client after each meal in 1 day.

Integumentary System

11.A patient recovering from a burn injury is told by the health care provider that hair will no longer grow
on the body part that was burned. The nurse realizes that this patient's burn extended into which skin
layer?

a.Epidermis

b.Dermis

c.Subcutaneous tissue

d.Distal phalanx

12.A patient's risk for pressure sore development according to the Braden Scale is as follows: Sensory
perception: 4
Moisture: 4
Activity: 2
Mobility: 2
Nutrition: 1
Friction and Shear: 3
From this assessment, the nurse determines that the patient's risk for pressure sore development is:

a.No risk

b.Mild risk

c.Moderate risk

d.High risk

13.While assessing a patient's arms, the nurse notes a 3-mm oval lesion located on left forearm. The
lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to
document this lesion in the client's medical record?

a.Vascular

b.Purpuric

c.Primary

d.Secondary

14.The nurse is preparing an educational program on effective hygiene methods for a group of high
school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on
which layer of the skin?

a.Dermis
b.Adipose

c.Epidermis

d.Subcutaneous

15.The nurse expects what change in a client's hair as a result of aging?

a.The is an increase in the loss of fine, relatively unpigmented hair referred to as villus hair.

b.The existing terminal hair will become coarser and less pigmented.

c.Sebaceous glands will secrete less causing hair to be drier.

d.Eyebrows will thin and gradually disappear.

16.When assessing for apocrine gland function, the nurse would assess for moisture where on the client's
body?

a.palms of the hands

b.face

c.soles of the feet

d.underarms

17.What abnormal physical response should the nurse be prepared to manage after noting pallor in a
client?

a.Fainting

b.Vomiting

c.Diarrhea

d.diaphoresis

Assessment of Head and Neck

18.The nurse assesses a client's submental lymph nodes. In which area of the client's head should the
nurse palpate these lymph nodes?

a.Superficial to the sternomastoid

b.In front of the ear

c.In the midline, a few centimeters behind the tip of the mandible

d.At the angle of the mandible

19.While the nurse is obtaining a client's health history regarding the head and neck, the client reports
having a lump in the neck. In order to assess for associated manifestations of this problem, which of the
following questions should the nurse ask next?

a."Do you have difficulty swallowing?"

b.How long have you experienced discomfort from the lump?"

c."When did you first notice the lump?"

d."Is there more than one lump?"

20.The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and
neck. What should the nurse first?

a.Displace the trachea to the right

b.Listen over the thyroid with a stethoscope.

c.Ask the patient to sip and swallow water.

d.Ask the client to lie down for further assessment

21.When documenting the findings from a physical examination of the head and neck, what will the nurse
include when describing the client's head?

a.Sclera color

b.Hair color

c.Nasal mucosa color

d.Facial skin color

22.The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries.
What should be included in these instructions?

a.Always use seat belts.

b.Wear nonslip shoes in the house

c.Avoid risky activities such as snowboarding

d.Use of guns should be supervised by an adult

23.A 57-year-old client reports, “I am having the worst headache I have ever experienced.” Which action
should the nurse perform next?

a.Assess the client's blood pressure.

b.Provide medication for pain relief.

c.Inquire about family history of headaches.

d.Review the client's medical record.

24.A client reports using pain medication and sitting in a dark room on the onset of a migraine headache.
In which part of the subjective section of the physical examination should the nurse document this
information?

a.Onset

b.Location

c.Treatment

d.relieving factors

25.A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale
from 1 to 10. This subjective data should be documented in which section of the assessment?

a.characteristic symptoms
b.associated manifestations

c.relieving factors

d.location

26.A nurse assesses a young adult client who lost consciousness after a head-to-head collision while
playing football. Which question should the nurse ask in order to determine characteristic symptoms of
the head trauma?

a."Do you have a history of seizures?"

b."Do you feel like vomiting?"

c."Are you feeling dizzy?"

d."How long were you unconscious?"

27.As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-
clavicular region. This finding is consistent with which condition?

a.Malignancy

b.Inflammation

c.Enlargement

d.Hypothyroidism

28.When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism,
why is it important to bring a cup of water to the physical examination?

a.to assist the client to feel more comfortable

b.to prevent further dehydration

c.to observe the movement of the thyroid gland

d.to promote the nurse–client relationship

29.The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft,
rushing sound is heard over the lateral lobes. Which condition is most likely?

a.Hyperthyroidism

b.thyroid cyst

c.Hashimoto thyroiditis

d.benign tumor

Assessment of the Eyes

30.During the health history of the eye, a patient tells the nurse about occasional floaters within the field
of vision. The nurse identifies the structure causing this symptom to be from the:

a.Retina

b.Brainstem

c.Cerebellum
d.Vitreous humor

31.What eye function is the nurse preparing to assess when the patient is asked to stand 20 feet from a
specific chart that is mounted on the examination room wall?

a.Near vision

b.Distant vision

c.Peripheral vision

d.External eye structures

32.While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye
is constricted. What does this finding suggest to the nurse?

a.Myopia

b.Presbyopia

c.Direct reaction

d.Consensual reaction

33.In order to effectively examine a patient's eyes with an ophthalmoscope, the nurse should follow which
procedure related to this piece of equipment?

a.Remove eyeglasses before looking into the ophthalmoscope.

b.Place the ophthalmoscope in the right hand and look through the right eye.

c.Place the ophthalmoscope in the left hand and look through the right eye.

d.Close the eye that is not looking through the ophthalmoscope during the examination.

34.When considering eye safety, all of the instructions should the nurse provide to a patient newly
prescribed contact lenses but one?

a.Do not share lenses&keep the lenses clean.

b.Wash hands before inserting or removing the lenses.

c.Inspect the lenses every week for scratches or damage

d.Discard unused portions of contact solutions at the expiration date.

35.When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse
should instruct the patient to move both eyes to look in which direction?

a.Up

b.Down
c.To the right

d.To the left

36.During the physical examination of a patient's eyes, the nurse asks the patient to follow the tracing of a
giant H with the eyes. What function is the nurse assessing in this patient?

a.Pupil reaction to light

b.Extraocular movements

c.Convergence

d.Corneal light reflex

37.A patient is diagnosed with glaucoma affecting the left eye. What assessment data concerning the left
noted in the patient's medical record supports this diagnosis?

a.Increased intraocular pressure

b.Sluggish pupillary reaction

c.Displaced optic nerve

d.Opaque lens

38.What information, acquired during an eye assessment and history,all would the nurse document as
lifestyle habits but one?

a.Has smoked for last 12 years

b.Uses sunglasses when outdoors

c.Uses protective eyewear when appropriate

d.Eyes itch when in a smoky environment

39.When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented
in dark-skinned individuals?

a.slightly darker fovea is just discernible

b.no light reflex is visible

c.fundus is grayish brown with a purplish cast

d.the lower field of the fundus has characteristic stripes

40.When the client reports a problem associated with the drainage of tears from the left eye, the nurse
would focus the eye assessment on which eye structure?

a.lacrimal gland
b.lacrimal puncta

c.lacrimal sac

d.nasolacrimal duct

41.When assessing the eye, the nurse recognizes that all physical structures of the face limit the normal
visual field that a client can experience but one.

a.the brow

b.the medial aspect of the nose

c.the cheek

d.the lashes

42.Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)?

a.II (optic)

b.III (oculomotor)

c.IV (trochlear)

d.VI (abducens)

43.Which statement by the nurse indicates the best understanding of the purpose of an eye-related
health history?

a."The history allows the client to discuss their vision-related problems."

b.The nurse is able to visualize the client's eye with the benefit of an ophthalmoscope."

c."Broad, open-ended questions provide an opportunity to identify changes in the client's eyes."

d."The history encourages the client to reflect upon the state of client's eyes and vision."

44.Which question should the nurse ask when assessing a client for a possible detached retina?

a."Is your vision loss located in the center of your view of vision?"

b."Are you seeing flashing lights?"

c."Can you see objects on the outer edges of your field of vision?"

d."Is the vision in both of your eyes affected?"

45.When a client reports a sudden but painless loss of vision in the right eye, which question should the
nurse ask?

a."Have you ever been diagnosed with acute angle closure glaucoma?"
b."May I assess your eye for a possible corneal ulcer?"

c."Do you have a history of diabetes?"

d."Are you currently prescribed a steroid medication?"

46.The nurse should make it a priority to assess which client for papilledema?

a.a 45-year-old suspected of experiencing a subarachnoid hemorrhage

b.an 80-year-old diagnosed with chronic open-angle glaucoma

c.a 12-year-old demonstrating a deviated left eye

d.a 56-year-old reporting double vision

47.A client is being assessed for indications of a possible obstructed nasolacrimal duct in the right eye.
Under what circumstances should the nurse avoid compressing the lacrimal sac?

a.Mucopurulent fluid is observed near the sac.

b.There is excessive tearing in the right eye.

c.The area around the sac is inflamed.

d.The client reports experiencing floaters.

48 .A client reports, "There is something in my left eye that is causing me considerable discomfort." What
initial step should the nurse take when everting the client's upper eyelid in order to search for the foreign
body?

a.Place a tongue blade at least 1 cm above the right lid margin.

b.Raise the upper eyelid slightly to cause the eyelashes to protrude.

c.Grasp the upper eyelashes, and gently pull down and forward

d.Ask the client to look down toward the left cheek.

Assessment of the Ears, Nose, Mouth and Throat

49.When planning care for a client with an inner ear infection, the nurse will need to include interventions
for which of the following potential problems?

a.Rhinorrhea

b.Fever

c.Headache

d.Vertigo

50.The nurse is planning instructions for a patient with a broken nose. All teaching will be included to
address the alterations in nasal function but one?

a.How to breathe through the mouth

b.Importance to increase oral fluids

c.Expect a sore throat and difficulty swallowing

d.Remind that the voice may sound different

51.During the health history of the nose and sinuses, a patient reports having rhinorrhea. What question
would the nurse ask to determine associated manifestations of this symptom?

a."In which side does it occur?

b."How long does it last?"

c."What color is the drainage?"

d."Are there any other symptoms?"

52.The nurse is preparing to use an otoscope to examine a client's ear canal and drum. With which of the
following grip techniques should the nurse use to hold the otoscope?

a.Pencil

b.Hammer

c.Wrench

d.Handshake

53.A client has been receiving intravenous antibiotics for several weeks. Which prevention strategy would
be best for the nurse to recommend for this client?

a.Whisper hearing test

b.Rubbing fingers test

c.Formal hearing test

d.Tuning fork test

54.A patient is experiencing sinus tenderness associated with a head cold. What techniques should the
nurse use to assess this patient's symptom?

a.Press down on the head.

b.Press up on the area next to the ear.

c.Press up on the frontal sinuses from under the bony brows & press up on the maxillary sinuses.

d.Press down on the lower jaw.

55.The nurse is planning to provide discharge teaching for a client with surgical repair of a septal
perforation. All points should be included to address the expected alterations in nasal function but one.

a.techniques for breathing effectively through the mouth

b.increasing oral fluid intake

c.awareness of loss of smell

d.management of difficulty swallowing

e.anticipating short term hoarseness of the voice

56.When the nurse is obtaining the health history of the nose and sinuses, a client reports symptoms of
rhinorrhea. Which question should the nurse ask to determine associated manifestations of this
symptom?

a."In which side does it occur"

b."How long does it last?"

c."What color is the drainage?"

d."Have you had a sore throat?"

57.A client reports occasionally experiencing hoarseness. In response to this statement, the nurse asks,
“What makes the hoarseness go away?” Which characteristic of the client's symptom is the nurse
assessing?

a.Treatment

b.relieving factors

c.duration

d.onset

58.The nurse is preparing to examine a client's mouth floor. To move the tongue to one side for this
examination, which tool should the nurse use?

a.tongue blade

b.gloves

c.gauze pad

d.penlight

59.An older adult client who wears dentures reports having soreness of the gums. Which intervention
should the nurse recommend to the client to alleviate this problem?

a.Avoid excessive intake of sugary foods.

b.Use toothpaste containing fluoride.

c.Have a dental examination every 2 years.

d.Massage the gums daily.

60.During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's
lips and surrounding skin. The nurse should document which problem?

a.angular cheilitis

b.herpes simplex

c.actinic cheilitis

d.angioedema

61.A nurse is assessing a client with referred otalgia. In order to identify the associated manifestations of
this problem, the nurse should ask which question?

a.Have you had any recent infectious contacts?"

b."Does pain medication help?"

c.Who did you see about this problem in the past?"

d."How long have you been experiencing pain?"

62.A client presents with otalgia and yellow-green discharge from the external ear canal. Which question
should the nurse ask to determine the cause of this problem?

a."Have you had any recent trauma to the inside of your ear?"

b."Do you hear ringing in your ears?"

c."Are their times when you feel dizzy?"

c.Have you ever taken medication that is ototoxic?"

63.A nurse is preparing a community education session on hearing loss. Which information should the
nurse include?

a.Hearing loss can lead to mental health problems.

b.All ethnic groups experience hearing loss in the same way.

c.In order to hold a driver's license, hearing must be tested regularly.

d.Hearing loss typically begins after the age of 40.

64..A client reports experiencing chronic headache after a recent upper respiratory tract infection. On
physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is
likely?

a.acute bacterial sinusitis

b.allergic rhinitis

c.rhinitis medicamentosa

d.epistaxis

65.A parent reports her preschool-aged child has been having epistaxis every 2 to 3 days for the past
month. All questions should the nurse ask to determine the possible causes but one.

a.Does your child have painless bruising?"

b."Does your child pick his nose?"

c."Is your child taking any medications?"

d."Has your child had a recent fever?"&”Does your child have difficulty breathing through his nose?"

66.A client reports having difficulty smelling food aromas over the past month. All questions should the
nurse include in the health history but one

a."Do you smoke cigarettes?'

b."Do you smoke cigarettes?'

c."Have you had nasal surgery before?"

d."Do you have frequent nosebleeds?"

e."Are you taking any antibiotic medication?"

67.A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and
noticeable weight gain over the past month. Which cause should the nurse consider as most

a.Hypothyroidism

b.Gingivitis

c.Dysphagia

d.apthous ulcers

68.In order to effectively assess the oral mucosa, the nurse should have all assessment tools available
but one

a.Gloves

b.Penlight

c.tongue depressor

d.tuning fork

69.A nurse prepares an educational session on the importance of oral hygiene. Which teaching tip should
be included in the section about preventing gingivitis?

a.Brushing more than twice per day irritates the gums.

b.A firm toothbrush is most effective in plaque removal.

c.Avoid flossing if there is bleeding at the gumline.