Ha 4

Health Assessment NCLEX Questions
Study online at https://quizlet.com/_1gzu9m
1. According to the holis- B

tic model, a narrow def-
inition of holistic health From a biomedical perspective, health is defined
includes: as the absence of disease or elimination of symp-
A. an optimal function- toms and signs of disease, whereas a holistic
ing of mind, body, and model approach examines mind, body, and spirit
spirit within the envi- working interdependently within the environment
ronment. Incorrect to maintain health and well-being.
B. the absence of dis- Nursing has an expanded concept of health; holis-
ease. tic health includes the mind, body, and spirit as
C. the response of the interdependent and functioning as a whole within
whole person to actual the environment.
or potential problems. Nursing diagnoses are clinical judgments about a
D. the internal and ex- person's response to an actual or potential health
ternal environment. state.
In a holistic model approach to health, both the
internal and the external environment affect a pa-
tient's health and well-being.
2. What type of data- C

base is most appro-
priate when rapid col- An emergency database includes rapid collection
lection of data is re- of data often obtained concurrently with lifesaving
quired and often com- measures.
piled concurrently with An episodic database is for a limited or short-term
lifesaving measures? problem; this database concerns mainly one prob-
A. Episodic lem, one cue complex, or one body system.
B. Follow-up A follow-up database is used to follow up
C. Emergency short-term or chronic health problems; the status-
D. Complete es of identified problems are evaluated at regular
and appropriate intervals.
A complete database includes a complete health
history and a full physical examination; it describes
the current and past health state and forms a
baseline against which all future changes can be
measured.
3. A medical diagnosis is D.
used to evaluate:
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A. a person's state of Medical diagnoses are used to evaluate the cause
health. or etiology of disease.
B. the response of the Nursing diagnoses are clinical judgments about a
whole person to actu- person's response to an actual or potential health
al or potential health state.
problems. Nursing diagnoses are used to evaluate the re-
C. a person's culture. sponse of the whole person to actual or potential
D. the cause of disease. health problems.
The holistic model of health care is used in nursing,
and culture is an important factor to consider in a
nursing assessment.
4. An example of subjec- C
tive data is:
A. decreased range of Subjective data is what the patient says about
motion. himself or herself during history taking.
B. crepitation in the left Objective data is what the health professional
knee joint. observes by inspecting, percussing, palpating,
C. left knee has been and auscultating during the physical examination.
swollen and hot for the Range of motion is assessed by inspection.
past 3 days. Objective data is what the health professional
D. arthritis. observes by inspecting, percussing, palpating,
and auscultating during the physical examination.
Crepitation is assessed by palpating.
Arthritis is a medical diagnosis.
5. What type of database D

is most appropriate for
an individual who is ad- A complete database includes a complete health
mitted to a long-term history and a full physical examination; it describes
care facility? the current and past health state and forms a
A. Episodic baseline against which all future changes can be
B. Follow-up measured.
C. Emergency An episodic database is for a limited or short-term
D. Complete problem; this database concerns mainly one prob-
lem, one cue complex, or one body system.
A follow-up database is used to follow up
short-term or chronic health problems; the status-
es of identified problems are evaluated at regular
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and appropriate intervals.
An emergency database includes rapid collection
of data often obtained concurrently with lifesaving
measures.
6. Which of the following A

is an example of objec-
tive data? Objective data is what the health professional ob-
A. Alert and oriented serves; level of consciousness and orientation are
B. Dizziness observations.
C. An earache Subjective data is what the person says about
D. A sore throat himself or herself during history taking.
Subjective data is what the person says about
himself or herself during history taking.
Subjective data is what the person says about
himself or herself during history taking.
7. An example of objec- B
tive data is:
A. a complaint of left Objective data is what the health professional
knee pain. observes by inspecting, percussing, palpating,
B. crepitation in the left and auscultating during the physical examination.
knee joint. Crepitation is assessed by palpation.
C. left knee has been Subjective data is what the person says about
swollen and hot for the himself or herself during history taking.
past 3 days. Subjective data is what the person says about
D. a report of impaired himself or herself during history taking.
mobility from left knee Subjective data is what the person says about
pain as evidenced by himself or herself during history taking.
an inability to walk,
swelling, and pain on
passive range of mo-
tion.
8. A nursing diagnosis is D
best described as:
A. a determination of Nursing diagnoses are clinical judgments about a
the etiology of disease. person's response to an actual or potential health
B. a pattern of coping. state.
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C. an individual's per- Medical diagnoses determine the cause or etiolo-
ception of health. gy of disease.
D. a concise statement Coping patterns include methods to relieve stress.
of actual or potential Health perception is how the person describes and
health concerns or lev- defines personal health.
el of wellness.
9. A complete database D
is:
A. used to collect data A complete database includes a complete health
rapidly and is often history and a full physical examination; it describes
compiled concurrently the current and past health state and forms a
with lifesaving mea- baseline against which all future changes can be
sures. measured.
B. used for a limited An emergency database is rapid collection of data
or short-term problem often obtained concurrently with lifesaving mea-
usually consisting of sures.
one problem, one cue An episodic database is for a limited or short-term
complex, or one body problem; this database concerns mainly one prob-
system. lem, one cue complex, or one body system.
C. used to evaluate the Medical diagnoses are used to evaluate the cause
cause or etiology of dis- or etiology of disease.
ease.
D. used to perform a
thorough or compre-
hensive health history
and physical examina-
tion.
10. A patient admitted to C

the hospital with asth-
ma has the follow- First-level priority problems are problems that are
ing problems identi- emergent, life-threatening, and immediate. Im-
fied based on an ad- paired gas exchange is an emergent and immedi-
mission health histo- ate problem.
ry and physical assess- Third-level priority problems are problems that are
ment. Which problem is important to the patient's health but can be ad-
a first-level priority? dressed after more urgent health problems are
A. Ineffective addressed. Ineffective self-health management is
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self-health manage- an example of a third-level priority.
ment Second-level priority problems are problems that
B. Risk for infection are next in urgency; these problems require
C. Impaired gas ex- prompt intervention to forestall further deteriora-
change tion. Risk for infection is an example of a sec-
D. Readiness for ond-level priority.
enhanced spiritual Third-level priority problems are problems that are
well-being important to the patient's health but can be ad-
dressed after more urgent health problems are
addressed. Wellness diagnoses are third-level pri-
ority problems.
11. Each culture has its C

own healers who usual-
ly: Most healers cost significantly less than healers
A. speak at least two practicing in the biomedical or scientific health care
languages. system.
B. own and operate spe- Most healers speak the person's native tongue.
cialty community clin- Most healers make house calls.
ics. Most health practices used by folk healers are not
C. cost less than tra- dangerous and are usually harmless.
ditional or biomedical
providers.
D. recommend folk
practices that are dan-
gerous.
12. While evaluating the C

health history, the
nurse determines that The hot/cold theory of health is based on humoral
the patient subscribes theory; the treatment of disease is based on the
to the hot/cold theory balance of the humors.
of health. Which of the Beverages, foods, herbs, medicines, and diseases
following would most are classified as hot or cold according to their
likely describe this pa- perceived effects on the body, not their physical
tient's view of well- characteristics.
ness? Beverages, foods, herbs, medicines, and diseases
A. Good is hot. are classified as hot or cold according to their
B. Evil is hot. perceived effects on the body, not their physical
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C. The humors must be characteristics.
balanced. The four humors of the body include the blood,
D. The phlegm will be phlegm, black bile, and yellow bile; the humors
replaced with dryness. regulate basic bodily functions and are described
in terms of temperature, dryness, and moisture.
The treatment of disease consists of adding or
subtracting cold, heat, dryness, or wetness to re-
store the balance of the humors.
13. On the basis of median C

age:
A. the non-Hispanic The Asian population is younger with a median
white population tends age of 36 years.
to be younger. The non-Hispanic, single-race white population is
B. the Hispanic popula- older than the population as a whole; the respec-
tion tends to be older. tive median age is 40.2 years.
C. the Asian population The Hispanic population is much younger, with a
tends to be younger. median age of 27.7 years.
D. minorities tend to be Minorities tend to be younger than non-Hispanic
older than non-Hispan- white populations.
ic white populations.
14. Spirituality is defined B

as:
A. participating in reli- Spirituality is a personal effort to find purpose and
gious services on a reg- meaning in life.
ular basis. Religion refers to an organized system of beliefs
B. a personal effort to concerning the cause, nature, and purpose of the
find meaning and pur- universe.
pose in life. Socialization is the process of being raised within
C. the process of being a culture and acquiring the characteristics of that
raised within a culture. group.
D. a social group that Ethnicity pertains to a social group within the social
claims to possess vari- system that claims to possess variable traits.
able traits.
15. Which of the follow- A

ing statements regard-
ing language barriers Title VI of the Civil Rights Act of 1964 provides
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and health care is true? people with limited English proficiency access to
A. There is a law that ad- health care; these individuals cannot be denied
dresses language barri- health care services.
ers and health care. Limited English proficiency is associated with a
B. Limited English pro- lower quality of care.
ficiency is associated English proficiency is associated with a higher
with a higher quality of quality of care.
care. Patients with language barriers have an increased
C. English proficiency risk of nonadherence to medication regimens.
is associated with a
lower quality of care.
D. Patients with lan-
guage barriers have a
decreased risk of non-
adherence to medica-
tion regimens.
16. What is the yin/yang A

theory of health?
A. Health exists when In the yin/yang theory, health is believed to exist
all aspects of the per- when all aspects of the person are in perfect bal-
son are in perfect balance.
ance. In the hot/cold theory, health consists of a pos-
B. Health exists when itive state of total well-being, including physical,
physical, psychologi- psychological, spiritual, and social aspects of the
cal, spiritual, and social person.
needs are met. The biomedical model of Western tradition views
C. Health exists in the health as the absence of disease.
absence of illness. In the biomedical or scientific theory, high-level
D. Health exists when wellness (or health) exists with optimal functioning
there is optimal func- of the human body.
tioning.
17. Which theory has been B

expanded in an at-
tempt to study the de- Heritage consistency theory has been expanded
gree to which a per- in an attempt to study the degree to which a per-
son's lifestyle reflects son's lifestyle reflects his or her traditional her-
his or her traditional itage.
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heritage? Behavior theory or behaviorism is a learning theo-
A. Behavior theory ry.
B. Heritage consistency Carl Rogers described the concepts of congru-
C. Congruence mecha- ence and incongruence as important ideas in his
nism theory of personality and human development.
D. Socialization experi- Socialization is the process of being raised within
ence a culture and acquiring the characteristics of that
group.
18. Which of the following B

symptoms is greatly in-
fluenced by a person's Pain is a very private, subjective experience that
cultural heritage? is greatly influenced by cultural heritage. Expecta-
A. Hearing loss tions, manifestations, and management of pain all
B. Pain are embedded in a cultural context.
C. Breast lump Hearing loss is more common in whites than in
D. Food intolerance blacks.
The incidence of breast cancer varies with different
cultural groups.
Food intolerance varies with different cultural
groups. For example, lactose intolerance is com-
mon in African Americans, American Indians, and
Asian Americans.
19. When considering cul- A, C, D, E

tural competence, the
nurse must develop Discrete areas of knowledge for cultural compe-
knowledge of discrete tence include understanding of one's own her-
areas to understand the itage, the heritage of the nursing profession, the
health care needs of heritage of the patient, and the heritage of the
others. These discrete health care system. Understanding cultural and
areas include under- ethnic values is not an area of knowledge for cul-
standing of: (Select all tural competence.
that apply.)
A. his or her own her-
itage.
B. cultural and ethnic
values.
C. the heritage of the
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nursing profession.
D. the heritage of the
patient.
E. the heritage of the
health care system.
20. When preparing the C

physical setting for an
interview, the interview- Both the interviewer and the patient should be at
er should: eye level at a distance of 4 to 5 feet.
A. set the room temper- The room temperature should be set at a comfort-
ature between 64° F and able level; a temperature between 64° F and 66° F
66° F. is too cool.
B. reduce noise by Turn off the television or radio and any unneces-
turning the volume on sary equipment to reduce noise.
the television or radio The interviewer and the patient should be com-
down. fortably seated; standing communicates haste and
C. conduct the inter- assumes superiority.
view at eye level and at
a distance of 4 to 5 feet.
D. stand next to the pa-
tient to convey a profes-
sional demeanor.
21. Parents or caretakers B

accompany children to
the health care setting. School-age children (starting at age 7) have the
Starting at ___ years verbal ability to add important data to the history.
of age, the interviewer The nurse should interview the parent and child
asks the child directly together, but when a presenting symptom or sign
about his or her pre- exists, the nurse should ask the child about it first
senting symptoms. and then gather data from the parent.
A. 5
B. 7
C. 9
D. 11
22. Which of the following D

statements made by the
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interviewer would be an "Tell me what you mean by 'bad blood'" is an ap-
appropriate response? propriate communication technique referred to as
A. "I know just how you seeking further clarification.
feel." "I know just how you feel" is an inappropriate com-
B. "If I were you, I would munication technique referred to as false reassur-
have the surgery." ance.
C. "Why did you wait "If I were you, I would have the surgery" is an
so long to make an ap- inappropriate communication technique referred
pointment?" to as giving unwanted advice.
D. "Tell me what you "Why did you wait so long to make an appoint-
mean by 'bad blood.'" ment?" is an inappropriate communication tech-
nique referred to as using "Why" questions.
23. While discussing the C

treatment plan, the
nurse infers that the Patients may experience barriers to communica-
patient is uncomfort- tion with a health care provider seen as an au-
able asking the physi- thority figure. The patient may not share personal
cian for a different treat- feelings if fear is experienced. In this situation,
ment because of fear the nurse identified the patient's personal feelings
of the physician's reac- in relation to the patient's verbal message. The
tion. In this situation, nurse-physician relationship is not the barrier to
the nurse's verbal inter- communication in this situation. The interpreta-
pretation: tion by the nurse will improve communication. The
A. affects the nurse's feelings are not the barrier to communica-
nurse-physician relation in this situation.
tionship.
B. impedes further dis-
cussion.
C. helps the patient un-
derstand personal feel-
ings in relation to his or
her verbal message.
D. helps the nurse un-
derstand his or her
own feelings in relation
to the patient's verbal
message.
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24. The use of euphemisms C
to avoid reality or to
hide feelings is known Euphemisms are used to avoid reality or to hide
as: feelings. Using direct language is the best way to
A. distancing language. deal with frightening topics instead of using avoid-
B. sympathetic lan- ance language.
guage. Distancing is the use of impersonal speech to put
C. avoidance language. space between a threat and the self.
D. ethnocentric lan- Empathy means viewing the world from the other
guage. person's inner frame of reference. Empathy is ther-
apeutic; sympathy is nontherapeutic.
Ethnocentrism is the belief that one's ethnic or
cultural group is more important or superior.
25. When addressing a tod- C

dler during the inter-
view, the health care A toddler's communication is direct, concrete, liter-
provider should: al, and set in the present. The health care provider
A. ask the child, before should use short, simple sentences with concrete
the caretaker, about explanations.
symptoms. For a younger child such as a toddler, the parent
B. use nonverbal com- will provide all or most of the history.
munication. Nonverbal communication is the primary commu-
C. use short, simple, nication method for infants.
concrete sentences. Detailed explanations would be more appropriate
D. use detailed explana- for a school-age child, adolescent, or adult.
tions.
26. Nonverbal communica- A

tion is the primary form
of communication for Nonverbal communication is the primary commu-
which group of individ- nication method for infants.
uals? Preschoolers' communication is direct, concrete,
A. Infants literal, and set in the present.
B. Preschoolers Adolescents should be treated with respect; the
C. Adolescents nurse should use open, honest, professional com-
D. Older adults munication.
Older adults may need special considerations re-
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lated to physical limitations (e.g., adjusted pace to
avoid fatigue, impaired hearing).
27. Viewing the world from B

another person's inner
frame of reference is Empathy means viewing the world from the other
called: person's inner frame of reference.
A. reflection. Reflection is repeating part of what the person has
B. empathy. just said.
C. clarification. Clarification is used to summarize the person's
D. sympathy. words or to simplify the words to make them clear-
er.
Sympathy is a social affinity in which one person
stands with another person, closely understanding
his or her feelings.
28. An example of an A
open-ended question
or statement is: Open-ended questions and statements ask for
A. "Tell me about your narrative information; they state the topic to be
pain." discussed but only in general terms. "Tell me about
B. "On a scale of 1 to your pain" encourages the person to respond in
10, how would you rate paragraphs and to give a spontaneous account in
your pain?" any order chosen.
C. "I can see that you "On a scale of 1 to 10, how would you rate your
are quite uncomfort- pain?"; "I can see that you are quite uncomfort-
able." able"; and "You are upset about the level of pain,
D. "You are upset about right?" are closed or direct questions. Closed or
the level of pain, right?" direct questions and statements ask for specific
information. This type of question or statement will
elicit a short, one- or two-word answer, a yes or no
response, or a forced choice.
29. The most appropriate A

introduction to use to
start an interview with An older adult should be addressed by the last
an older adult patient name; older adults may be offended by a younger
is: person using their first names.
A. "Mr. Jones, I want The initial introduction should include the person's
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to ask you some ques- surname (unless a child) and the reason for the
tions about your health interview.
so that we can plan "Mr. Jones, is it okay if I ask you several questions
your care." this morning about your health?" is a closed-ended
B. "David, I am here question.
to ask you questions "Because so many people have already asked you
about your illness; we questions, I will just get the information from the
want to determine what chart" does not allow for free expression of ideas.
is wrong."
C. "Mr. Jones, is it okay
if I ask you several
questions this morning
about your health?"
D. "Because so many
people have already
asked you questions, I
will just get the informa-
tion from the chart."
30. Which of the follow- D

ing is included in
documenting a history The source of history is a record of who furnishes
source? the information, how reliable the informant seems,
A. Appearance, dress, and how willing he or she is to communicate. In
and hygiene addition, there should be a note of any special
B. Cognition and litera- circumstances, such as the use of an interpreter.
cy level Appearance, dress, and hygiene are observations
C. Documented rela- included in the general survey.
tionship of support sys- Cognition and literacy level are part of the mental
tems status assessment.
D. Reliability of infor- Interpersonal relationships and resources such as
mant support systems are assessed during the function-
al assessment of the complete health history.
31. A patient seeks C

care for "debilitating
headaches that cause Aggravating factors are determined by asking the
excessive absences at patient what makes the pain worse.
work." On further ex- To determine the patient's perception of pain, the
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ploration, the nurse nurse would determine the meaning of the symp-
asks, "What makes tom by asking how it affects daily activities and
the headaches worse?" what the patient thinks the pain means.
With this question, the The nature or character calls for specific descrip-
nurse is seeking infor- tive terms to describe the pain.
mation about: Relieving factors are determined by asking the
A. the patient's percep- patient what relieves the pain, what is the effect of
tion of pain. any treatment, what the patient has tried, and what
B. the nature or charac- seems to help.
ter of the headache.
C. aggravating factors.
D. relieving factors.
32. The CAGE test is C

a screening question-
naire that helps to iden- CAGE is a screening questionnaire to identify ex-
tify: cessive or uncontrolled drinking (C = Cut down; A
A. unhealthy lifestyle = Annoyed; G = Guilty; E = Eye opener).
behaviors. The health history assesses lifestyle, including fac-
B. personal response to tors such as exercise, diet, risk reduction, and
stress. health promotion behaviors.
C. excessive or uncon- Coping and stress management are assessed dur-
trollable drinking. ing the functional assessment of the complete
D. depression. health history.
Depression is assessed during the review of sys-
tems and during the mental status assessment
(mood and affect). The Geriatric Depression Scale,
Short Form is an assessment instrument for use
with older adults.
33. The "review of sys- A

tems" in the health his-
tory is: The purpose of the review of systems is to evaluate
A. an evaluation of the past and present health state of each body
past and present health system, to double-check in case any significant
state of each body sys- data were omitted in the present illness section,
tem. and to evaluate health promotion practices.
B. a documentation of The reason for seeking care is a statement in the
the problem as per- person's own words that describes the reason for
14 / 47
ceived by the patient. the visit. This is typically known as a "chief com-
C. a record of objective plaint" or the reason for the health care visit.
findings. Objective data are the observations obtained by
D. a short statement of the health care professional during the physical
general health status. examination.
A short statement related to the patient's general
health status is typically included in the complete
physical assessment record.
34. When recording infor- C

mation for the review of
systems, the interview- When recording information for the review of sys-
er must document: tems, the interviewer should record the presence
A. physical findings, or absence of all symptoms; otherwise it is un-
such as skin appear- known which factors were asked.
ance, to support his- Recording physical findings in the review of sys-
toric data. tems is incorrect; review of systems is limited to
B. "negative" under the the patient's statements or subjective data.
system heading. Writing "negative" after the system heading is also
C. the presence or ab- incorrect because it would be unknown which fac-
sence of all symptoms tors were asked.
under the system head- Recording objective data in the review of systems
ing. is incorrect; review of systems is limited to the
D. objective data that patient's statements or subjective data.
support the history of
present illness.
35. Assessment of self-es- A

teem and self-concept
is part of the function- Functional assessment measures a person's
al assessment. Areas self-care ability. The areas assessed under the
covered under self-es- self-esteem and self-concept section of the func-
teem and self-concept tional assessment include education, financial sta-
include: tus, and value-belief system.
A. education, financial These areas are related to the activity and exercise
status, and value-belief section of the functional assessment.
system. These areas are related to the interpersonal rela-
B. exercise and activi- tionships and resources section of the functional
ty, leisure activities, and assessment.
15 / 47
level of independence. These areas are related to the coping and stress
C. family role, interper- management section of the functional assess-
sonal relations, social ment.
support, and time spent
alone.
D. stressors, cop-
ing mechanisms, and
change in past year.
36. PQRSTU is a mnemonic C

that helps the clinician
to remember to address The eight critical characteristics of pain symptoms
characteristics specific reported in the history are: P = provocative or
to: palliative; Q = quality or quantity; R = region or
A. severity of dementia. radiation; S = severity scale; T = timing; and U =
B. substance use and understand patient's perception.
abuse. Tests used to assess for dementia include the
C. pain presentation. Mini-Mental State Examination, the Set Test, the
D. the ability to perform Short Portable Mental Status Questionnaire, the
activities of daily living Mini-Cog, and the Blessed Orientation-Memo-
(ADLs). ry-Concentration Test.
Functional assessment includes questions on sub-
stance use and abuse.
Functional assessment measures a person's
self-care ability including the ability to perform
ADLs.
37. The nurse questions B

the reliability of the his-
tory provided by the pa- A reliable person always gives the same answers,
tient. One method to even when questions are rephrased or are repeat-
verify information with- ed later in the interview.
in the context of the in- This option is not within the context of the inter-
terview is to: view.
A. review previous med- Although this may possibly lead to verification of
ical records. information, asking the patient for corrobation of
B. rephrase the same information from another individual is not within the
questions later in the context of the present interview.
interview.
16 / 47
C. ask the patient if This would occur outside the context of the inter-
there is someone who view.
could verify informa-
tion.
D. call a family member
to confirm information.
38. When taking a health C

history from an ado-
lescent, the interviewer The adolescent interview during the health history
should: should be with the youth alone; a parent may wait
A. ask about violence in the waiting area and complete other past health
and abuse before ask- questionnaire forms.
ing about alcohol and Questions should move from expected and less
drug use. threatening questions to questions that are more
B. have at least one par- personal. Ask about alcohol and drug use before
ent present during the asking about safety (related to injury and vio-
interview. lence).
C. interview the youth Questions about condom use would be appro-
alone with a parent in priate only if the youth is sexually active. The
the waiting area. HEEADSSS method of interviewing adolescents
D. ask every youth has essential questions, important questions, and
about the use of con- situational questions.
doms.
39. What information is in- A

cluded in greater detail
when taking a health The amount of nutritional information needed de-
history on an infant? pends on the child's age; the younger the child is,
A. Nutritional data the more detailed and specific the data should be.
B. History of present ill- The health history is adapted to include informa-
ness tion specific for the age and developmental stage
C. Family history of the child (e.g., mother's health during pregnan-
D. Environmental haz- cy, labor, and delivery and the perinatal period).
ards The developmental history and nutritional data are
important for current health of infants and children.
40. To examine a toddler, A

the nurse should:
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A. allow the child to sit A toddler should be sitting up on the parent's lap
on the parent's lap. for the examination.
B. remove the child's An infant will not object to having clothing removed;
clothing at the begin- a toddler does not like to take off his or her clothing.
ning of the examina- A school-age child has a sense of modesty; to
tion. maintain privacy, ask a child who is 11 or 12 years
C. ask the child to de- old to decide whether parents or siblings should be
cide whether parents or present.
siblings should be pre- The sequence of the examination for a toddler
sent. should start with nonthreatening areas first; save
D. perform the assess- distressing procedures such as assessment of the
ment from head to toes. head, ears, nose, or throat for last.
41. Deep palpation is used A

to:
A. identify abdominal Deep palpation is used to identify abdominal con-
contents. tents.
B. evaluate surface Light palpation is used to evaluate surface charac-
characteristics. teristics.
C. elicit deep tendon re- Percussion with a reflex hammer is used to elicit
flexes. deep tendon reflexes.
D. determine the densi- Percussion is used to determine the density (air,
ty of a structure. fluid, or solid) of a structure by a characteristic
note.
42. Amplitude is: A

A. the intensity (soft or
loud) of sound. Amplitude is the intensity of sound.
B. the length of time the Duration is the length of time the note lingers.
note lingers. Pitch is the number of vibrations per second (high
C. the number of vibra- or low).
tions per second. Quality is the subjective difference owing to a
D. the subjective differ- sound's distinctive overtones.
ence in a sound's dis-
tinctive overtones.
43. The dorsa of the hands B

are used to determine:
A. vibration. The dorsa (back) of hands and fingers are best
18 / 47
B. temperature. for determining temperature because the skin is
C. position of an organ. thinner than on the palms.
D. fine tactile discrimi- The base of the fingers or ulnar surface of the hand
nation. is best for vibration.
A grasping action of the fingers and thumb is the
best way to detect the position, shape, and consis-
tency of an organ or mass.
The fingertips are best for fine tactile discrimina-
tion.
44. Fine tactile discrimina- B

tion is best achieved
with the: The grasping action of the fingers and thumb is
A. opposition of the fin- used to detect the position, shape, and consisten-
gers and thumb. cy of an organ or mass.
B. fingertips. The fingertips are best for fine tactile discrimina-
C. back of the hands tion such as skin texture, swelling, pulsation, and
and fingers. presence of lumps.
D. base of the fingers. The dorsa (back) of hands and fingers are best
for determining temperature because the skin is
thinner than on the palms.
The base of the fingers or ulnar surface of the hand
is best for detecting vibration.
45. A funduscopic exami- A

nation is an examina-
tion of the: An ophthalmoscope is used for a funduscopic ex-
A. inner ear. amination, which is an examination of the internal
B. pharynx. structures of the eye.
C. internal structures of An otoscope is used to visualize the ear canal and
the eye. tympanic membrane.
D. nasal turbinates. A flashlight or penlight and tongue depressor are
used to examine the pharynx.
An otoscope may also be used with a short, broad
speculum to view the nasal turbinates and nares.
46. Which of the follow- The pace of the examination should be adjusted
ing is considered when to match the possible slowed pace of the aging
preparing to examine person.
19 / 47
an older adult? Use physical touch (if it is not a cultural contraindi-
A. Base the pace of the cation) to offset the disadvantages of diminishing
examination on the pa- vision and hearing.
tient's needs and abili- Be aware that loss is inevitable, and adaptation to
ties. loss affects health status.
B. Avoid physical touch Confusion with a sudden onset may signify a dis-
to avoid making the old- ease state and is not a normal process of aging.
er adult uncomfortable.
C. Be aware that loss
will result in poor cop-
ing mechanisms.
D. Confusion is a nor-
mal, expected finding in
an older adult.
47. When performing per- B

cussion, the examiner:
A. strikes the flank area To perform percussion, the examiner strikes the
with the palm of the stationary finger at the distal interphalangeal joint
hand. (just behind the nail bed).
B. strikes the stationary
finger at the distal inter-
phalangeal joint.
C. strikes the stationary
finger at the proximal
interphalangeal joint.
D. taps fingertips over
bony processes.
48. At the end of the ex- D

amination, the examin-
er should: At the end of the examination, the examiner should
A. complete documen- summarize the findings and share necessary infor-
tation before leaving mation with the patient.
the examination room. The examiner may take short notes during the ex-
B. have findings con- amination; complete documentation should occur
firmed by another after leaving the examination room.
provider. The examiner should have findings confirmed only
C. compare objective if the finding is abnormal and requires confirmation
20 / 47
and subjective data for from another examiner.
discrepancies. Subjective and objective data should be compared
D. review the findings throughout the history and physical examination.
with the patient.
49. The examiner should A

use handwashing in-
stead of an alco- The examiner should use the mechanical action
hol-based hand rub: of soap-and-water handwashing when hands are
A. if the patient has an visibly soiled and when patients are infected with
infection with Mycobac- spore-forming organisms (e.g., C. difficile or Bacil-
terium tuberculosis. lus anthracis).
B. if the patient has an An alcohol-based hand rub would be effective
infection with Clostridi- against M. tuberculosis.
um difficile. An alcohol-based hand rub would be effective
C. if the patient has an against hepatitis B virus.
infection with hepatitis An alcohol-based hand rub would be effective
B virus. against HIV.
D. if the patient is HIV
positive.
50. The general survey C

consists of four distinct
areas. These areas in- The general survey is a study of the whole per-
clude: son, covering the general health state and any
A. mental status, obvious physical characteristics. The four areas of
speech, behavior, and the general survey are physical appearance, body
mood and affect. structure, mobility, and behavior.
B. gait, range of motion, A general survey does not include assessment of
mental status, and be- mental status and physical condition.
havior.
C. physical appearance,
body structure, mobili-
ty, and behavior.
D. level of conscious-
ness, personal hygiene,
mental status, and
physical condition.
21 / 47
51. A common error in B
blood pressure mea-
surement is: Waiting less than 1 to 2 minutes before repeating
A. taking the blood the blood pressure reading on the same arm will
pressure in an arm that result in a falsely high diastolic pressure related to
is at the level of the venous congestion in the forearm.
heart. The patient's arm should be positioned at the level
B. waiting less than 1 of the heart when obtaining a blood pressure mea-
to 2 minutes before re- surement.
peating the blood pres- The cuff should be deflated at a rate of 2 mm Hg
sure reading on the per heartbeat.
same arm. The blood pressure cuff bladder length should be
C. deflating the cuff about 80% of the arm circumference.
about 2 mm Hg per
heartbeat.
D. using a blood pres-
sure cuff whose blad-
der length is 80% of the
arm circumference.
52. Data collection for the A

general survey begins:
A. at the first encounter. The general survey is initiated at the first en-
B. at the beginning of counter with the patient.
the physical examina-
tion.
C. while taking vital
signs.
D. during the mental
status examination.
53. The Doppler technique: B

A. is used to assess the
apical pulse. The Doppler technique may be used to locate pe-
B. augments Ko- ripheral pulse sites and for blood pressure mea-
rotkoff sounds during surement to augment Korotkoff sounds.
blood pressure mea- A stethoscope is used to assess an apical pulse.
surement. The systolic blood pressure is more easily identi-
C. provides an easy and fied with the Doppler technique than the diastolic
22 / 47
accurate measurement pressure.
of the diastolic pres- A pulse oximeter measures arterial oxygenation
sure. saturation.
D. measures arteri-
al oxygenation satura-
tion.
54. The tympanic mem- A

brane thermometer
(TMT): The TMT accurately measures core body temper-
A. provides an accurate ature.
measurement of core The TMT senses the infrared emissions of the tym-
body temperature. panic membrane; the tympanic membrane shares
B. senses the infrared the same vascular supply that perfuses the hypo-
emissions of the cere- thalamus.
bral cortex. The TMT is used with unconscious patients or
C. is not used in uncon- patients in the emergency department, recovery
scious patients. areas, and labor and delivery units.
D. accurately measures The temperature is displayed in 2 to 3 seconds.
temperature in 20 to 30
seconds.
55. Endogenous obesity is: B

A. due to inadequate se-
cretion of cortisol by Endogenous obesity is caused by either the ad-
the adrenal glands. ministration of adrenocorticotropin or excessive
B. caused by production of adrenocorticotropin by the pituitary.
excess adrenocorti- Adrenocorticotropin stimulates the adrenal cortex
cotropin production by to secrete excess cortisol and causes Cushing
the pituitary gland. syndrome, which is characterized by weight gain
C. characterized by and edema with central trunk and cervical obesity.
evenly distributed ex- Excessive catabolism causes muscle wasting with
cess body fat. thin arms and legs. Body fat is evenly distributed
D. a result of excessive in exogenous obesity because of excessive caloric
secretion of growth intake.
hormone in adulthood. Acromegaly is caused by an excessive secretion
of growth hormone in adulthood.
56.
23 / 47
To perform an accu- C
rate assessment of res-
pirations, the examiner Respirations should be counted for 30 seconds
should: (if regular) and multiplied by two. The respirations
A. inform the person should be counted after the pulse assessment.
of the procedure and Patients have conscious control over respirations;
count for 1 minute. the examiner should not mention that respirations
B. count for 15 seconds will be counted.
while keeping fingers Avoid counting respirations for 15 seconds be-
on the pulse and then cause the results can vary +4 or -4 with such a
multiply by four. small number.
C. count for 30 sec- Respirations should be counted for 1 minute if
onds after completing a abnormalities are suspected.
pulse assessment and
multiply by two.
D. assess respirations
for a full 2 minutes if an
abnormality is suspect-
ed.
57. Physical appearance B

includes statements
that compare appear- Physical appearance includes statements that
ance with: compare appearance with age, sex, level of con-
A. mood and affect. sciousness, skin color, and facial features.
B. stated age. Behavior is compared with mood and affect.
C. gait. Mobility is compared with gait.
D. nutrition. Body structure is compared with nutrition.
58. An adult patient's pulse B

is 46 beats per minute.
The term used to de- A heart rate of less than 50 beats per minute in an
scribe this rate is: adult is bradycardia.
A. tachycardia. A heart rate of greater than 90 beats per minute in
B. bradycardia. an adult is tachycardia.
C. weak and thready. Weak and thready describes the force of the pulse
D. sinus arrhythmia. reflecting a decreased stroke volume.
Sinus arrhythmia is a pulse that is irregular; the
heart rate varies with the respiratory cycle.
24 / 47
59. The nurse records that D
the patient's pulse is 3+
or full and bounding. A full, bounding pulse (3+) reflects an increased
Which of the following stroke volume, as with anxiety and exercise.
could be the cause? A weak, thready pulse may reflect a decreased
A. Dehydration stroke volume, as with dehydration.
B. Shock A weak, thready pulse may reflect a decreased
C. Bleeding stroke volume, as with shock.
D. Anxiety A weak, thready pulse reflects a decreased stroke
volume, as with bleeding.
60. Pain signals are carried B

to the central nervous
system by way of: Nociceptors carry the pain signal to the central
A. perception. nervous system by two primary sensory (or affer-
B. afferent fibers. ent) fibers.
C. modulation. Perception indicates the conscious awareness of
D. referred pain. a painful sensation.
Modulation inhibits the pain message producing
an analgesic effect.
Referred pain is pain felt at a particular site that
originates from another location.

is the most reliable indi-
cator for chronic pain? The most important and reliable indicator for
A. Magnetic resonance chronic pain is the patient's self-report.
imaging (MRI) results Chronic pain is transmitted on a cellular level, and
B. Patient self-report current technology such as MRI cannot reliably
C. Tissue enzyme levels detect this process.
D. Blood drug levels Chronic pain is transmitted on a cellular level, and
current technology such as tissue enzyme levels
cannot reliably detect this process.
Chronic pain is transmitted on a cellular level,
and blood drug levels cannot reliably detect this
process.

25 / 47
ing cultural/racial dif- studies describe how black and Hispanic patients
ferences in the treat- are often prescribed less analgesic therapy than
ment of pain is true? white patients, although most of these differences
A. White individuals re- are small. No evidence supports anything else.
ceive more analgesic
therapy than black
or Hispanic individuals
with similar symptoms.
B. Black and Hispanic
individuals have been
found to have a high-
er pain tolerance than
white individuals.
C. Pain modulation is
more highly developed
in black and Hispanic
individuals.
D. Neurotransmitters
are more concentrat-
ed in white individuals
than in black and His-
panic individuals.
63. What occurs during A

transduction (the first
phase of nociceptive Transduction is the first phase of nociceptive pain.
pain)? During this phase, injured tissue releases chem-
A. Pain signals move icals that propagate the pain message; an action
from the site of origin to potential moves along an afferent fiber to the spinal
the spinal cord. cord.
B. The pain impulse During transmission (the second phase), the pain
moves from the spinal impulse moves from the level of the spinal cord to
cord to the brain. the brain.
C. The brain interprets The third phase is perception; the person has con-
the pain signal. scious awareness of a painful sensation.
D. Chemical mediators In phase four, modulation, the neurons from the
are neutralized to de- brainstem release neurotransmitters that block the
crease the perception pain impulse.
of pain.
26 / 47
64. What type of pain is C
short and self-limiting
and dissipates after the Acute pain is short-term and self-limiting, often fol-
injury heals? lows a predictable trajectory, and dissipates after
A. Chronic an injury heals.
B. Persistent Chronic pain lasts 6 months or longer; the pain
C. Acute persists after the predicted trajectory.
D. Breakthrough Persistent pain is another term for chronic pain.
Breakthrough pain starts again or escalates before
the next scheduled analgesic dose.
65. Neuropathic pain im- B

plies an abnormal:
A. degree of pain inter- Neuropathic pain results from abnormal process-
pretation. ing of the pain message.
B. processing of the Neuropathic pain does not adhere to the typical
pain message. and predictable phases inherent in nociceptive
C. transmission of pain pain.
signals.
D. modulation of pain
signals.
66. What is the source of B

deep somatic pain?
A. Skin and subcuta- Deep somatic pain comes from the blood vessels,
neous tissues joints, tendons, muscles, and bones.
B. Bones and joints Cutaneous pain is derived from skin surface and
C. Pancreas subcutaneous tissues.
D. Intestine Visceral pain originates from the larger interior
organs such as the pancreas.
Visceral pain originates from the larger interior
organs such as the intestine.

has been found to influ-
ence pain sensitivity in Gender differences are influenced by societal ex-
women? pectation, hormones, and genetic makeup. Hor-
A. Age monal changes are found to have strong influ-
B. Hormonal changes ences on pain sensitivity for women.
27 / 47
C. Parity Age has not been found to influence pain sensitiv-
D. Weight ity in women.
Parity has not been found to influence pain sensi-
tivity in women.
Weight has not been found to influence pain sen-
sitivity in women.
68. Specialized nerve end- C

ings that are designed
to detect painful sensa- Nociceptors are specialized nerve endings de-
tions are: signed to detect painful sensations from the pe-
A. synapses. riphery and transmit them to the central nervous
B. dorsal horns. system.
C. nociceptors. A synapse is a region (or small gap) where nerve
D. C fibers. impulses are transmitted and received.
The dorsal horn is a longitudinal subdivision of
gray matter in the dorsal part of each lateral half of
the spinal cord that receives terminals from some
afferent fibers of the dorsal roots of the spinal
nerves.
C fibers are one of two primary sensory or afferent
fibers that are unmyelinated and smaller; C fibers
transmit the signal slowly.
69. An older adult patient B

with dementia has a
pain rating of 5 on A patient with a pain score of 4 or greater on
the Pain Assessment the PAINAD scale should receive pain intervention.
in Advanced Demen- Patients with dementia can be given an analgesic
tia (PAINAD) scale. The trial or option.
nurse should: The nurse should not wait an additional 3 to 4
A. reassess the pain hours for another pain assessment.
level in 3 to 4 hours. A patient with dementia may say "no" if asked
B. administer pre- about having pain even if he or she is having pain.
scribed pain medica- Words lose their meaning with dementia.
tion. Nonpharmacologic pain relief interventions can be
C. ask the patient to ver- implemented with or without prescribed pain med-
ify the pain rating. ication.
D. use only nonpharma-
28 / 47
cologic pain relief inter-
ventions.
70. When taking the health D

history, the patient
complains of pruritus. Drug reactions can lead to pruritus or itching.
What is a common Excessive bruising can occur in response to a
cause of this symp- traumatic event or a coagulation abnormality. It is
tom? associated with erythema, not pruritus.
A. Excessive bruising Hyperpigmentation is related to color changes.
B. Hyperpigmentation Melasma (also known as chloasma or the mask of
C. Melasma pregnancy) is a facial skin discoloration related to
D. Drug reactions hormones of pregnancy.
71. A flat macular hemor- A

rhage is called a(n):
A. purpura. Purpura is a flat, macular, red-to-purple hemor-
B. ecchymosis. rhage that is a confluent and extensive patch of
C. petechiae. petechiae and ecchymoses greater than 3 mm.
D. hemangioma. An ecchymosis is a hemorrhage that is greater
than 3 mm.
Petechiae are tiny punctate hemorrhages that are
1 to 3 mm; round and discrete; and dark red, pur-
ple, or brown caused by bleeding from superficial
capillaries.
Hemangiomas are vascular lesions caused by a
benign proliferation of blood vessels in the dermis.
72. A student nurse has D

been assigned to teach
fourth graders about Newborn infants' eccrine glands do not secrete
hygiene. While prepar- sweat in response to heat until the first few months
ing, the student nurse of life; newborn temperature regulation is ineffec-
adds information about tive.
the sweat glands. There are two types of sweat glands: eccrine
Which of the follow- glands and apocrine glands.
ing should be included The evaporation of sweat reduces body tempera-
while discussing this ture.
topic? The apocrine glands produce a thick, milky secre-
29 / 47
A. There are two types tion and open into the hair follicles; they are located
of sweat glands: ec- mainly in the axillae, anogenital area, nipples, and
crine glands and seba- navel.
ceous glands.
B. The evaporation
of sweat, a dilute
saline solution, in-
creases body tempera-
ture.
C. Eccrine glands pro-
duce sweat and are
mainly located in the
axillae, anogenital area,
and navel.
D. Newborn infants do
not sweat and use com-
pensatory mechanisms
to control body temper-
ature.
73. Functions of the skin D

include:
A. production of vita- Functions of the skin include protection, prevention
min C. of penetration, perception (of touch, pain, tem-
B. temperature regula- perature, and pressure), temperature regulation,
tion. identification, communication, wound repair, ab-
C. production of new sorption and excretion, and production of vitamin
cells by melanocytes. D.
D. secretion of a dry- The skin produces vitamin D, not vitamin C.
ing substance called The basal cell layer of the epidermis forms new
sebum. skin cells. Melanocytes produce melanin, which
gives brown tones to the skin and hair.
Sebum is produced by the sebaceous glands to
lubricate the skin and hair.
74. Risk factors that may C

lead to skin disease
and breakdown in- Accumulating factors that place an aging person at
clude: risk for skin disease and breakdown include thin-
30 / 47
A. loss of protective ning of the skin, decrease in vascularity and nu-
cushioning of the der- trients, loss of protective cushioning of the subcu-
mal skin layer. taneous layer, a lifetime of environmental trauma
B. decreased vascular to skin, social changes of aging, an increasingly
fragility. sedentary lifestyle, and the chance of immobility.
C. a lifetime of environ- Aging results in the loss of protective cushioning of
mental trauma. the subcutaneous layer of the skin.
D. increased thickness Aging results in decreased vascularity of the skin.
of the skin. Aging results in thinning of the skin.
75. What term refers to a A

linear skin lesion that
runs along a nerve Zosteriform describes a lesion that has a linear
route? arrangement along a nerve root.
A. Zosteriform Annular describes a lesion that is circular and be-
B. Annular gins in the center and spreads to the periphery.
C. Dermatome A dermatome is an area of skin that is mainly
D. Shingles supplied by a single spinal nerve.
Shingles (herpes zoster) are small grouped vesi-
cles that emerge along the route of a cutaneous
sensory nerve, followed by pustules, and then
crusts; shingles is caused by the herpes zoster
virus.
76. The components of a A

nail examination in-
clude: The nails should be assessed for shape and con-
A. contour, consisten- tour, consistency, and color.
cy, and color.
B. shape, surface, and
circulation.
C. clubbing, pitting, and
grooving.
D. texture, toughness,
and translucency.
77. To determine if a A
dark-skinned patient is
pale, the nurse should To detect pallor in a dark-skinned patient, the
31 / 47
assess the color of the: nurse should assess an area with the least pig-
A. conjunctivae. mentation, such as the conjunctivae or mucous
B. earlobes. membranes.
C. palms of the hands.
D. skin in the antecu-
bital space.
78. An example of a prima- C

ry lesion is a(n):
A. erosion. Urticaria is a primary lesion; a primary lesion is one
B. ulcer. that develops on previously unaltered skin.
C. urticaria. Erosions are secondary lesions; a secondary le-
D. port-wine stain. sion is one that changes over time or changes
because of a factor such as scratching or infection.
Ulcers are secondary lesions; a secondary lesion
is one that changes over time or changes because
of a factor such as scratching or infection.
A port-wine stain is a vascular lesion.
79. A scooped-out, shallow D

depression in the skin
is called a(n): An ulcer is a deeper depression extending into the
A. ulcer. dermis.
B. excoriation. An excoriation is a self-inflicted abrasion that is
C. fissure. superficial.
D. erosion. A fissure is a narrow opening of tissue or skin.
An erosion is a scooped-out, shallow depression
in the skin.
80. Bleeding into the pe- D

riosteum during birth is
known as: A cephalhematoma is a subperiosteal hemorrhage
A caput succedaneum. resulting from birth trauma.
B craniosynostosis. A caput succedaneum is edematous swelling and
C molding. ecchymosis of the presenting part of the head
D cephalhematoma. caused by birth trauma.
Craniosynostosis is marked asymmetry that is due
to a severe deformity caused by premature closure
of the sutures and resulting in a long, narrow head.
32 / 47
Molding of the cranial bones during passage
through the birth canal makes the head asymmet-
ric and ridges more prominent.
81. Craniosynostosis is A
a severe deformity
caused by: Craniosynostosis is marked asymmetry that is due
A premature closure of to a severe deformity caused by premature closure
the sutures. of the sutures and resulting in a long, narrow head.
B increased intracra- Hydrocephalus (obstruction of drainage of cere-
nial pressure. brospinal fluid) results in excessive accumulation
C a localized bone dis- of cerebrospinal fluid, increasing intracranial pres-
ease that softens, thick- sure, and enlargement of the head.
ens, and deforms bone. Paget disease (osteitis deformans) is a localized
D excess growth hor- bone disease of unknown etiology that softens,
mone or a deficit in thy- thickens, and deforms bone.
roid hormone. Acromegaly results from excessive secretion of
growth hormone from the pituitary after puber-
ty. Congenital hypothyroidism and myxedema are
caused by thyroid hormone deficiency.
82. Narrow palpebral fis- B

sures, epicanthal folds,
and midfacial hypopla- Facial characteristics of fetal alcohol syndrome in-
sia are characteristic clude narrow palpebral fissures, epicanthal folds,
of: and midfacial hypoplasia.
A Down syndrome. Facial characteristics of Down syndrome include
B fetal alcohol syn- upslanting eyes with inner epicanthal folds; flat
drome. nasal bridge; small, broad, flat nose; protruding
C chronic childhood al- thick tongue; and ear dysplasia.
lergies. Facial characteristics of chronic allergies include
D congenital hypothy- exhausted face, blue shadows below the eyes,
roidism. double or single crease on the lower eyelids, cen-
tral facial pallor, open mouth breathing (maloc-
clusion of the teeth and malformed jaw), and a
transverse line on the nose.
Facial characteristics of congenital hypothyroidism
include low hairline, hirsute forehead, swollen
eyelids, narrow palpebral fissures, widely spaced
33 / 47
eyes, depressed nasal bridge, puffy face, thick
tongue protruding through an open mouth, and a
dull expression.
83. Kyphosis of the spine B

is common with aging.
To compensate, older An older adult may show an increased anterior
adults: cervical (concave or inward) curve when the head
A increase their center and jaw are extended forward to compensate for
of gravity. kyphosis of the spine.
B extend their heads
and jaws forward.
C stiffen their gait.
D shuffle.

ing statements related
to aggravating symp- Aggravating symptoms or triggers for cluster
toms or triggers of headaches include alcohol consumption, stress,
headaches is true? or wind or heat exposure. Aggravating symptoms
A Alcohol consumption or triggers for migraines include hormonal fluctua-
may precipitate the on- tions, certain foods, letdown after stress, changes
set of cluster or mi- in sleep pattern, sensory stimuli, and changes in
graine headaches. weather or physical activity.
B Certain foods such Aggravating symptoms or triggers for tension
as chocolate or cheese headaches include stress anxiety, depression, and
may precipitate the poor posture.
onset of tension
headaches.
C Premenstrual hor-
monal fluctuations may
precipitate the onset of
cluster headaches.
D Poor posture may
trigger a migraine
headache.
85. Most facial bones artic- B

ulate at a suture. Which
34 / 47
facial bone articulates The facial bones articulate at sutures (nasal
at a joint? bone, zygomatic bone, and maxilla) except for the
A Nasal bone mandible. The mandible articulates at the temporo-
B Mandible mandibular joint.
C Zygomatic bone
D Maxilla
86. A severe deficiency of C

thyroid hormone lead-
ing to nonpitting ede- Myxedema (hypothyroidism) is a deficiency of thy-
ma, coarse facial fea- roid hormone. If severe, the symptoms include
tures, dry skin, and dry nonpitting edema or myxedema; a puffy edema-
coarse hair is known tous face, especially around the eyes (periorbital
as: edema); coarse facial features; dry skin; and dry
A congenital hypothy- coarse hair and eyebrows.
roidism. Congenital hypothyroidism is a thyroid deficiency
B scleroderma. that occurs at an early age; characteristics include
C myxedema. low hairline, hirsute forehead, swollen eyelids, nar-
D Hashimoto thyroidi- row palpebral fissures, widely spaced eyes, de-
tis. pressed nasal bridge, puffy face, thick tongue pro-
truding through an open mouth, and a dull expres-
sion.
Scleroderma is a rare connective tissue disease
characterized by chronic hardening and shrinking
degenerative changes in the skin blood vessels,
synovium, and skeletal muscles.
Hashimoto thyroiditis is a condition with excess
thyroid hormone production; symptoms include
goiter, nervousness, fatigue, weight loss, muscle
cramps, heat intolerance, tachycardia, shortness
of breath, excessive sweating, fine muscle tremor,
thin silky hair and skin, infrequent blinking, and a
staring appearance.
87. Which of the following C

statements describing
a headache would war- A sudden severe headache in an adult or child
rant an immediate refer- who has never had it before warrants an immediate
ral?
35 / 47
A "This is the worst mi- referral. A sudden severe headache could indicate
graine of my life." a subarachnoid hemorrhage.
B "This is the worst
headache I've had since
puberty."
C "I have never had a
headache like this be-
fore; it is so bad I can't
function."
D "I have had daily
headaches for years."
88. What disease is char- D

acterized by a flat, ex-
pressionless, or mask- Facial characteristics of Parkinson disease include
like face; a staring gaze; a flat, expressionless face that is masklike with
oily skin; and elevated elevated eyebrows, a staring gaze, oily skin, and
eyebrows? drooling.
A Acromegaly Facial characteristics of acromegaly include an
B Scleroderma elongated head, a massive face, a prominent nose
C Cushing syndrome and lower jaw, a heavy eyebrow ridge, and coarse
D Parkinson disease facial features.
Facial characteristics of scleroderma include hard,
shiny skin on the forehead and cheeks; thin,
pursed lips with radial furrowing; absent skinfolds;
muscle atrophy of the face and neck; and absence
of expression.
Facial characteristics of Cushing syndrome in-
clude a plethoric, rounded, "moonlike" face; promi-
nent jowls; red cheeks; and hirsutism on the upper
lip, lower cheeks, and chin.
89. A patient is admitted to A

the emergency depart-
ment after a motor ve- The trachea is normally midline; with a right pneu-
hicle accident. The tra- mothorax, the trachea is deviated to the unaffected
chea is deviated to the side (left).
left side. This finding is The trachea is pulled downward with systole of an
characteristic of: aortic arch aneurysm.
36 / 47
A right pneumothorax. With a large right-sided pleural adhesion, the tra-
B aortic arch aneurysm. chea is deviated to the affected side (right).
C right pleural adhe- With a large right-sided atelectasis, the trachea is
sion. deviated to the affected side (right).
D right-sided atelecta-
sis.
90. The extraocular mus- C

cles consist of four
straight or ________ The four straight, or rectus, muscles are the superi-
muscles and two slant- or, inferior, lateral, and medial rectus muscles. The
ing or ______ muscles. two slanting, or oblique, muscles are the superior
A palpebral; conjugate and inferior muscles.
B superior; inferior
C rectus; oblique
D rectilinear; diagonal
91. A slight protrusion of B

the eyeballs may be no-
ticed when examining African Americans normally may have a slight
individuals who come protrusion of the eyeball beyond the supraorbital
from which ethnic/cul- ridge.
tural group?
A Asian
B African American
C Hispanic
D American Indian
92. The location in the A

brain where optic nerve
fibers from the tempo- At the optic chiasm, nasal fibers (from both tempo-
ral fields of vision cross ral visual fields) cross over.
over is identified as the: The fovea centralis is the area of the retina that has
optic chiasm. the sharpest and keenest vision.
fovea centralis. The optic disc is the area in which fibers from the
optic disc. retina converge to form the optic nerve.
choroid. The choroid is the middle vascular layer of the eye;
the choroid has dark pigmentation to prevent light
37 / 47
from reflecting internally and is heavily vascular-
ized to deliver blood to the retina.

groups of individuals
need to be tested for the Color blindness is an inherited recessive X-linked
presence of color blind- trait affecting about 8% of white boys and 4% of
ness (deficiency)? black boys. Test only boys for color vision once
A Black boys between between the ages of 4 and 8 years.
the ages of 10 and 15
years
B White boys between
the ages of 4 and 8
years
C Asian girls between
the ages of 3 and 6
years
D White girls between
the ages of 4 and 8
years
94. Which of the follow- B

ing the results obtained Using the Snellen chart, the larger the denomina-
from use of the Snellen tor, the poorer the vision.
chart is true?
A The smaller the de-
nominator, the poorer
the vision.
B The larger the denom-
inator, the poorer the vi-
sion.
C The larger the numer-
ator, the better the vi-
sion.
D The smaller the nu-
merator, the poorer the
vision.
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95. The lens of the eye A
functions as a:
A refracting medium. The lens serves as a refracting medium, keeping
B mediator of light. a viewed object in continual focus on the retina.
C sensory facilitator. The muscle fibers of the iris function as the medi-
D controller of intraocu- ator of light.
lar pressure. The cornea is very sensitive to touch.
The intraocular pressure is determined by a bal-
ance between the amount of aqueous humor pro-
duced and resistance to its outflow at the angle of
the anterior chamber.
96. When inspecting the C

eyeballs of an African
American individual, Dark-skinned people may normally have small
which of the following brown macules on the sclera.
might the examiner ex-
pect to observe?
A A slight misalignment
of the eyeballs
B A slight yellow discol-
oration of the sclera
C Small brown macules
on the sclera
D A slight amount of
drainage around the
lacrimal apparatus
97. The normal color of the C

optic disc is:
A red. The color of a normal optic disc ranges from
B creamy pink. creamy yellow-orange to pink.
C creamy yellow-or-
ange to pink.
D creamy red to yel-
low-orange.
98. Which of the follow- B

ing is an expected re-
39 / 47
sponse on the cover A normal response to the cover test is a steady
test? fixed gaze.
A The covered eye If muscle weakness is present, the covered eye will
moves into a relaxed drift into a relaxed position.
position. A normal response to the cover test is a steady
B The covered eye fixed gaze.
maintains its position When the eye is uncovered, if it jumps to reestab-
when uncovered. lish fixation, eye muscle weakness exists.
C The uncovered eye is
unable to maintain its
gaze on a fixed object.
D The covered eye
jumps to reestablish
fixation when it is un-
covered.

findings is associated
with Horner syndrome? Horner syndrome is caused by a lesion of the
A Bilateral miosis sympathetic nerve. An individual with Horner syn-
B Bilateral mydriasis drome has a unilateral small regular pupil that
C A unilateral small reg- reacts to light and accommodation. There is uni-
ular pupil that reacts to lateral ptosis and absence of sweat on the same
light and accommoda- side.
tion
D A unilateral dilated
pupil with no reaction
to light or accommoda-
tion
100. Decreased vision in an A

elderly patient may be
due to which of the fol- Decreased vision in elderly patients is most com-
lowing conditions? monly caused by cataracts, glaucoma, or macular
A Macular degenera- degeneration.
tion Retinoblastoma is a malignant tumor of the retina
B Retinoblastoma that usually affects children younger than 6 years
C Fixation old.
D Presbyopia Fixation is a reflex direction of the eye toward an
40 / 47
object attracting a person's attention; fixation is im-
paired by drugs, alcohol, fatigue, and inattention.
The lens in an older adult loses elasticity and be-
comes hard and glasslike; this decreases the lens'
ability to change shape to accommodate for near
vision and is called presbyopia.
101. Binaural interaction at B

the level of the brain-
stem permits: The function at the brainstem level is binaural in-
A interpretation of teraction, which permits locating the direction of a
sound. sound in space as well as identifying the sound.
B identification and lo-
cation of the direction
of the sound.
C amplification of
sound.
D direction of sound
toward the appropriate
conduction pathway.

behaviors demonstrat-
ed by an individual may Hearing loss is indicated when a person frequently
be indicative of hearing asks to have statements repeated.
loss? Hearing loss is indicated when a person lip reads
A Not looking at the or watches faces and lips closely.
examiner when being Hearing loss is indicated when a person has a flat,
questioned monotonous tone of voice.
B Frequently asking for Hearing loss is indicated when speech sounds
the question to be re- are garbled, vowel sounds are distorted, and the
peated person uses an inappropriately loud voice.
C Talking in a
high-pitched voice
D Speaking slowly with
well-articulated conso-
nants
103.
41 / 47
Which of the following D
children is at risk of
recurrent otitis media A first episode of OM that occurs within 3 months
(OM)? of life increases risk of recurrent OM. Recurrent
A An 18-month-old in- OM is three episodes within the past 3 months or
fant who lives with a four episodes within the past year.
smoker
B A 2-year-old child
who has had two ear in-
fections in the past 6
months
C A 6-month-old infant
who has a sibling who
had tubes inserted at 3
years of age
D An 18-month-old in-
fant who has had three
episodes of ear infec-
tions in a 5-month peri-
od
104. The external structure A

of the ear is identified
as the: The auricle or pinna is the external structure of the
A auricle. ear.
B atrium. The atrium is the upper chamber of the heart.
C aureole.
D auriga.
105. The labyrinth of the C

inner ear is responsi-
ble for maintaining the The labyrinth maintains the body's equilibrium.
body's: Binaural interaction is controlled by the brainstem
A binaural interaction. and permits locating the direction of a sound.
B air conduction. The normal pathway of hearing is by air conduc-
C equilibrium. tion.
D pressure equaliza- The eustachian tube allows equalization of air
tion. pressure on each side of the tympanic membrane.
42 / 47
106. When an otoscopic ex- C
amination is performed
on an older adult During otoscopy, the tympanic membrane of an
patient, the tympanic older adult may be whiter in color than that of a
membrane may be: younger adult. The tympanic membrane may also
A pinker than that of a appear more opaque and dull.
younger adult. A yellow-amber eardrum color occurs with otitis
B thinner than that of a media with effusion. A red color occurs with acute
younger adult. otitis media.
C whiter than that of a The tympanic membrane of an older adult may be
younger adult. thicker compared with that of a younger adult.
D more mobile than that Hypomobility is an early sign of acute otitis media.
of a younger adult.

tests provides a precise
quantitative measure of An audiometer gives a precise quantitative mea-
hearing? sure of hearing by assessing the person's ability
A Tuning fork tests to hear sounds of varying frequency.
B Romberg test The tuning fork tests (Weber and Rinne) are inac-
C Audiometer test curate and should not be used for general screen-
D Whispered voice test ing.
The Romberg test assesses the ability of the
vestibular apparatus in the inner ear to help main-
tain standing balance.
The whispered voice test is nonquantitative; this
test documents the presence of hearing loss but
does not measure the degree of loss.
108. The position of the A

tympanic membrane in
the neonate is more The position of the eardrum is more horizontal in
________________, the neonate, making it more difficult to see com-
making it more difficult pletely and harder to differentiate from the canal
to visualize with the wall.
otoscope. By 1 month of age, the eardrum is in the oblique
A horizontal position similar to an older child, and examination
B vertical is easier.
43 / 47
C perpendicular
D oblique
109. The tympanic mem- C

brane of a child
with acute otitis media The tympanic membrane would be bulging and red
would be: with acute otitis media.
A flat and slightly A normal tympanic membrane is flat and slightly
pulled in at the center. pulled in at the center.
B mobile and would A normal tympanic membrane is mobile and flut-
flutter with the Valsalva ters with the Valsalva maneuver.
maneuver. A normal tympanic membrane is shiny and translu-
C bulging with a dis- cent, with a pearly gray color.
tinct red color.
D shiny and translu-
cent, with a pearly gray
color.
110. If the tympanic mem- B

brane has white dense
areas, the examiner White dense areas indicate scarring on the tym-
suspects: panic membrane from recurrent ear infections.
A perforation from a Dark oval areas indicate perforation from a rup-
ruptured membrane. tured tympanic membrane.
B scarring from recur- Air or fluid levels or air bubbles indicate serous fluid
rent ear infections. from serous otitis media.
C serous fluid from Black or white dots indicate a fungal infection.
serous otitis media.
D a fungal infection.
111. The nasal mucosa of an C

individual with rhinitis
would be: The nasal mucosa is bright red and swollen with
A moist and pink. rhinitis.
B swollen, boggy, and Normally, the nasal mucosa is red with a smooth
gray. and moist surface.
C bright red and The nasal mucosa is swollen, boggy, pale, and
swollen. gray with chronic allergies.
44 / 47
D pale with bright red Bright red bleeding occurs with epistaxis (bleeding
bleeding. from the nose).
112. The examiner notices a A

fine tremor when the
patient sticks out his or A fine tremor of the tongue occurs with hyperthy-
her tongue. What disor- roidism.
der is consistent with A patient in diabetic ketoacidosis would have a
this finding? sweet, fruity breath odor.
A Hyperthyroidism Halitosis is a term used to describe any breath
B Diabetic ketoacidosis odor.
C Halitosis A coarse tremor occurs with alcoholism.
D Alcoholism

questions would the ex-
aminer ask to deter- Epistaxis is the medical term for a nosebleed.
mine whether an indi- Dysphagia is the medical term for difficulty swal-
vidual has epistaxis? lowing.
A "Do you have any Rhinorrhea is the medical term for a runny nose.
difficulty with swallow-
ing?"
B "Have you ever no-
ticed any unusual le-
sions on the inside of
your mouth?"
C "Do you experience
nosebleeds?"
D "Do you experience
a runny nose frequent-
ly?"
114. On examination of the A

mouth of an Ameri-
can Indian, the examin- Bifid uvula is a condition in which the uvula is split
er notices the presence either completely or partially. This condition occurs
of a bifid uvula. How in 18% of individuals in some American Indian
should this finding be groups.
interpreted? Bifid uvula may indicate a submucous cleft palate.
45 / 47
A This is an expect- Bifid uvula is not associated with oral cancer.
ed variation associated The incidence of bifid uvula is common in Ameri-
with this individual. can Indians.
B This condition is fre-
quently associated with
cleft palate.
C This may indicate the
presence of oral can-
cer.
D This is rare and indi-
cates other congenital
anomalies may be pre-
sent.
115. An enlarged tongue C

(macroglossia) may ac-
company: Macroglossia occurs with Down syndrome; it
A cleft palate. also occurs with cretinism, myxedema, and
B hairy tongue. acromegaly. A transient swelling also occurs with
C Down syndrome. local infections.
D fissured tongue.
116. One of the purposes of A

the paranasal sinuses
is to: The paranasal sinuses lighten the weight of the
A lighten the weight of skull bones.
the skull bones. Nasal mucosa and nasal turbinates warm, humid-
B warm and moisten ify, and filter the inhaled air.
the inspired air. The paranasal sinuses serve as resonators for
C amplify sound. sound production.
D augment the sensory Olfactory receptors (responsible for the sensation
sensation of smell. of smell) are located in the nasal cavity and septum
and merge into the olfactory nerve.
117. The duct in the parotid C

gland that opens into
the mouth opposite the The duct in the parotid gland is the Stensen duct;
second molar is: it runs forward to open on the buccal mucosa op-
A the Wharton duct. posite the second molar.
46 / 47
B the salivary duct. The Wharton duct (for the submandibular gland)
C the Stensen duct. runs up and forward to the floor of the mouth and
D the sublingual duct. opens at either side of the frenulum.
The mouth contains three pairs of salivary glands,
which are the parotid gland, the submandibular
gland, and the sublingual gland.
The sublingual gland lies within the floor of the
mouth under the tongue.

pairs of sinuses is ab-
sent at birth, is fair- The frontal sinuses are absent at birth, are fairly
ly well developed be- well developed between 7 and 8 years of age, and
tween 7 and 8 years of reach full size after puberty.
age, and is fully devel- The maxillary sinuses are present at birth and
oped after puberty? reach full size after all permanent teeth have erupt-
A Maxillary ed.
B Frontal The sphenoid sinuses are minute at birth and de-
C Sphenoid velop after puberty.
D Ethmoid The ethmoid sinuses are present at birth and grow
rapidly between 6 and 8 years of age and after
puberty.
119. What is the major cause A

of decreased saliva pro-
duction in older adults? The major cause of decreased saliva flow is the
A Use of anticholiner- use of medications that have anticholinergic ef-
gic medications fects.
B Normal aging Normal aging is a secondary cause of decreased
process saliva flow.
C Decreased fluid in- Decreased fluid intake is not the major cause of
take decreased saliva production in an older adult.
D A diminished sense Diminished sense of taste and smell associated
of taste and smell with aging may decrease an older adult's interest
in food and may contribute to malnutrition.
47 / 47

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Health Assessment NCLEX Questions

Study online at https://quizlet.com/_1gzu9m

1. According to the holis- B

2. What type of data- C

5. What type of database D

6. Which of the following A

10. A patient admitted to C

11. Each culture has its C

12. While evaluating the C

13. On the basis of median C

14. Spirituality is defined B

15. Which of the follow- A

16. What is the yin/yang A

17. Which theory has been B

18. Which of the following B

19. When considering cul- A, C, D, E

20. When preparing the C

21. Parents or caretakers B

22. Which of the following D

23. While discussing the C

25. When addressing a tod- C

26. Nonverbal communica- A

27. Viewing the world from B

29. The most appropriate A

30. Which of the follow- D

31. A patient seeks C

32. The CAGE test is C

33. The "review of sys- A

34. When recording infor- C

35. Assessment of self-es- A

36. PQRSTU is a mnemonic C

37. The nurse questions B

38. When taking a health C

39. What information is in- A

40. To examine a toddler, A

41. Deep palpation is used A

42. Amplitude is: A

43. The dorsa of the hands B

44. Fine tactile discrimina- B

45. A funduscopic exami- A

47. When performing per- B

48. At the end of the ex- D

49. The examiner should A

50. The general survey C

52. Data collection for the A

53. The Doppler technique: B

54. The tympanic mem- A

55. Endogenous obesity is: B

57. Physical appearance B

58. An adult patient's pulse B

60. Pain signals are carried B

61. Which of the following B

62. Which of the follow- A

63. What occurs during A

65. Neuropathic pain im- B

66. What is the source of B

67. Which of the following B

68. Specialized nerve end- C

69. An older adult patient B

70. When taking the health D

71. A flat macular hemor- A

72. A student nurse has D

73. Functions of the skin D