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Health Assessment Nclex Questions
Physical Assessment in Healthcare
Keiser University
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Health Assessment NCLEX-Style Review Ques:ons
Chapter 1: Evidence-Based Assessment
What type of database is most appropriate when rapid collec:on of data is required and oHen compiled concurrently with lifesaving measures? a) Complete b) Focused c) Follow-up d) Emergency
A nurse precep:ng a student nurse asks, <What9s the most important step in the cri:cal- thinking process?= a) Clustering subjec:ve and objec:ve data b) Analyzing health data c) Using evidence-based assessment techniques d) Priori:zing health concerns
An example of subjec:ve data is a) decreased range of mo:on. b) crepita:on in the leH knee joint. c) arthri:s. d) le8 knee has been swollen and hot for the past 3 days.
What type of database is most appropriate for an individual who is admiYed to a long-term care facility? a) Focused b) Complete c) Emergency d) Follow-up
Which of the following is an example of objec:ve data? a) A sore throat b) An earache c) Alert and oriented d) Dizziness
An example of objec:ve data is a) a report of impaired mobility from leH knee pain as evidenced by an inability to walk, swelling, and pain on passive range of mo:on. b) a complaint of leH knee pain. c) crepitaBon in the le8 knee joint. d) leH knee has been swollen and hot for the past 3 days.
Which of the following is an example of subjec:ve data? a) Blood glucose 126 md/dL b) Pain rated at 7 out of 10 c) Heart rate of 76 bpm d) Bruising on lower leg
A complete database is a) used to collect data rapidly and is oHen compiled concurrently with lifesaving measures. b) used to evaluate the cause or e:ology of disease. c) used for a limited or short-term problem usually consis:ng of one problem, one cue complex, or one body system. d) used to perform a thorough or comprehensive health history and physical examinaBon.
A pa:ent admiYed to the hospital with asthma has the following problems iden:aed based on an admission health history and physical assessment. Which problem is a arst-level priority? a) Inecec:ve self3health management b) Impaired gas exchange c) Readiness for enhanced spiritual well-being d) Risk for infec:on
Which of the following ac:ons/behaviors in the cri:cal-thinking process are important for the novice nurse to remember? ( Select all that apply. ) ð Disregard ini:al cues ð Approach assessment with a nonjudgmental aJtude ð Cluster associated assessment data ð Perform assessment in whatever manner works for you. ð Avoid making assumpBons
Chapter 2: Cultural Assessment
Each culture has its own healers who usually a) own and operate specialty community clinics. b) cost less than tradiBonal or biomedical providers. c) recommend folk prac:ces that are dangerous. d) speak at least two languages.
While evalua:ng the health history, the nurse determines that the pa:ent subscribes to the hot/cold theory of health. Which of the following would most likely describe this pa:ent9s view of wellness? a) The phlegm will be replaced with dryness. b) The humors must be balanced. c) Good is hot. d) Evil is hot.
When considering cultural competence, the nurse must develop knowledge of discrete areas to understand the health care needs of others. These discrete areas include understanding of ( Select all that apply. ) ð his or her own heritage. ð cultural and ethnic values. ð the heritage of the health care system. ð the heritage of the nursing profession. ð the heritage of the paBent.
Chapter 3: The Interview
When preparing the physical sekng for an interview, the interviewer should a) stand next to the pa:ent to convey a professional demeanor. b) conduct the interview at eye level and at a distance of 4 to 5 feet. c) reduce noise by turning the volume on the television or radio down. d) set the room temperature between 64° F and 66° F.
Parents or caregivers accompany children to the health care sekng. Star:ng at ___ years of age, the interviewer asks the child directly about his or her presen:ng symptoms. a) 11 b) 7 c) 9 d) 5
Which of the following statements made by the interviewer would be an appropriate response? a) <Tell me what you mean by 8bad blood= b) <If I were you, I would have the surgery.= c) <I know just how you feel.= d) <Why did you wait so long to make an appointment?=
While discussing the treatment plan, the nurse infers that the pa:ent is uncomfortable asking the physician for a dicerent treatment because of fear of the physician9s reac:on. In this situa:on, the nurse9s verbal interpreta:on a) impedes further discussion. b) helps the nurse understand his or her own feelings in rela:on to the pa:ent9s verbal message. c) acects the nurse-physician rela:onship. d) helps the paBent understand personal feelings in relaBon to his or her verbal message.
The use of euphemisms to avoid reality or to hide feelings is known as a) avoidance language. b) distancing language. c) sympathe:c language. d) ethnocentric language.
When addressing a toddler during the interview, the health care provider should a) use detailed explana:ons. b) ask the child, before the caregivers, about symptoms. c) use nonverbal communica:on. d) use short, simple, concrete sentences.
Nonverbal communica:on is the primary form of communica:on for which group of individuals? a) Older adults b) Infants c) Preschoolers d) Adolescents
Viewing the world from another person9s inner frame of reference is called a) empathy. b) clariaca:on. c) rejec:on. d) sympathy.
An example of an open-ended ques:on or statement is a) <Tell me about your pain.= b) <You are upset about the level of pain, right?= c) <On a scale of 1 to 10, how would you rate your pain?= d) <I can see that you are quite uncomfortable.=
The most appropriate introduc:on to use to start an interview with an older adult pa:ent is a) <Mr. Jones, I want to ask you some quesBons about your health so that we can plan your care.= b) <David, I am here to ask you ques:ons about your illness; we want to determine what is wrong.= c) <Because so many people have already asked you ques:ons, I will just get the informa:on from the chart.= d) <Mr. Jones, is it okay if I ask you several ques:ons this morning about your health?=
PQRSTU is a mnemonic that helps the nurse remember to address characteris:cs speciac to a) the ability to perform ac:vi:es of daily living (ADLs). b) substance use and abuse. c) pain presentaBon. d) severity of demen:a.
The nurse ques:ons the reliability of the history provided by the pa:ent. One method to verify informa:on within the context of the interview is to a) ask the pa:ent if there is someone who could verify informa:on. b) rephrase the same quesBons later in the interview. c) call a family member to conarm informa:on. d) review previous medical records.
When taking a health history from an adolescent, the interviewer should a) ask every youth about the use of condoms. b) have at least one parent present during the interview. c) ask about violence and abuse before asking about alcohol and drug use. d) interview the youth alone with a parent in the waiBng area.
What informa:on is included in greater detail when taking a health history on an infant? a) Environmental hazards b) History of present illness c) NutriBonal data d) Family history
Chapter 5: Mental Status Assessment
A full mental status examina:on should be completed if the pa:ent a) develops dysphagia. b) has a new diagnosis of type 2 diabetes mellitus. c) complains of insomnia. d) has a change in behavior and the family is concerned.
Aphasia is best described as a) a disturbance in execu:ve func:oning (planning, organizing, sequencing, abstrac:ng). b) a language disturbance in speaking, wriBng, or understanding. c) the impaired ability to recognize or iden:fy objects despite intact sensory func:on. d) the impaired ability to carry out motor ac:vi:es despite intact motor func:on.
A pa:ent in whom a seizure disorder was recently diagnosed plans to con:nue a career as a pilot. At this :me in the interview, the nurse begins to ques:on the pa:ent9s a) thought process. b) intellect. c) judgment. d) percep:on.
A major characteris:c of demen:a is a) hallucina:ons. b) sudden onset of symptoms. c) cogni:ve deacits that are substance-induced. d) impaired short-term and long-term memory.
Mental status assessment documents a) schizophrenia and other mental health disorders. b) ar:s:c or wri:ng ability in the mentally ill person. c) emoBonal and cogniBve funcBoning. d) intelligence and educa:onal level.
Although a full mental status examina:on may not be required for every pa:ent, the health care provider must address the four main components during a health history and physical examina:on. The four components are a) language, orienta:on, aYen:on, and abstract reasoning. b) mood, acect, consciousness, and orienta:on. c) appearance, behavior, cogniBon, and thought processes. d) memory, aYen:on, thought content, and percep:ons.
An older adult a) has a slower response Bme. b) has diminished recent and remote memory recall. c) experiences a 10-point decrease in intelligence. d) has ditculty with problem solving.
Which of the following statements about mental status tes:ng of children is correct? a) The behavioral checklist is useful to assess children who are 3 to 5 years old. b) Input from parents and caregivers is discouraged when assessing psychosocial development. c) The results of the Denver II screening test are valid for white, middle-class children only. d) Abnormal Nndings are usually r/t not achieving an expected developmental milestone.
Which of the following best illustrates an abnormality of thought process? a) Lability b) Compulsion c) Aphasia d) Blocking
One of the most frequently abused prescrip:on opioid pain medica:ons is a) morphine. b) propoxyphene. c) meperidine. d) oxycodone.
A female pa:ent asks the nurse about the safe use of alcohol before and during pregnancy. The best response by the nurse is to instruct the pa:ent to a) reduce alcohol intake before pregnancy and to avoid alcohol aHer a posi:ve pregnancy test. b) limit alcoholic beverages to two or fewer drinks per week during pregnancy. c) talk about alcohol use with the physician. d) avoid alcohol before concepBon and during pregnancy.
Pa:ents should be instructed to consume alcohol in modera:on. To consume at a moderate drinking paYern, a female pa:ent should be instructed to consume no more than a) two drinks per day. b) six drinks per week. c) three drinks per week. d) one drink per day.
If a pa:ent admits not being able to quit drinking, having to have more drinks to get the same ecect, and having withdrawal symptoms, the pa:ent meets criteria for a) harmful drinking. b) at-risk drinking. c) alcohol dependence. d) hazardous drinking.
Which of the following ques:onnaires was designed speciacally to be used when screening older adults for an alcohol use disorder? a) CAGE b) AUDIT c) TWEAK d) SMAST-G
Chapter 7: Domes:c & Family Violence Assessment
- Dehydra:on and malnutri:on can be manifesta:ons of ________________ in older adults. a) physical abuse b) in:mate partner violence c) psychological abuse d) neglect
2.
Increased bruising and bleeding in older adults may be r/t which of the following? a) IngesBon of nonsteroidal anB-in_ammatory drugs b) A reduc:on in the integrity of blood vessels c) Thinning of the skin d) Decreased juid intake
Women and men who have been physically abused are most oHen abused by a) a man with a substance use problem. b) an inBmate male partner. c) a known sex ocender. d) a man convicted of a serious crime.
An extremely important part of the history and examina:on in situa:ons of in:mate partner violence or older adult abuse is the a) mental status examinaBon. b) family genogram. c) history of the present illness. d) skin assessment.
The health care system may help abused women by a) providing anancial and suppor:ve services. b) es:ma:ng the ages of bruises. c) providing shelter from the abusive individual. d) idenBfying abuse in the early stages.
Abused women have been found to have signiacantly more health problems, including a) cardiovascular disease. b) chronic anemia. c) chronic pain. d) cancer.
A woman seeks medical aYen:on for a cut made by a knife during a physical assault. The health care provider would document the cut as an a) incision. b) ecchymosis. c) avulsion. d) abrasion.
The nurse caring for an older adult suspects older adult abuse. Which ac:on is appropriate? a) Confront the caregivers about the suspicion of abuse. b) Collect proof of abuse before no:fying the authori:es. c) Report the abuse if the older adult gives permission. d) NoBfy the authoriBes of the suspected older adult abuse.
6.
An ophthalmoscopic examina:on is an examina:on of the a) pharynx. b) nasal turbinates. c) inner ear. d) internal structures of the eye.
Which of the following is considered when preparing to examine an older adult? a) Avoid physical touch to avoid making the older adult uncomfortable. b) Confusion is a normal, expected anding in an older adult. c) Be aware that loss will result in poor coping mechanisms. d) Base the pace of the examinaBon on the paBent9s needs and abiliBes.
When performing percussion, the examiner a) taps anger:ps over bony processes. b) strikes the staBonary Nnger at the distal interphalangeal joint. c) strikes the jank area with the palm of the hand. d) strikes the sta:onary anger at the proximal interphalangeal joint.
At the end of the examina:on, the examiner should a) compare objec:ve and subjec:ve data for discrepancies. b) have andings conarmed by another provider. c) review the Nndings with the paBent. d) complete documenta:on before leaving the examina:on room.
The examiner should use handwashing instead of an alcohol-based hand rub a) if the pa:ent is HIV posi:ve. b) if the paBent has an infecBon with Clostridium di,cile. c) if the pa:ent has an infec:on with Mycobacterium tuberculosis. d) if the pa:ent has an infec:on with hepa::s B virus.
Chapter 9: General Survey & Measurement
The general survey consists of four dis:nct areas. These areas include a) gait, range of mo:on, mental status, and behavior. b) level of consciousness, personal hygiene, mental status, and physical condi:on. c) physical appearance, body structure, mobility, and behavior. d) mental status, speech, behavior, and mood and acect.
The nurse is comple:ng a general survey assessing the level of consciousness of a person. Which of the following andings are expected in this assessment? a) No signs of acute distress are present
b) Facial features symmetric with movement c) Pa:ent appears drowsy and is having ditculty answering ques:ons. d) PaBent is alert and oriented to person, place, Bme, and situaBon. 3. Data collec:on for the general survey begins a) at the beginning of the physical examina:on. b) at the Nrst encounter. c) while taking vital signs. d) during the mental status examina:on.
Which of the following assessments should be included as part of the body structure por:on of the general survey? a) Sexual development, skin color, and overall appearance b) Gait and range of mo:on c) Facial expression, speech paYern, and dress d) Stature, nutriBon, and symmetry
The nurse documents the following andings for the behavioral por:on of the general survey assessment, <pa:ent demonstrates jat acect, lack of eye contact, hair not brushed, and strong body odor=. The nurse should be concerned that the pa:ent is which of the following? a) Depression b) Bulimia c) Dysarthria d) Seizures
Endogenous obesity is a) characterized by evenly distributed excess body fat. b) due to inadequate secre:on of cor:sol by the adrenal glands. c) caused by excess adrenocorBcotropin (ACTH) producBon by the pituitary gland. d) a result of excessive secre:on of growth hormone in adulthood.
An adult with a body mass index (BMI) less than 18 kg/m 2 is considered which of the following? a) Underweight b) Obesity c) Normal weight d) Overweight
Physical appearance includes statements that compare appearance with a) mood and acect. b) nutri:on. c) gait. d) stated age.
Which of the following would be most appropriate when weighing an infant?
An adult pa:ent9s pulse is 46 beats per minute. The term used to describe this rate is a) weak and thready. b) tachycardia. c) sinus dysrhythmia. d) bradycardia.
The nurse records that the pa:ent9s pulse is 3+ or full and bounding. Which of the following could be the cause? a) Anxiety b) Shock c) Bleeding d) Dehydra:on
Which of the following respiratory rates recorded for an infant without chronic illness would require further interven:ons and assessment by the nurse? a) 27 b) 45 c) 35 d) 30
Which technique would the nurse use to noninvasively assess arterial oxygen satura:on? a) Arterial blood gas b) Pulse oximeter c) Blood Pressure d) Respiratory rate
Which of the following factors control a person9s blood pressure? ( Select all that apply .) ð Cardiac output ð Age ð Emo:ons ð Viscosity ð Vascular resistance
Chapter 11: Pain Assessment
Pain signals are carried to the central nervous system by way of a) percep:on. b) modula:on. c) referred pain. d) aMerent Nbers.
Which of the following is the most reliable indicator for chronic pain? a) Blood drug levels b) PaBent self-report c) Magne:c resonance imaging (MRI) results d) Tissue enzyme levels
Which of the following statements regarding cultural/racial dicerences in the treatment of pain is true? a) NeurotransmiYers are more concentrated in white individuals than in black and Hispanic individuals. b) White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms. c) Pain modula:on is more highly developed in black and Hispanic individuals. d) Black and Hispanic individuals have been found to have a higher pain tolerance than white individuals.
What occurs during transduc:on (the arst phase of nocicep:ve pain)? a) Chemical mediators are neutralized to decrease the percep:on of pain. b) Pain signals move from the site of origin to the spinal cord. c) The brain interprets the pain signal. d) The pain impulse moves from the spinal cord to the brain.
What type of pain is short and self-limi:ng and dissipates aHer the injury heals? a) Acute b) Persistent c) Chronic d) Breakthrough
Neuropathic pain implies an abnormal a) processing of the pain message. b) degree of pain interpreta:on. c) modula:on of pain signals. d) transmission of pain signals.
What is the source of deep soma:c pain? a) Pancreas b) Intes:ne c) Skin and subcutaneous :ssues d) Bones and joints
a) Ethnic b) Economic c) Religious d) Cultural 4. Nutri:onal status is best determined by a) triglycerides. b) 24-hour diet recall. c) serum albumin. d) clinical manifesta:ons.
In order for a weight-loss program to be ecec:ve, what fat intake would be considered a low- fat diet? a) Mostly trans-faYy acid or saturated fat b) Between 20% and 25% of the total calorie intake c) Between 10% and 20% of the total calorie intake d) Less than 300 mg per day
For op:mum health, infants and children up to 2 years of age should receive whole milk. What component of whole milk is essen:al for neurologic development? a) For:aed vitamin D b) Fat c) Pasteurized protein d) Lactose
A comprehensive nutri:onal assessment always includes a) a direct observa:on of feeding and ea:ng processes. b) a comprehensive metabolic panel. c) anthropometric measures. d) a work history.
Which of the following is the most accurate and easy to implement nutri:onal assessment method? a) Food diary b) 24-hour recall c) Food frequency ques:onnaire d) Direct observa:on
Which of the following signs and symptoms would indicate malnutri:on? ( Select all that apply. ) ð Lips cracked and pale pink, tongue beefy red. ð Skin color appropriate for race, intact, without evidence of dryness ð Erect posture with symmetric gait and muscle tone appropriate for age ð Hair dull and dry ð Bleeding gums
Which of the following changes in aging adults acect nutri:onal status? ( Select all that apply. ) ð Increased muscle mass ð Poor denBBon ð Increased saliva produc:on ð Decreased visual acuity ð Slowed GI moBlity
Health Assessment Nclex Questions
Course: Physical Assessment in Healthcare
University: Keiser University
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