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Exam 2 HA questions - practice question for exam 1
Health Assessment II (NR-304)
Chamberlain University
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Exam 2 Health Assessment and Physical Examination
- A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygen? Clubbing of the fingers
- A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? Barrel
- A home health nurse visits a client who has COPD and receives oxygen at 2 liters per minute via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following nursing actions is the priority at this time? Evaluate/assess the client's respiratory status.
- A newborn infant is in the clinic for a well-baby check. The nurse observes the infant for the possibly of fluid loss because of which of these factors? The newborn skin is more permeable than that of the adult.
- A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? Color variation
- What is the test for skin turgor used to assess on a patient?
Capillary refill
- What test are done to see if the patient is dehydrated? Capillary refill, skin turgor, inspect mucous and tongue?
- The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? Wheezes
- A teenage patient/or client comes to the emergency room with complaints of an inability to "breathe and a sharp pain in my left chest." Your assessment findings include the following: Cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. This description is consistent with?
A pneumothorax 10. An African American is in the intensive care unit bring treated for hematocrit shock for an accident. Ashen gray 11. The nurse conducting an otoscopic examination visualization of the ear drum that is shiny and pearl grey in color. Normal Tympanic Membrane 12. A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? Conjunctivae 13. The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: Papule 14. Before insertion of the otoscope speculum in the ear of an adult client, the nurse would pull the pinna which direction Up and back
15 performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should Consider this a normal finding. 16. A client’s laboratory data reveal an elevated thyroxine (t4) level. Which structure is the priority for the nurse to assess? Thyroid 17. During an assessment of a client with a two-day history of nausea and vomiting the nurse notices pink and moist oral mucosa. Norma oral assessment 18 nurse is assessing a 3-year-old for drainage from the nose. On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? Perform an otoscopic/internal examination of the left nares.
28 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? Nerve degeneration in the inner ear
- The nurse is beginning an assessment on a pregnant client which assessment finding would the nurse document as normal. Dysphasia/epistaxis
- The nurse is beginning the respiratory assessment of an 87-year-old client what would the nurse consider a normal finding. Decreased mobility of the thorax. 31 client is being seen in the clinic for complaints of a cough that is associated with rust- colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: Tuberculosis
- A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? Briefly ask specific questions about this episode of respiratory distress. 33 auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? Inspiratory crackles at the bases
34 performing a respiratory assessment which findings will the nurse document as normal? Decrease vital capacity in a 70-year old client, the client is alert and cooperative, a pregnant client who states that she needs to “sit up straight to breathe better”
35 nurse instructs a client to breathe deeply to open collapsed alveoli. What should the nurse include in the explanation of the relationship between alveoli and improved oxygenation?
Oxygen is exchanged for carbon dioxide in the alveolar membrane. 36 nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. side-to-side
The nurse is caring for a child with a tracheostomy. What clinical manifestation should the nurse recognize as an early sign of impending respiratory distress or failure? Restlessness
A nurse is assessing accommodation to a client what findings should the nurse expect. Asymmetric movement of the eyes, Bilateral pupillary construction, nystagmus in extreme lateral gaze
A school nurse is performing eye testing on children at a local daycare center. When examining a 2-year old child, the school nurse suspects the child has strabismus. Which assessment should the nurse perform to confirm strabismus? Perform corneal light reflux test perform the cover test
A nurse is reinforcing teaching about self-care with a pt. who has pelvic inflammatory disease. the pt. does not speak English, what action by the nurse is appropriate. seek assistance from a facility-approved interpreter.
Pressure Injuries --- Do not blanch Stage I Non- blanchable erythema- intact skin is red but unbroken- Dark skin appears darker but does not blanch. May have changes in sensation, tempt, or firmness. 42. Question on this - Stage II- Partial thickness- loss epidermis exposed dermis superficial ulcer looks shallow like an abrasion or open blister with red and pink. No visible fat or deeper tissue. *Stage III – Full- thickness skin loss – extends into subcutaneous tissue. *Stage IV- Full thickness skin/ tissue loss
*Fissure – Cracked skin around mouth of patient
A nurse is discussion the skin functions with a client, select all that apply. Identification
bradypnea 53. A nurse is performing the Weber test on a client. What would be consider the normal finding? Sound heard equally as long by bone conduction as by the air conduction 54. A client presents to the client with complaints of middle ear pressure and fever that started yesterday upon assessment the nurse notes that the eardrum is red and bulging. Acute Otitis Media
A client presents to the clinic with a lesion on the ear that will not heal, upon assessment the nurse notice ulcerated, crusted nodule with an indurated base on the pinna of the right ear. Carcinoma
A client presents to the clinic with paralysis noted to the left side of the face. Bells Palsy or stroke?
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client’s potential allergies during which phase of the nursing process? Assessment
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication? The client's sociocultural background influences nonverbal communication
A nurse is admitting a client from a long-term care facility. The nurse should use close-ended questions when assessing which of the following factors? When asking if the client took his medications this morning
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Exam 2 HA questions - practice question for exam 1
Course: Health Assessment II (NR-304)
University: Chamberlain University
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