Nursing Process and Basic Health Assessment

MULTIPLE CHOICE
1. In assessing the integumentary system, how does one assess skin turgor?
a. Gently pinching the skin under the clavicle.c. Pinch for half an inch
b. Gently pinching the lips. d. Pinch skin for 5 seconds
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$. In assessing for skin temperature, the back of the hands are used. %hich of the following is the
rationale for this procedure?
a. &he back of the hand is more accessible to
the nurse.
c. &he back of the hand is less sensitive to
germs.
b. &he back of the hand is more sensitive to
temperature.
d. &he back of the hand is less noticeable to
the patient.
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(. %hich of the following instruments is used in e)amining the pupils?
a. *ight buld c. Penlight
b. +ye glasses d. ,lashlight
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.. %hich of the following findings upon performing head and neck assessment is abnormal?
a. -onstriction of the pupils in reaction to
light.
c. "kull is tender
b. ,acial e)pression is appropriate d. &ongue is soft and nontender
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5. &his techni/ue can detect enlarged lymph nodes.
a. Inspection and palpation of the
supraclavicular area.
c. Inspection and palpation of the left and
right carotid arteries.
b. Inspection of the client0s ability to move
his head.
d. Palpation of the thyroid gland
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1. %hich of the following is the correct order of doing physical asssessment?
a. Inspection, palpation, percussion,
auscultation
c. Palpation, percussion, inspection,
auscultation
b. Inspection, auscultation, percussion,
palpation.
d. uscultation, percussion, palpation,
inspection.
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2. In assessing patient0s anterior chest, the client is placed in what position?
a. 3orsal recumbent c. 4nee -hest
b. 5ecumbent d. "upine with head elevated
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6. %hich of the following findings is abnormal in assessing the cardiovascular system?
a. 7ugular distention c. !o pulsations over the aortic and pulmonic
areas.
b. 'ruit upon auscultation of the right carotid
artery.
d. 8eart rate of 25 bpm
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9. %hich nursing procedure deters the spread of microorganisms?
a. 3ocumenting findings c. Performing hand hygiene
b. 5epositiong the patient d. 5eplacing patient0s gown
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1:. &he presence of bowel sounds upon the auscultation of the abdomen using the diaphragm of the
stethoscope indicates;;;;;;;;;;;;.
a. Peristalsis c. neurysm
b. 'ruit d. -ardiac overload
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11. %hat is the normal heart rate of an adult?
a. 5:<1:: bpm c. 1:<1(: bpm
b. 1:<1:: bpm d. 1$<$: bpm
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1$. &he following are peripheral pulses checked during cardiovascular assessment, e)cept#
a. 'rachial c. -arotid
b. 3orsalis pedis d. =andibular
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ESSAY
1. 8ow do you assess for rebound tenderness if the patient reports abdominal pain? > (points?
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Press deeply and gently into the abdomen with the hand and fingers downward and then withdrawing
the hand rapidly.
$. In assessing the abdomen, palpation is performed last for what reason?>(points?
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&his assessment techni/ue is performed last because it can cause pain and muscle spasm that could
interfere with the rest of the e)amination.
(. 8ow does one assess for tactile fremitus?> ( points?
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Instruct patient to take a deep breath. @sing the ball of the hands, palpate over the posterior thora)
while the patient says A ninety<nineB.