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HEALTH ASSESSMENT FINAL EXAM
PRACTICE EXAM WITH CORRECT ACTUAL
QUESTIONS AND CORRECTLY WELL
DEFINED ANSWERS LATEST 2025 ALREADY
GRADED A+
When assessing a female client's LOC & orientation, the RN notes that she is alert, knows her name, where she is and the time of day. The clientis able to explain why she is in the hospital. How should the RN document these assessment findings?
a.A&O X b.Altered LOC c.A&O X d.A&O X2 - ANSWERS-c.A&O X
What should the nurse include when educating a male client about testicular self exam (TSE)?
a.Perform TSE prior to taking a shower b.If you note an enlarged testicle or lump, notify your healthcare provider c.The testicle should feel lumpy d.Perform TSE weekly - ANSWERS-b.If you note an enlarged testicle or lump, notify your healthcare provider
Which of the following may be auscultated during the abdominal assessment? Select all that apply
a.Vascular Sounds b.Pulsations below the xiphoid c.Referred pain d.Bowel Sounds - ANSWERS-a.Vascular Sounds
d.Bowel Sounds
When auscultating bowel sounds, the nurse knows:
a.It is normal to inspect pulsations in thin clients b.Palpation should precede auscultation c.The bell of the stethoscope should be used
a.Petechiae b.Pruritis c.Herpes zoster d.Psoriasis - ANSWERS-a. Petechiae
A 65-year-old man with emphysema has come to the clinic for a follow-up appt. On assessment of the skin, the nurse might expect to assess the following:
a.Jaundice b.Senile angiomas c.Herpes zoster d.Clubbing of the nails - ANSWERS-d. Clubbing of the nails
A mother presents with her son, who has been in a new day care facility. On examination the nurse assesses moist, thin vesicles with an erythematous base around the nose and mouth. The nurse suspects:
a.Eczema b.Impetigo c.Herpes zoster d.Dermatitis - ANSWERS-b. Impetigo
A healthcare provider has diagnosed a client with purpura. The nurse knows this is:
a.Blue dilation of blood vessels in a star-shaped linear pattern on the legs b.Fiery red star-shaped markings on the cheek with a solid center c.Confluent & extensive patches of petechiae d.Tiny little areas of hemorrhage less than 2 mm, round & discrete - ANSWERS-c. Confluent & extensive patches of petechiae
During assessment of the lower extremities of a male client the nurse is unable to palpate the dorsalis pedis pulse. What action should the nurse take first? a. Notify the Physician b. Return in a few hours and reassess c. Ask the client if this is "normal" for him d. Reposition the fingers and assess again - ANSWERS-C. Ask the Client if this is normal
An example of objective data obtained during the physical assessment includes: Select all that apply
a.Sore throat
c.Leaves interactions neutral d.Calls for short one-to two-word answers e.Used when narrative information is needed - ANSWERS-b.Builds & enhances rapport
e.Used when narrative information is needed
Match the following: 1)Tiny punctuate hemorrhages 2)A large patch of capillary bleeding into tissues 3)A hypertrophic scar 4)Elevated cavity containing free fluid up to 1 cm 5)Variations of hyperpigmentation 6)Solid, elevated, hard or soft lesion larger than 1 cm
___Lentigine ___Petechiae ___Nodule ___Keloid ___Vesicle ___Ecchymosis - ANSWERS-___Lentigine
___Petechiae ___Nodule ___Keloid ___Vesicle ___Ecchymosis
A nurse is assessing a client admitted with congestive heart failure (CHF) for edema. The nurse assesses the following in dependent parts of the body. - when applying pressure there is a dent in the skin that lasts a very long time. The nurse should document this as:
a.1+ - (2mm depth) b.2+ - (4mm depth) c.3+ - (6mm depth) d.4+ - (8mm depth) - ANSWERS-d. 4+ - (8mm depth)
The nurse is performing a skin assessment on a client & assesses the skin for turgor. The nurse grasps a fold of skin in which body area to best assess?
a.Back of the hand b.Sternal area c.Top of foot d.Sacral area
b.Decreased tactile fremitus c.Hypertrophied neck muscles d.Anterior/posterior-to transverse diameter of 1: e.Tripod positioning - ANSWERS-c.Hypertrophied neck muscles
d.Anterior/posterior-to transversediameter of 1:
e.Tripod positioning
Where will the nurse place the stethoscope to auscultate the apices of the Lungs?
- ANSWERS-Anterior-Above our Clavicles
Posterior - Very high up
During palpation of the anterior chest wall, the nurse palpates a coarse crackling sensation over the skin surface. The nurse suspects:
a.Tactile fremitus b.Friction rub c.Crepitus d.Adventitious sounds - ANSWERS-c. Crepitus
An adult client with a history of allergies comes to the clinic with c/o wheezing and dyspnea. The assessment reveals nasal flaring, use of accessory muscles and tachypnea. This description is consistent with?
a.Atelectasis b.Lobar pneumonia c.Asthma d.CHF - ANSWERS-c.Asthma
A nurse is performing a lung assessment on a client diagnosed w/ RLL pneumonia. The client is asked to say "eee" & through the stethoscope the nurse hears an "aaa" sound over the RLL. What term should be used to document the finding?
a.Tactile fremitus b.Egophony c.Bronchophony d.Whispered pectoriloquy - ANSWERS-b. Egophony
During percussion, the nurse knows that a resonant percussion tone over a lung lobe most likely results from:
a.Shallow breathing b.Normal lung tissue
a.Palpate the artery in the upper neck at the angle of the jaw b.Palpate the arteries simultaneously c.Instruct the pt. to take slow deep breaths during auscultation d.Listen w/the bell of the stethoscope to assess for bruit - ANSWERS-d. Listen w/the bell of the stethoscope to assess for bruit
The nurse notes documentation that a client's peripheral pulses are 2+. The nurse determines that the pulses are:
a.Bounding b.Absent c.Normal d.Weak - ANSWERS-c. Normal
A 67-year-old client states he recently began to have pain in his left calf when climbing 10 stairs to his apartment. The pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. This client is most likely experiencing:
a.Thrombophlebitis b.Arterial obstruction (claudication) c.Paresthesia d.Venous insufficiency - ANSWERS-b. Arterial obstruction (claudication)
On inspection of a client's leg the nurse notes an ulcer on the lateral ankle with drainage. The nurse knows this could be :
a.A varicosity b.A venous stasis ulcer c. An arterial ulcer d.Pitting edema - ANSWERS-b. A venous stasis ulcer
Hypothyroidism can have the following signs and symptoms: Select all that apply
a.Dry skin b.Dry hair c.Tachycardia d.Exophthalmos e.Bradycardia - ANSWERS-a.Dry skin
b.Dry hair
e.Bradycardia
d.A rectal abscess - ANSWERS-c.Hemorrhoids
A client recovering from an open reduction of the humerus states, "I haven't been able to extend the fingers on my hand since this morning."What action should the RN take next?
a.Massage the fingers b.Administer prescribed analgesics c.Elevate the arm to prevent edema d.Assess CMS with the 5 P's - ANSWERS-d. Assess CMS with the 5 P's
A client in the ICU develops pre-renal failure following surgery. Which of the following causes should the RN suspect?
a.Vascular Disease b.Urethral obstruction c.Hypovolemia d.Glomerulonephritis - ANSWERS-c. Hypovolemia
The nurse has just recorded, guarding of the abdomen, positive Blumberg& Psoas signs in a client. The nurse suspects:
a.Perforated spleen
b.Enlarged gallbladder c.Hepatitis d.Appendicitis - ANSWERS-d.Appendicitis
The nurse assesses a positive Murphy's sign in the client brought to the unit from the ED. The nurse continues with the assessment and begins the POC, which would most likely include:
a.A report to the healthcare providerregarding the diagnosis of appendicitis b.Expecting that this client will be placed on a general diet c.Expecting that this client will be NPO for upcoming surgery to remove the gallbladder (cholecystectomy) d.Measuring of the abdominal girth for ascites - ANSWERS-c. Expecting that this client will be NPO for upcoming surgery to remove the gallbladder (cholecystectomy)
The Advanced Practice Nurse (APN) is performing a clinical breast exam (CBE) on a female client. Which of the following will the nurse include?
a.Do not include palpation of the axilla in the exam
b.Palpate the 4 quadrants in a systematic manner
c.Palpate only if there is pain
The nurse is caring for a client s/p hip arthroplasty. Which of the following interventions should the nurse include in the client's plan of care (POC)?
a.Flex the operative hip 90 degrees b.Abduct the operative hip c.Adduct the operative hip d.Turn 45 degrees to the operative side - ANSWERS-b. Abduct the operative hip
Which of the following are age-related changes found in the musculoskeletal system of the older adult:
a.Decreased height b.Progressive decrease in reaction time c.Slight flexion of the hips and knees d.Decreased ROM and flexibility e.Kyphosis f.Altered gait g.Changes in the normal angle of the hip, decreased abduction h.All of the above - ANSWERS-h.All of the above
Which of the following is a normal finding in the abdominal assessment?
a.The presence of a bruit b.A tympanic percussion tone c.A palpable spleen d.A resonant percussion tone - ANSWERS-b. A tympanic percussion tone
A clientis complaining of new-onset calf & foot pain. The nurse notes that the leg below the knee is cool & pale. The dorsalis pedis & posterior-tibial pulses are assessed as "0" w/ palpation and "0" following validation with a Doppler. The priority nursing intervention is:
a.Place a cradle over the bed to prevent pressure from bedding b.Elevate the leg c.Massage the leg d.Notify the healthcare provider immediately - ANSWERS-d. Notify the healthcare provider immediately
The RN is performing a Romberg test to assess cerebellar function. A negative Romberg is:
a.Maintaining balance with feet together & eyes closed for 20-30 seconds without support b.Maintaining balance when sitting with eyes closed c.Maintaining balance with feet separated & eyes closed while standing
