NCLEX Questions: Health History and Physical Assessment Vol. 1.

NCLEX QUESTIONS: HEALTH HISTORY AND PHYSICAL ASSESSMENT VOL. 1

Dr. Evelyn J. Biluk Copyright Dr. Evelyn J. Biluk 2012 Published by Dr. Evelyn J. Biluk Publishing at Smashwords Smashwords License Statement This ebook is licensed for your personal enjoyment only. This ebook may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each reader. If you’re reading this book and did not purchase it, or it was not purchased for your use only, then please return to Smashwords.com and purchase your own copy. Thank you for respecting the hard work of this author.

Table of Contents

Health History Physical Assessment Physical Assessment: Preparation Health Assessment: Techniques Health Assessment: General Survey Health Assessment: Vital Signs Health Assessment: Nutrition Status Health Assessment: Skin Health Assessment: Hair Health Assessment: Nails Health Assessment: Head Health Assessment: Eyes Health Assessment: Ears

Health Assessment: Sinuses and Nose

Health History

What is the first step of patient assessment? a. Interpret physical data b. Decide on necessary interventions c. Assess current health status d. Collect subjective information regarding patient’s health history Answer: d

What kind of data is collected during the health history? a. Age, sex, marital status b. Biographical information c. History of present illness or condition d. Patient reason for seeking health care Answer: a, b, c, d

When gathering a health history, which of the following is part of the past health history of a patient? a. Genogram b. Medical history c. Surgical history d. Medications e. Communicable diseases Answer: b, c, d, e

All of the following are also part of the past health history except?

a. Sexual history b. Allergies c. Injuries and/or accidents d. Disabilities and/or handicaps e. Blood transfusions, childhood illnesses and immunizations Answer: a

Which of the following is included in the family health history of a client? a. Familial diseases b. Genetic diseases c. Genogram d. Religion Answer: a, b, c

Taking a social history of a client is an important part of a health assessment.

What should it include? a. Alcohol, tobacco and drug use b. Travel history and work environment c. Home environment and hobbies/leisure activities d. Stressors e. Education Answer: a, b, c, d, e

What else should the social history include besides those mentioned in the previous question? a. Economic status b. Military service c. Religion and culture d. Roles and relationships e. Sexual history and patterns of daily living

Answer: a, b, c, d, e

Lastly, a health maintenance history should be taken. What should it include? a. Sleep and diet b. Exercise and stress management c. Safety practices d. Patterns of healthcare practices e. Review of systems Answer: a, b, c, d, e

Physical Assessment

Select the purpose of performing a physical assessment on a patient. a. To assess the patient’s current health status b. To interpret the physical data c. To decide on interventions based on the data collected d. To cover any areas not sufficiently covered during the health history interview Answer: a, b, c

Physical Assessment: Preparation

Before beginning a physical assessment, what types of equipment are needed? a. Ophthalmoscope and tuning fork b. Cotton swabs and Snellen eye chart c. Thermometer and penlight d. Tongue depressor and ruler/tape measure

e. Safety pin, balance scale and gloves f. Nasal speculum and vaginal speculum Answer: a, b, c, d, e, f

Where should a physical assessment be conducted? a. In a quiet environment b. In a well-lit environment c. In a private room d. All of these choices Answer: d

What considerations need to be taken into account before the physical assessment begins? a. Explain the procedure to the client b. Ask client to empty bladder c. Drape client for privacy d. All of these choices Answer: d

What considerations apply to the nurse/healthcare provider before the physical assessment begins? a. To remember to use a piece of equipment for the entire assessment and then return to equipment tray b. To make use of the teaching opportunities that may occur during the exam (such as dental care during examination of the oral cavity) c. To remember to compare findings on one side of the body with the other d. To remember to compare findings with normal e. To remember to take care of bad breath before starting exam Answer: a, b, c, d

Health Assessment: Techniques

What is the correct sequence for performing a health assessment (not an abdominal assessment)? a. Inspection, Palpation, Percussion, Auscultation b. Auscultation, Inspection, Palpation, Percussion c. Inspection, Percussion, Auscultation, Palpation d. Auscultation, Interaction, Inspection, Palpation Answer: a

What is the correct order for performing an abdominal assessment? a. Inspection, Auscultation, Percussion, Palpation b. Inspection, Palpation, Percussion, Auscultation c. Palpation, Percussion, Auscultation, Inspection d. Auscultation, Palpation, Percussion, Inspection Answer: a

A visual inspection involves determining _____. a. size and shape b. color and texture c. symmetry and position d. All of these choices Answer: d

What does palpation refer to? a. Tapping the patient b. Listening to lung sounds

c. Listening to heart sounds d. Touching the patient Answer: d Which of the following is not necessary during palpation? a. Warm hands before touching the client b. Approach slowly but proceed systematically c. Use the dorsum of fingers for temperature but the palm or ulnar edge for vibration d. Start with light palpation and proceed to deep palpation e. Use your sense of smell to determine if an infection may be present Answer: e

What is ballottement? a. Pushing fluid-filled tissue towards the palpating hand so the object floats against the fingertips b. Pushing fluid-filled tissue against the palpating hand so the object floats towards the fingertips c. Using a reflex hammer to check deep tendon reflexes d. Using blunt percussion with fist to assess CVA tenderness Answer: a

Palpation involves determining _______. a. masses, pulsation and organ size b. tenderness/pain, swelling and tissue fullness/elasticity c. vibration, crepitus and temperature d. texture and moisture e. All of these choices Answer: e

Percussion involves ______. a. tapping to produce sound and vibration b. using a bell to listen to low-pitched sounds c. using fingertips for fine touch d. tapping to produce abnormal breathing rhythms Answer: a

Select the incorrect pairing. a. Direct percussion : Strike body surface with 1 or 2 fingers b. Indirect percussion : Strike finger or hand placed over body surface c. Blunt percussion : Use reflex hammer to check deep tendon reflexes d. Blunt percussion : Use dorsum of fingers to assess CVA tenderness Answer: d

A percussion sound associated with very dense tissue that is very soft, highpitched sound of short duration. a. Resonance b. Hyperresonance c. Flat d. Dull Answer: c A percussion sound associated with dense, fluid-filled tissue that is soft, muffled and moderate to high-pitched sound of short duration. a. Tympany b. Dull c. Resonance d. Light Answer: b

A percussion sound associated with enclosed, air-filled structure that is loud, drum-like, high-pitched sound of moderately long duration. a. Resonance b. Hyperresonace c. Tympany d. Dull Answer: c

A percussion sound associated with air-filled tissue that is moderate to loud, low-pitched sound of moderate duration. a. Hyporesonance b. Resonance c. Hyperresonance d. Sharp e. Dull Answer: b

Hyperresonance is a loud, booming low-pitched sound of longer duration found ______. a. with overinflated air-filled tissue b. with pulmonary emphysema c. in children normally d. All of these choices Answer: d

Auscultation is _____. a. listening to sounds b. listening to vibrations

c. producing sounds d. producing vibrations Answer: a

This part of the stethoscope is used to listen to high-pitched sounds. a. Rubber tubing b. Diaphragm c. Bell d. Speculum Answer: b

This part of the stethoscope is used to listen to soft, low-pitched sounds. a. Speculum b. Bell c. Rubber tubing d. Condenser Answer: b

Health Assessment: General Survey

During the physical assessment, which of the following is not included in the finds of general appearance of a client? a. Signs of distress b. Apparent age c. Sex d. Racial and ethnic groups e. Apparent state of health f. Proportionate height and weight g. Posture

h. Gait, movements, ROM i. Suitable clothing j. Hygiene k. Body and breath odor l. Skin color and condition m. Presence of assistive devices, hearing aid, glasses Answer: a

In terms of general behavior, what should be evaluated? a. Sexual attitude b. Signs of distress c. Level of consciousness d. Mood e. Speech f. Level of cooperation g. Eye contact h. Appropriate thought process Answer: b, c, d, e, f, g, h

Health Assessment: Vital Signs

Select the vital signs that are measure during a health assessment. a. Respiratory rate b. Kidney function c. Pulse rate d. Blood pressure e. Fasting glucose level Answer: a, c, d

Select the incorrect statement. a. The normal respiratory rate for a newborn is 30-60 per minute. b. The normal respiratory rate for a 1-4 year old is 20-40 per minute. c. The normal respiratory rate for a 5-12 year old is 15-25 per minute. d. The normal respiratory rate for an adult is 12-20 per minute. e. Factors that influence respiration include cardiac output, peripheral resistance and disease.

Answer: e

Select the incorrect statement. a. The normal pulse rate of an adult is 60-100 bpm. b. The normal pulse rate of a 5-12 year old is 70-115 bpm. c. The normal pulse rate of a 1-4 year old is 80-140 bpm. d. The normal pulse rate of a new born is 90-120 bpm. e. Factors that influence pulse rate include drugs, pathology, exercise, age, gender, temperature, BP and serum electrolytes.

Answer: d

Select the incorrect statement. a. The normal BP of a 1-4 year old is 90-99/50-59 mm Hg. b. The normal BP of a newborn is 65/41 mm Hg. c. The normal BP of an adult is less than 120/80 mm Hg. d. The normal BP of a 5-12 year old is 100-110/56-60 mm Hg. e. Factors that influence BP includes age, weight, exercise, blood viscosity, blood volume, arterial elasticity, disease, drugs, anxiety, cardiac output and peripheral resistance.

Answer: a

Where is an infant’s temperature taken? a. Oral cavity

b. Anal cavity c. Axillary region d. External auditory canal Answer: c

What is the normal body temperature when it is taken in the oral cavity? a. 94 degrees Fahrenheit b. 37 degrees Celsius c. 100 degrees Fahrenheit d. 36.5 degrees Celsius e. 35 degrees Celsius Answer: b

What is the normal rectal temperature? a. 94 degrees Fahrenheit b. 99.6 degrees Fahrenheit c. 97.6 degrees Fahrenheit d. 35 degrees Celsius e. 38 degrees Celsius Answer: b

What is the normal axillary temperature? a. 36.5 degrees Celsius b. 33 degrees Celsius c. 34 degrees Celsius d. 35.5 degrees Celsius e. 99.8 degrees Fahrenheit Answer: a

Abdominal respirations are accomplished by the _______. a. nervous system and endocrine system b. diaphragm and abdominal muscles c. lumbar plexus and diaphragm d. abdominal muscles only Answer: b

_____ is the temporary cessation of breathing. a. Coma b. Death c. Apnea d. Aphasia e. Ataxia Answer: c

_____ is/are characterized by periodic waxing and waning of the depth of respirations. a. Orthopnea b. Eupnea c. Cheyne-Stokes respirations d. Cyanosis e. Stridor Answer: c

_____ is difficult, labored or painful breathing. a. Hypoventilation b. Hyperventilation c. Dyspnea d. Cough

e. Hyperpnea Answer: c

_____ is abnormally deep breathing. a. Hyperventilation b. Hyperpnea c. Periodic breathing d. Apnea e. Kussmaul’s respirations Answer: b

Hyperventilation: a. is defined as abnormally rapid, deep and prolonged breathing b. is caused by CNS disorders, drugs that increase sensitivity of the respiratory center or acute anxiety c. produces respiratory alkalosis due to a reduction in carbon dioxide d. is caused by PNS disorders only e. a, b and c are correct Answer: e

Which of the following conditions is produced by hypoventilation? a. Metabolic acidosis due to an elevation in carbon monoxide b. Respiratory acidosis due to an elevation in carbon dioxide c. Metabolic alkalosis due to a decrease in nitric oxide d. Respiratory alkalosis due to increased vomiting and diarrhea Answer: b

Kussmaul’s respirations are characterized by a _____.

a. marked decrease in depth of respirations b. marked decrease in the rate of respirations c. marked increase in the irregularity of respirations d. marked increase in the depth and rate of respirations Answer: d

_____ is the inability to breathe except when the trunk is in an upright position. a. Asthma b. COPD c. Orthopnea d. Emmetropia e. Stridor Answer: c

Paradoxical respirations are defined as the _____. a. breathing pattern in which a lung deflates during inspiration b. breathing pattern in which both lungs deflate during expiration c. breathing pattern that occurs when large amounts of antidepressants are consumed d. breathing pattern that occurs after extreme physical exertion e. None of these choices Answer: a

Periodic breathing occurs when the _____ changes markedly from one interval to the next. a. tidal volume b. depth c. rate d. A, B or C are correct

Answer: d

During cyanosis, the skin appears _____ because of an excessive accumulation of unoxygenated hemoglobin in the blood. a. pink b. blue c. white d. yellow Answer: b

_____ is a harsh, high-pitched sound associated with airway obstruction near larynx. a. Cough b. Stridor c. Ptosis d. Choking e. Hiccupping Answer: b

A cough is _____. a. a normal reflex b. allows us to remove foreign material from the lungs c. is normally present in newborns d. is normally absent in newborns e. A, B, and C are correct Answer: e

A client’s BP should be checked in _____.

a. the left arm only since it is closest to the heart b. the right arm only since it is furthest from the heart c. both arms and then a comparison of the results with a difference of 5-10 mm Hg is considered normal d. the right thigh and left thigh Answer: c

Health Assessment: Nutrition Status

What is the ideal body weight for a man? a. 106 lbs for the first 4 feet and then add 10 lbs for each additional inch b. 106 lbs for the first 5 feet and then add 6 lbs for each additional inch c. 100 lbs for the first 5 feet and then add 4 lbs for each additional inch d. 140 lbs for the first 2 feet and then add 5 lbs for each additional inch e. 175 lbs for the first 2 feet and then add 1 lb for each additional inch Answer: b

What is the ideal body weight for a woman? a. 100 lbs for the first 4 feet and then add 4 lbs for each additional inch b. 100 lbs for the first 5 feet and then add 5 lbs for each additional inch c. 125 lbs for the first 3 feet and then add 3 lbs for each additional inch d. 115 lbs for the first 4 feet and then add 4 lbs for each additional inch e. 90 lbs for the first 5 feet and then add 10 lbs for each additional inch Answer: b

If an individual has a large frame, ____ can be added to their ideal weight. a. 1% b. 5% c. 10%

d. 15% e. 20% Answer: c

If an individual has a small frame, _____ can be subtracted from their ideal weight. a. 2% b. 4% c. 8% d. 10% e. 12% Answer: d

Health Assessment: Skin

When examining a client’s skin, what should be checked and/or examined? a. Scars, bruises and lesions b. Pallor (on buccal mucosa or conjunctivae) c. Edema (eyes, sacrum) d. Moisture and hydration e. Texture and turgor f. Cyanosis on nail beds or oral mucosa g. Jaundice on sclera h. All of these choices Answer: h

How is turgor of the skin tested? a. Pinch the skin and tenting for 3 seconds is less is considered normal b. Pinch the skin and wait until it turns purple

c. Pinch the skin and tenting for 5 seconds or more is considered normal d. Pinch the skin and wait for it to turn blue Answer: a

Health Assessment: Hair

Excessive hair growth is referred to as _____. a. alopecia b. hirsutism c. ptosis d. albinism Answer: b

Health Assessment: Nails

Select the incorrect statement. a. The color, shape and contour of nails should be examined. b. The texture and thickness of nails should be examined. c. The capillary test is performed on nail beds of fingers or toes. d. Examination of the nails indicates respiratory and nutritional status. e. None of these statements is incorrect.

Answer: e

Health Assessment: Head

Which of the following should be assessed when examining a client’s head? a. Size

b. Shape c. Symmetry d. Temporal arteries e. Cranial nerve function f. Peripheral nerve function g. Carotid arteries Answer: a, b, c, d, e

Select the incorrect pairing. a. CN I : Have client smell a pungent substance (such as coffee) with eyes closed b. CN II : Test far vision using Snellen chart; Test near vision using a newspaper; Perform ophthalmoscopic examination c. CN IX : Elicit gag reflex; Place salty, sour, sweet and bitter substances on tongue and observe client’s ability to swallow and manage secretions d. CN XII : Inspect client’s tongue; Have client stick out tongue and move it rapidly from side to side; Observe for midline, symmetry and rhythmic movement e. CN VIII : Instruct client to look down, up and inward Answer: e

This cranial nerve is tested using the Rinne and Weber tests. a. CN IV b. CN VI c. CN VIII d. CN IX e. CN X Answer: c

This cranial nerve is has motor branches that assist in pharyngeal movement

and swallowing and sensory branches associated with taste on the posterior 1/3 of the tongue. a. CN I b. CN VII c. CN IX d. CN XI e. CN XII Answer: c

Health Assessment: Eyes

Select the correct mnemonic that relates to examination of the pupils. a. PERRLA b. OOTOMO c. BBTBBR d. CCLTSC Answer: a

A Snellen chart would be useful in determining _____. a. ptosis b. nystagmus c. photophobia d. strabismus e. visual acuity Answer: e

Select the incorrect definition. a. Ptosis is drooping of the upper eyelid. b. Photophobia is light intolerance.

c. Nystagmus is abnormal, involuntary, rapid eye movements. d. Strabismus is involuntary drifting of one eye out of alignment with the other eye. e. None of these choices are incorrect.

Answer: e

What does an ophthalmoscope exam entail? a. Examining the fundus b. Testing the red reflex c. Examining the macula d. Examining the optic disk e. All of these are correct Answer: e

Select the value associated with normal vision. a. 40/40 b. 20/40 c. 30/15 d. 20/20 e. 15/20 Answer: d

What eye changes may occur in the gerontological population? a. Yellow sclera b. Milky-colored ring around the periphery of the cornea c. Increased incidence of floaters d. Cataracts e. Decreased corneal reflex f. Delayed pupil reflex g. Delayed accommodation

h. Presbyopia i. Emmetropia j. Extrinsic eye muscle atrophy Answer: a, b, c, d, e, f, g, h

Health Assessment: Ears

How should child (aged 3 or older) and adult ears be examined? a. They do not need to be examined. b. The pinna is pulled up and back to examine the ears. c. The pinna is pulled down and anterior to examine the ears. d. The pinna remains in a normal, unaltered position to examine the ears.

Answer: b

Upon examination, the tympanic membrane is a cone of light at the _____ position in the right ear and at the _____ position in the left ear. a. six o’clock : six o’clock b. five o’clock : five o’clock c. seven o’clock : nine o’clock d. five o’clock : seven o’clock e. nine o’clock : three o’clock Answer: d

The _____ is used to assess bone conduction. The vibrating tuning fork is placed in the middle of the forehead. A normal finding occurs when sound is heard equally in both ears. a. Rinne test b. Weber test c. Louis test

d. Smith test e. Grey’s test Answer: b

The _____ is used to compare bone conduction with air conduction. A vibrating tuning fork is placed on the mastoid process until the client no longer hears sound and then it is positioned in front of the ear canal. A normal finding is the client should still be able to hear sound in a 2:1 ratio (air conduction to bone conduction). a. Kline test b. Glassman test c. Rinne test d. Linney test e. None of these choices Answer: c

Health Assessment: Sinuses and Nose

Which of the following procedures is used to assess the sinuses? a. Auscultation and inspection b. Palpation and percussion c. Inspection and palpation d. Percussion and auscultation Answer: b

Examining the nose includes evaluating _____. a. the color b. presence/absence of discharge c. its alignment

d. the septum pellucidum e. the septum midline Answer: a, b, c, e