Physical Assessment for Nurses
Test Preparation
Course Introduction
Physical Assessment for Nurses is designed to equip nursing students with the foundational knowledge and practical skills necessary to perform comprehensive health assessments across the lifespan. The course focuses on developing proficiency in collecting health histories, conducting systematic physical examinations, and utilizing assessment findings to formulate nursing judgments. Students will learn techniques for inspection, palpation, percussion, and auscultation, as well as vital sign measurement and documentation. Emphasis is placed on recognizing normal versus abnormal findings, effective communication with patients, and the integration of cultural sensitivity in assessment practices, ultimately preparing students for competent patient care in diverse healthcare settings.
Recommended Textbook
Health Assessment for Nursing Practice 6th Edition by Wilson
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634 Verified Questions
634 Flashcards
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Chapter 1: Introduction to Health Assessment
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14 Verified Questions
14 Flashcards
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Sample Questions
Q1) Which situation illustrates a screening assessment?
A) A patient visits an obstetric clinic for the first time and the nurse conducts a detailed history and physical examination.
B) A hospital sponsors a health fair at a local mall and provides cholesterol and blood pressure checks to mall patrons.
C) The nurse in an urgent care center checks the vital signs of a patient who is complaining of leg pain.
D) A patient newly diagnosed with diabetes mellitus comes to test his fasting blood glucose level.
Answer: B
Q2) The nurse documents which information in the patient's history?
A) The patient's skin feels warm to the touch.
B) The patient is scratching his arm.
C) The patient's temperature is 100° F.
D) The patient complains of itching.
Answer: D
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3
Chapter 2: Obtaining a Health History
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Sample Questions
Q1) A nurse is getting a history from a patient who is disabled from rheumatoid arthritis. Which question will provide data about this patient's functional ability?
A) "When did your arthritis symptoms begin?"
B) "How has your arthritis affected your daily life?"
C) "Why did you come to the clinic today?"
D) "How do you feel about your diagnosis of rheumatoid arthritis?"
Answer: B
Q2) For which patient is a focused health history most appropriate?
A) A new patient at the health clinic for an annual examination
B) A patient admitted to the hospital with vomiting and abdominal pain
C) A patient at the health care provider's office for a sport physical
D) A patient discharged 11 months ago who is being readmitted today
Answer: B
Q3) Which question is an example of an open-ended question?
A) "Have you experienced this pain before?"
B) "Do you have someone to help you at home?"
C) "How many times a day do you use your inhaler?"
D) "What were you doing when you felt the pain?"
Answer: D
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Page 4
Chapter 3: Techniques and Equipment for Physical Assessment
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31 Flashcards
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Sample Questions
Q1) Using an ophthalmoscope, how does the nurse bring a patient's interior eye structures into focus?
A) Using the red filter
B) Adjusting the diopters
C) Dilating the patient's pupils
D) Using the wide-beam light
Answer: B
Q2) A nurse is preparing to take a patient's blood pressure. The blood pressure cuff is 5 inches wide and the patient's upper arm circumference is 20 inches. How accurate will this patient's blood pressure be using this blood pressure cuff?
A) Accurate, the actual value
B) Higher than the actual value
C) Lower than the actual value
D) Unable to determine accuracy with available data
Answer: B
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Chapter 4: General Inspection and Measurement of Vital Signs
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Sample Questions
Q1) Which statement is correct regarding taking or interpreting axillary temperatures?
A) Axillary temperatures should not be used in patients less than 2 years of age.
B) Readings may be less accurate.
C) The thermometer is left in place for no more than 3 minutes.
D) The thermometer is placed in the axilla with the shoulder abducted.
Q2) The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation?
A) The measurement at 6 AM
B) The measurement at 12 PM
C) The measurement at 6 PM
D) The measurement at 12 AM
Q3) Which of these respiratory rates are within normal limits?
A) 16-month-old; 42
B) 6-year-old; 20
C) 14-year-old; 26
D) 40-year-old; 10
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Chapter 5: Cultural Assessment
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Sample Questions
Q1) An Asian woman comes to the clinic with a complaint of back pain. During the history, she tells the nurse that she usually uses acupuncture for her pain. What is the nurse's best response?
A) "When have you used acupuncture, and what effects did it have?"
B) "Acupuncture is good for some problems, but for major illnesses it's best to use medications."
C) "Why did you use acupuncture?"
D) "I have heard that many Asian people use acupuncture."
Q2) Which question is the most appropriate to learn about a patient's religious practices?
A) "How often do you go to church?"
B) "Where is your church located?"
C) "Do you mind telling me about your religion?"
D) "Do you have any specific religious or spiritual practices or beliefs?"
Q3) A nurse can improve cultural awareness with which behavior?
A) Being sensitive to differences between the cultures of the nurse and patient
B) Making generalizations about various ethnic and cultural groups
C) Learning everything about the various cultural groups in the nurse's city
D) Taking a foreign language class
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Page 7
Chapter 6: Pain Assessment
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Sample Questions
Q1) A patient who had an amputation of his lower leg comes to the clinic with a complaint of pain. He asks, "How I can be feeling pain in my foot-my foot is gone?" What is the appropriate response from the nurse?
A) "After your amputation, pain perception increases."
B) "Amputating your leg caused abnormal processing of sensory input by the peripheral nervous system."
C) "Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there."
D) "When sensory nerves enter the spinal cord, they stimulate nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located."
Q2) The nurse notes in the patient's history that the patient has persistent, malignant pain. What is the meaning of this type of pain?
A) The pain has been present for at least 2 weeks.
B) The pain began after recent surgery and is associated with healing incisions.
C) The pain has been present for 6 or more months.
D) The pain has been present since surgery to remove cancer.
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Chapter 7: Mental Health Assessment
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Sample Questions
Q1) During conversation, the nurse observes that the patient is talking continuously and excitedly, and is switching rapidly from one topic to another with seemingly no relationship between topics. This behavior is often associated with which disorder?
A) Depression
B) Obsessive-compulsive disorder
C) Schizophrenia
D) Bipolar disorder
Q2) During a visit to the clinic for an annual gynecologic examination, a patient tells the nurse that she had a bad experience on an airplane, saying, "When I sat down, my heart started racing, I was short of breath and sweaty, and I felt as if I was going to die." She stated that her husband helped her to calm down after a few minutes. The nurse recognizes that the patient was describing which problem?
A) Bipolar disorder, manic phase
B) Moderate anxiety
C) Panic
D) Delusions
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9
Chapter 8: Nutritional Assessment
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Sample Questions
Q1) Which patient needs to be taught about how diet and exercise can lower lipids to reduce the risk for coronary artery disease?
A) A woman with a high-density lipoprotein (HDL) level of 53 mg/dl
B) A man with an HDL level of 43 mg/dl
C) A woman with a low-density lipoprotein (LDL) level of 125 mg/dl
D) A man with an LDL level of 200 mg/dl
Q2) During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema, and suspects a nutritional deficiency. What additional data should the nurse expect to find to confirm the suspicion?
A) Hair loss and hair that is easily removed from the scalp
B) Inflammation of the tongue and fissured tongue
C) Inflammation of peripheral nerves, and numbness and tingling in extremities
D) Fissures and inflammation of the mouth
Q3) Which tool is the best choice for a nurse to use as a quick screening tool to assess a patient's dietary intake?
A) Food diary
B) Calorie count
C) Comprehensive diet history
D) 24-hour recall
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Page 10
Chapter 9: Skin, Hair, and Nails
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Sample Questions
Q1) When performing a skin assessment of an adult patient, the nurse expects what finding?
A) Reddened area does not blanch when gentle pressure is applied.
B) Indentation of the finger remains in the skin after palpation.
C) Flaking or scaling of the skin
D) Return of skin to its original position when pinched up slightly
Q2) A patient complains of itching on her feet. On inspection the nurse observes weeping vesicles and skin that is softened and broken down between the toes. What explanation does the nurse give the patient about the cause of this skin disorder?
A) "Your itching is caused by a bacterial infection."
B) "Your itching is caused by an allergic reaction."
C) "Your itching is caused by a viral infection."
D) "Your itching is caused by a fungal infection."
Q3) A patient expresses concern that a new lesion may be melanoma. Which finding suggests a malignant melanoma?
A) Nonblanching lesion
B) Irregular border
C) Diameter less than 5 mm
D) Black color of the lesion
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Page 11
Chapter 10: Head, Eyes, Ears, Nose, and Throat
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Sample Questions
Q1) During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo?
A) "I felt faint, like I was going to pass out."
B) "I just could not keep my balance when I sat up."
C) "It seemed that the room was spinning around."
D) "I was afraid that I was going to lose consciousness."
Q2) A patient reports a history of snorting cocaine and is concerned about his bloody nasal drainage. What does the nurse expect to see on inspection of his nose?
A) Deviated septum
B) Pale turbinates
C) Perforated nasal septum
D) Localized erythema and edema
Q3) A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action?
A) Document this finding as an abnormal finding.
B) Assess the patient for accommodation.
C) Document this finding as a consensual reaction.
D) Assess the patient's corneal light reflex.
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Chapter 11: Lungs and Respiratory System
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Sample Questions
Q1) A nurse notices a patient's chest wall moving in during inspiration and out during expiration. What additional assessment must the nurse perform immediately?
A) Palpate for tracheal deviation.
B) Auscultate for bronchovesicular breath sounds in the lung periphery.
C) Palpate posterior thoracic muscles for tenderness.
D) Auscultate for absence of breath sounds in the lung periphery.
Q2) Which patient should the nurse assess first?
A) The patient whose respiratory rate is 26 breaths/min and whose trachea deviates to the right.
B) The patient who has pleuritic chest pain, bilateral crackles, a productive cough of yellow sputum, and fever.
C) The patient who is short of breath, using pursed-lip breathing, and in a tripod position.
D) The patient whose respiratory rate is 20 breaths/min, and has eight-word dyspnea and expiratory wheezes.
Q3) A patient tells the nurse that he has smoked 1 \(\frac{1}{2}\) packs of cigarettes a day for 14 years. The number of packs the nurse should record in the medical record is ___ pack-years.
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Chapter 12: Heart and Peripheral Vascular System
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Sample Questions
Q1) Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border?
A) Pulmonic
B) Tricuspid
C) Mitral
D) Aortic
Q2) Which pulse may be a challenge for a nurse to palpate?
A) Temporal
B) Femoral
C) Popliteal
D) Dorsalis pedis
Q3) How is the first heart sound (S1) created?
A) Pulmonic and tricuspid valves close.
B) Mitral and aortic valves close.
C) Aortic and pulmonic valves close.
D) Mitral and tricuspid valves close.
Q4) A patient's blood pressure using the posterior tibial pulse is 104/72 while blood pressure using the brachial pulse is 112/84. This patient's ankle-brachial index is ____.
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Page 14
Chapter 13: Abdomen and Gastrointestinal System
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Sample Questions
Q1) A patient reports having abdominal distention. The nurse notices that the patient's sclerae are yellow. What question is appropriate for the nurse to ask in response to this information?
A) "Has there been a change in your usual pattern of urination?"
B) "Have you had any nausea or vomiting?"
C) "Has there been a change in your bowel habits?"
D) "Have you had indigestion or heartburn?"
Q2) Which patient has the lowest risk for colon cancer?
A) Patient A is 50 years old, is obese, and has type 2 diabetes mellitus.
B) Patient B is 60 years old, has alcoholism, and smokes a pack of cigarettes daily.
C) Patient C is 55 years old, has ulcerative colitis, and inflammatory bowel disease.
D) Patient D is 45 years old and has diverticulosis.
Q3) When inspecting a patient's abdomen, the nurse notes which finding as abnormal?
A) Protruding abdomen with skin that is lighter in color than the arms and legs
B) Marked, widely lateral pulsating mass to the left of the midline
C) Faint, fine vascular network
D) Small shadows created by changes in contour
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Chapter 14: Musculoskeletal System
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Sample Questions
Q1) In assessing a patient with a history of poliomyelitis, the nurse suspects the right leg muscles are smaller than the left leg. What is the best approach for the nurse to confirm or reject this suspicion?
A) Palpating both legs using the pads of the thumb and index fingers and comparing one side with another
B) Using a tape to measure each leg's circumference at the same location, above or below the nearest joint
C) Using a goniometer to measure the upper and lower legs with the patient in supine and standing positions
D) Palpating the legs using the tips of the thumb and index fingers, and comparing the findings with the Lovett scale
Q2) A patient asks, "Why is touching my toes necessary? This is a sports physical examination, not exercise class." What is the most appropriate response by the nurse?
A) "This is the best way to check for symmetry of your arms."
B) "I am looking at the stretch of your hamstrings."
C) "This allows me to see how straight your spinal column is."
D) "I am assessing the flexion of your spine."
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Page 16
Chapter 15: Neurologic System
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Sample Questions
Q1) To complete a symptom analysis, which questions does a nurse ask patient who recently had a seizure for the first time? (Select all that apply.)
A) "Did you have any warning signs before the seizure started?"
B) "Did you lose consciousness during the seizure?"
C) "Did the room seem to be spinning around before the seizure?"
D) "Did you urinate during the seizure?"
E) "What did you hear while you were seizing?"
F) "How did you feel after the seizure?"
Q2) A nurse holds the patient's relaxed left arm, with elbow flexed at a 90-degree angle, in one hand. The nurse palpates and then strikes the appropriate tendon just above the elbow with either end of the reflex hammer. What is the expected response for this deep tendon reflex?
A) Flexion of the left elbow
B) Pronation of the left forearm
C) Supination of the left arm
D) Extension of the left elbow
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Chapter 16: Breasts and Axillae
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Sample Questions
Q1) The nurse notices dimpling of the skin surrounding a palpable mass in the right breast of a female patient. What is the most appropriate action for the nurse to take next?
A) Record this as an expected finding.
B) Palpate the area of dimpling for pain.
C) Palpate the borders of the area of dimpling for irregularity.
D) Tell the patient that dimpling indicates the mass is benign.
Q2) A nurse becomes suspicious that a patient may have breast cancer based on which abnormal finding?
A) An irregularly shaped hard mass in one breast
B) Bilateral, small, nontender nodes close to the surface
C) Multiple rubbery-feeling lumps with well-defined borders
D) A mobile, firm lump located in the upper outer quadrant of the left breast
Q3) The nurse would give immediate attention to the patient who presents with which complaint?
A) Bilateral breast swelling
B) Unilateral nipple discharge
C) A breast lump that changes during the menstrual cycle
D) Unequal breast size
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Page 18
Chapter 17: Reproductive System and the Perineum
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Sample Questions
Q1) How does a nurse recognize when a patient has a testicular torsion?
A) The nurse sees a light red glow on transillumination of the scrotum.
B) The nurse palpates testicular edema that is painless.
C) The patient reports a pulling sensation and dull ache of the scrotum.
D) The patient complains of sudden onset of severe pain with edema of the scrotum.
Q2) While giving a history, a patient reports having a weak urinary stream and feeling that his bladder is not empty after urination. Based on these data, what finding does the nurse anticipate upon examination?
A) An enlarged prostate gland palpated on the anterior wall of the rectum
B) An indirect hernia palpated through the inguinal ring when the patient coughs
C) The foreskin of the penis cannot be returned to position after retraction behind the glans
D) A nodular prostate gland palpated on the posterior wall of the rectum
Q3) The nurse correlates which patient complaint with suspected enlargement of the prostate gland?
A) Constipation
B) Change in bowel patterns
C) Weak urine stream
D) Increased mucus in urine
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Page 19
Chapter 18: Developmental Assessment Throughout the Life Span
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Sample Questions
Q1) Which statement reflects a 21-year-old woman's achievement of an expected developmental task?
A) "I am planning to get married next year."
B) "I don't plan anything without asking my boyfriend first."
C) "I don't know which direction I'll take after college."
D) "I am living with my parents and may stay for a while."
Q2) Which statement best illustrates Erikson's theory of development?
A) The main goal is to establish equilibrium between self and environment.
B) One progresses through stages that involve specific psychosocial tasks.
C) There are four distinct, sequential levels of cognitive development.
D) Cognitive development occurs from birth to around age 15.
Q3) What suggestions does the nurse make to parents to support the development of their 8-year-old child?
A) They buy the child a computer to foster a sense of self-worth.
B) The emphasis is placed on the importance of being a success at all costs.
C) The child is rewarded for cooperation and healthy competition with peers.
D) Social relationships outside the home are limited to one or two close friends.
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Page 20
Chapter 19: Assessment of the Infant, Child, and Adolescent
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Sample Questions
Q1) An American Indian mother expresses concern about an irregularly shaped, dark area over her neonate's sacrum and buttocks. What is the nurse's most appropriate response to this mother?
A) "This area will continue to grow until the infant is 10 to 15 months old."
B) "This is a birth mark, which usually disappears by age 5 years."
C) "This skin abnormality will require follow-up care."
D) "This is a birth mark and they usually disappear by age 1 or 2 years."
Q2) While examining the genitalia of a 6-year-old girl, a nurse notices which finding as expected?
A) Clear mucoid vaginal discharge
B) Prepuce and clitoris are prominent.
C) Flat labia majora with thin labia minora
D) Sparse pubic hair over the inner thighs
Q3) Which finding indicates to a nurse that a neonate has a cephalhematoma?
A) Well-defined edematous area over one cranial bone
B) Molding of the cranium that causes generalized cerebral edema
C) Diffuse edema over two or more cranial bones
D) Anterior fontanelle that is deeply depressed
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Chapter 20: Assessment of the Pregnant Patient
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Sample Questions
Q1) In measuring fundal height, the nurse documents which finding as abnormal?
A) 29 cm at week 30
B) 28 cm at week 26
C) 34 cm at week 38
D) 26 cm at week 24
Q2) A pregnant patient presents to the clinic with a 3 lb/week weight gain for 2 successive weeks. The nurse is most concerned that this patient is demonstrating signs of which condition?
A) Gestational diabetes mellitus
B) Preeclampsia
C) Placenta enlargement
D) Multiple gestations
Q3) The nurse recognizes which clinical manifestation as a positive sign of pregnancy?
A) Cessation of menstruation
B) Visualization of the fetus by ultrasound
C) Nausea and increased abdominal girth
D) Positive pregnancy test (hCG)
Q4) If a patient's last menstrual period was May 13, her estimated date of birth is
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Chapter 21: Assessment of the Older Adult
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Sample Questions
Q1) What expected physiologic changes of aging put older adults at risk for respiratory infections? (Select all that apply.)
A) Breath sounds are bronchovesicular in the peripheral lung.
B) Alveoli are less elastic.
C) Weak intercostal muscles reduce effective coughing.
D) Mucous membranes drier
E) Curvature of the spine limits chest wall expansion.
F) Cough reflex is impaired due to deceased sensitivity of receptors.
Q2) Which finding on cardiovascular assessment of an older adult patient warrants further evaluation?
A) Occasional ectopic beats heard on auscultation of the heart
B) Murmur heard over the mitral valve
C) Systolic pressure of 156 in the right arm and 188 in the left arm
D) Persistent S4 sound in a patient with a history of decreased ventricular function
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Chapter 22: Conducting a Head-to-Toe Examination
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Q1) When does the health assessment begin?
A) When the nurse first meets the patient
B) When the patient tells the nurse his name and age
C) When the nurse asks the patient the first health-related question
D) When the patient consents to have a health assessment performed
Q2) Which techniques does a nurse use routinely to collect data when assessing the abdomen of a patient? (Select all that apply.)
A) Testing for presence of abdominal reflexes
B) Inspecting skin for contour, scars, lesions, vascularity, and bulges
C) Percussing in all quadrants for tone
D) Lightly palpating for tenderness, guarding, and masses
E) Auscultating for bowel sounds, bruits, and venous hums
F) Deeply palpating for tenderness, guarding, and masses
Q3) Which assessments are routine examination techniques of the upper extremities?
A) Palpating the epitrochlear lymph nodes for size and tenderness
B) Palpating the arms for skin characteristics, symmetry, tenderness, and deformities
C) Testing the range of motion and muscle strength comparing one arm with the other
D) Testing triceps, biceps, and brachioradialis deep tendon reflexes bilaterally
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24
Chapter 23: Documenting the Comprehensive Health Assessment
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Sample Questions
Q1) Which data do nurses document under the category of personal and psychosocial health history? (Select all that apply.)
A) Allergies to medications or food
B) Diet and foods eaten on a regular basis
C) Type of employment
D) Address and date of birth
E) Activities that promote health
F) Use of tobacco and alcohol
Q2) Which data do nurses document under the category of past health history?
A) Chronic diseases
B) Immunizations received
C) Allergies to medications or food
D) Causes of death of the patient's parents
Q3) A patient reports she has shortness of breath and peripheral edema. Under which category does the nurse document these data?
A) Review of systems
B) Present health status
C) Past health history
D) Functional ability
25
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Chapter 24: Adapting Health Assessment to the Hospitalized Patient
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Sample Questions
Q1) For which patient does the nurse make assessment of the oral mucous membrane a priority?
A) The patient who has an arteriovenous (AV) fistula
B) The patient who has a gastrostomy tube
C) The patient who uses a Ventimask
D) The patient who has a colostomy
Q2) During the assessment, the nurse determines that the patient's Glasgow Coma Scale score is 15. What is the meaning of this number for this patient?
A) This patient is fully conscious.
B) This patient has movement but does not open the eyes or speak.
C) This patient is unable to respond to any stimuli.
D) This patient opens the eyes but does not speak or move.
Q3) How does a nurse assess perfusion to the foot when a patient has a cast from the left middle calf to the toes?
A) Palpate the popliteal pulse of the left leg.
B) Palpate the posterior tibial pulse of the left leg.
C) Assess movement and sensation of the left toes.
D) Assess the capillary refill of the left toes.
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