Physical Assessment for Nurses
Textbook Exam Questions
Course Introduction
This course provides nursing students with a comprehensive foundation in the principles and techniques of physical assessment across the lifespan. Emphasis is placed on the systematic collection of subjective data (health history) and objective data (physical examination skills), including inspection, palpation, percussion, and auscultation. Through lectures, demonstrations, and hands-on practice, students learn to perform thorough head-to-toe assessments, recognize normal and abnormal findings, and document their observations accurately. The course also addresses cultural competence, effective communication with patients, and the critical thinking necessary to integrate assessment findings into individualized care planning.
Recommended Textbook
Physical Examination and Health Assessment 7th Edition by Jarvis
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31 Chapters
1092 Verified Questions
1092 Flashcards
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Chapter 1: Evidence-Based Assessment
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29 Verified Questions
29 Flashcards
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Sample Questions
Q1) Which critical thinking skill helps the nurse see relationships among the data?
A)Validation
B)Clustering related cues
C)Identifying gaps in data
D)Distinguishing relevant from irrelevant
Answer: B
Q2) In the health promotion model,the focus of the health professional includes:
A)Changing the patient's perceptions of disease.
B)Identifying biomedical model interventions.
C)Identifying negative health acts of the consumer.
D)Helping the consumer choose a healthier lifestyle.
Answer: D
Q3) The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain.Which would be the next appropriate action?
A)Establish priorities.
B)Identify expected outcomes.
C)Evaluate the individual's condition, and compare actual outcomes with expected outcomes.
D)Interpret data, and then identify clusters of cues and make inferences.
Answer: C
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Chapter 2: Cultural Competence
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37 Verified Questions
37 Flashcards
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Sample Questions
Q1) The nurse is asking questions about a patient's health beliefs.Which questions are appropriate? Select all that apply.
A)"What is your definition of health?"
B)"Does your family have a history of cancer?"
C)"How do you describe illness?"
D)"What did your mother do to keep you from getting sick?"
E)"Have you ever had any surgeries?"
F)"How do you keep yourself healthy?"
Answer: A,C,D,F
Q2) The nurse is reviewing concepts related to one's heritage and beliefs.The belief in divine or superhuman power(s)to be obeyed and worshipped as the creator(s)and ruler(s)of the universe is known as:
A)Culture.
B)Religion.
C)Ethnicity.
D)Spirituality. Answer: B
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Chapter 3: The Interview
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40 Flashcards
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Sample Questions
Q1) During the interview portion of data collection,the nurse collects __________ data.
A)Physical
B)Historical
C)Objective
D)Subjective
Answer: D
Q2) During an interview,the nurse states,"You mentioned having shortness of breath.Tell me more about that." Which verbal skill is used with this statement?
A)Reflection
B)Facilitation
C)Direct question
D)Open-ended question
Answer: D
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Chapter 4: The Complete Health History
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Sample Questions
Q1) The nurse is assessing a new patient who has recently immigrated to the United States.Which question is appropriate to add to the health history?
A)"Why did you come to the United States?"
B)"When did you come to the United States and from what country?"
C)"What made you leave your native country?"
D)"Are you planning to return to your home?"
Q2) The nurse is incorporating a person's spiritual values into the health history.Which of these questions illustrates the "community" portion of the FICA (faith and belief,importance and influence,community,and addressing or applying in care)questions?
A)"Do you believe in God?"
B)"Are you a part of any religious or spiritual congregation?"
C)"Do you consider yourself to be a religious or spiritual person?"
D)"How does your religious faith influence the way you think about your health?"
Q3) The review of systems provides the nurse with:
A)Physical findings related to each system.
B)Information regarding health promotion practices.
C)An opportunity to teach the patient medical terms.
D)Information necessary for the nurse to diagnose the patient's medical problem.
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Page 6
Chapter 5: Mental Status Assessment
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39 Flashcards
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Sample Questions
Q1) The nurse is performing a mental status examination.Which statement is true regarding the assessment of mental status?
A)Mental status assessment diagnoses specific psychiatric disorders.
B)Mental disorders occur in response to everyday life stressors.
C)Mental status functioning is inferred through the assessment of an individual's behaviors.
D)Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).
Q2) A woman brings her husband to the clinic for an examination.She is particularly worried because after a recent fall,he seems to have lost a great deal of his memory of recent events.Which statement reflects the nurse's best course of action?
A)Perform a complete mental status examination.
B)Refer him to a psychometrician.
C)Plan to integrate the mental status examination into the history and physical examination.
D)Reassure his wife that memory loss after a physical shock is normal and will soon subside.
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Chapter 6: Substance Use Assessment
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13 Flashcards
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Sample Questions
Q1) During an assessment,the nurse asks a female patient,"How many alcoholic drinks do you have a week?" Which answer by the patient would indicate at-risk drinking?
A)"I may have one or two drinks a week."
B)"I usually have three or four drinks a week."
C)"I'll have a glass or two of wine every now and then."
D)"I have seven or eight drinks a week, but I never get drunk."
Q2) The nurse is reviewing aspects of substance abuse in preparation for a seminar.Which of these statements illustrates the concept of tolerance to an illicit substance? The person:
A)Has a physiologic dependence on a substance.
B)Requires an increased amount of the substance to produce the same effect.
C)Requires daily use of the substance to function and is unable to stop using it.
D)Experiences a syndrome of physiologic symptoms if the substance is not used.
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Chapter 7: Domestic and Family Violence Assessments
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14 Flashcards
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Sample Questions
Q1) The nurse assesses an older woman and suspects physical abuse.Which questions are appropriate for screening for abuse? Select all that apply.
A)"Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?"
B)"Are you being abused?"
C)"Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?"
D)"Have you been upset because someone talked to you in a way that made you feel shamed or threatened?"
E)Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?
Q2) The nurse is aware that intimate partner violence (IPV)screening should occur with which situation?
A)When IPV is suspected
B)When a woman has an unexplained injury
C)As a routine part of each health care encounter
D)When a history of abuse in the family is known
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Chapter 8: Assessment Techniques and Safety in the Clinical Setting
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43 Flashcards
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Sample Questions
Q1) During an examination of a patient's abdomen,the nurse notes that the abdomen is rounded and firm to the touch.During percussion,the nurse notes a drumlike quality of the sounds across the quadrants.This type of sound indicates:
A)Constipation.
B)Air-filled areas.
C)Presence of a tumor.
D)Presence of dense organs.
Q2) When examining a 16-year-old male teenager,the nurse should:
A)Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness.
B)Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety.
C)Talk to him the same manner as one would talk to a younger child because a teen's level of understanding may not match his or her speech.
D)Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development.
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10
Chapter 9: General Survey, Measurement, Vital Signs
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Sample Questions
Q1) When assessing a patient's pulse,the nurse should also notice which of these characteristics?
A)Force
B)Pallor
C)Capillary refill time
D)Timing in the cardiac cycle
Q2) When evaluating the temperature of older adults,the nurse should remember which aspect about an older adult's body temperature?
A)The body temperature of the older adult is lower than that of a younger adult.
B)An older adult's body temperature is approximately the same as that of a young child.
C)Body temperature depends on the type of thermometer used.
D)In the older adult, the body temperature varies widely because of less effective heat control mechanisms.
Q3) What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and whose pulse rate is 72 beats per minute?
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Chapter 10: Pain Assessment: The Fifth Vital Sign
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Sample Questions
Q1) The nurse knows that which statement is true regarding the pain experienced by infants?
A)Pain in infants can only be assessed by physiologic changes, such as an increased heart rate.
B)The FPS-R can be used to assess pain in infants.
C)A procedure that induces pain in adults will also induce pain in the infant.
D)Infants feel pain less than do adults.
Q2) When assessing the intensity of a patient's pain,which question by the nurse is appropriate?
A)"What makes your pain better or worse?"
B)"How much pain do you have now?"
C)"How does pain limit your activities?"
D)"What does your pain feel like?"
Q3) The nurse is reviewing the principles of nociception.During which phase of nociception does the conscious awareness of a painful sensation occur?
A)Perception
B)Modulation
C)Transduction
D)Transmission
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Page 12
Chapter 11: Nutritional Assessment
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33 Verified Questions
33 Flashcards
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Sample Questions
Q1) The nurse is performing a nutritional assessment on an 80-year-old patient.The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include:
A)Slowed gastrointestinal motility.
B)Hyperstimulation of the salivary glands.
C)Increased sensitivity to spicy and aromatic foods.
D)Decreased gastrointestinal absorption causing esophageal reflux.
Q2) If a 29-year-old woman weighs 156 pounds,and the nurse determines her ideal body weight to be 120 pounds,then how would the nurse classify the woman's weight?
A)Obese
B)Mildly overweight
C)Suffering from malnutrition
D)Within appropriate range of ideal weight
Q3) A patient tells the nurse that his food simply does not have any taste anymore.The nurse's best response would be:
A)"That must be really frustrating."
B)"When did you first notice this change?"
C)"My food doesn't always have a lot of taste either."
D)"Sometimes that happens, but your taste will come back."
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Page 13
Chapter 12: Skin, Hair, and Nails
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48 Verified Questions
48 Flashcards
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Sample Questions
Q1) The nurse is bathing an 80-year-old man and notices that his skin is wrinkled,thin,lax,and dry.This finding would be related to which factor in the older adult?
A)Increased vascularity of the skin
B)Increased numbers of sweat and sebaceous glands
C)An increase in elastin and a decrease in subcutaneous fat
D)An increased loss of elastin and a decrease in subcutaneous fat
Q2) 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:
A)Bulla.
B)Wheal.
C)Nodule.
D)Papule.
Q3) The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?
A)Severe obesity
B)Childhood growth spurts
C)Severe dehydration
D)Connective tissue disorders such as scleroderma
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
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41 Flashcards
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Sample Questions
Q1) During a well-baby checkup,the nurse notices that a 1-week-old infant's face looks small compared with his cranium,which seems enlarged.On further examination,the nurse also notices dilated scalp veins and downcast or "setting sun" eyes.The nurse suspects which condition?
A)Craniotabes
B)Microcephaly
C)Hydrocephalus
D)Caput succedaneum
Q2) When examining the face of a patient,the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands.
A)Occipital; submental
B)Parotid; jugulodigastric
C)Parotid; submandibular
D)Submandibular; occipital
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15
Chapter 14: Eyes
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40 Flashcards
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Sample Questions
Q1) An ophthalmic examination reveals papilledema.The nurse is aware that this finding indicates:
A)Retinal detachment.
B)Diabetic retinopathy.
C)Acute-angle glaucoma.
D)Increased intracranial pressure.
Q2) The nurse is performing the diagnostic positions test.Normal findings would be which of these results?
A)Convergence of the eyes
B)Parallel movement of both eyes
C)Nystagmus in extreme superior gaze
D)Slight amount of lid lag when moving the eyes from a superior to an inferior position
Q3) The nurse is assessing color vision of a male child.Which statement is correct? The nurse should:
A)Check color vision annually until the age of 18 years.
B)Ask the child to identify the color of his or her clothing.
C)Test for color vision once between the ages of 4 and 8 years.
D)Begin color vision screening at the child's 2-year checkup.
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Chapter 15: Ears
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40 Flashcards
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Sample Questions
Q1) The nurse is preparing to perform an otoscopic examination of a newborn infant.Which statement is true regarding this examination?
A)Immobility of the drum is a normal finding.
B)An injected membrane would indicate an infection.
C)The normal membrane may appear thick and opaque.
D)The appearance of the membrane is identical to that of an adult.
Q2) While discussing the history of a 6-month-old infant,the mother tells the nurse that she took a significant amount of aspirin while she was pregnant.What question would the nurse want to include in the history?
A)"Does your baby seem to startle with loud noises?"
B)"Has your baby had any surgeries on her ears?"
C)"Have you noticed any drainage from her ears?"
D)"How many ear infections has your baby had since birth?"
Q3) In an individual with otitis externa,which of these signs would the nurse expect to find on assessment?
A)Rhinorrhea
B)Periorbital edema
C)Pain over the maxillary sinuses
D)Enlarged superficial cervical nodes
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Page 17
Chapter 16: Nose, Mouth, and Throat
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Sample Questions
Q1) A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth.During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding,as well as other areas that have a white,cheesy coating.The nurse recognizes that this abnormality is:
A)Aphthous ulcers.
B)Candidiasis.
C)Leukoplakia.
D)Koplik spots.
Q2) A patient has been diagnosed with strep throat.The nurse is aware that without treatment,which complication may occur?
A)Rubella
B)Leukoplakia
C)Rheumatic fever
D)Scarlet fever
Q3) The primary purpose of the ciliated mucous membrane in the nose is to:
A)Warm the inhaled air.
B)Filter out dust and bacteria.
C)Filter coarse particles from inhaled air.
D)Facilitate the movement of air through the nares.
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Page 18
Chapter 17: Breasts and Regional Lymphatics
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Sample Questions
Q1) During an examination of a 7-year-old girl,the nurse notices that the girl is showing breast budding.What should the nurse do next?
A)Ask the young girl if her periods have started.
B)Assess the girl's weight and body mass index (BMI).
C)Ask the girl's mother at what age she started to develop breasts.
D)Nothing; breast budding is a normal finding.
Q2) The nurse is preparing to teach a woman about BSE.Which statement by the nurse is correct?
A)"BSE is more important than ever for you because you have never had any children."
B)"BSE is so important because one out of nine women will develop breast cancer in her lifetime."
C)"BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations."
D)"BSE will save your life because you are likely to find a cancerous lump between mammograms."
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19
Chapter 18: Thorax and Lungs
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Sample Questions
Q1) 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?
A)Wheezes
B)Bronchial sounds
C)Bronchophony
D)Whispered pectoriloquy
Q2) When auscultating the lungs of an adult patient,the nurse notes that low-pitched,soft breath sounds are heard over the posterior lower lobes,with inspiration being longer than expiration.The nurse interprets that these sounds are:
A)Normally auscultated over the trachea.
B)Bronchial breath sounds and normal in that location.
C)Vesicular breath sounds and normal in that location.
D)Bronchovesicular breath sounds and normal in that location.
Q3) The nurse is auscultating the chest in an adult.Which technique is correct?
A)Instructing the patient to take deep, rapid breaths
B)Instructing the patient to breathe in and out through his or her nose
C)Firmly holding the diaphragm of the stethoscope against the chest
D)Lightly holding the bell of the stethoscope against the chest to avoid friction
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Page 20
Chapter 19: Heart and Neck Vessels
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42 Flashcards
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Sample Questions
Q1) In assessing a 70-year-old man,the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S? heart sound.Which of these findings can be explained by expected hemodynamic changes related to age?
A)Increase in resting heart rate
B)Increase in systolic blood pressure
C)Decrease in diastolic blood pressure
D)Increase in diastolic blood pressure
Q2) The nurse knows that normal splitting of the S? is associated with:
A)Expiration.
B)Inspiration.
C)Exercise state.
D)Low resting heart rate.
Q3) The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics.Which racial group has the highest prevalence of hypertension in the world?
A)Blacks
B)Whites
C)American Indians
D)Hispanics
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21
Chapter 20: Peripheral Vascular System and Lymphatic System
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39 Flashcards
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Sample Questions
Q1) When using a Doppler ultrasonic stethoscope,the nurse recognizes venous flow when which sound is heard?
A)Low humming sound
B)Regular "lub, dub" pattern
C)Swishing, whooshing sound
D)Steady, even, flowing sound
Q2) During an assessment,a patient tells the nurse that her fingers often change color when she goes out in cold weather.She describes these episodes as her fingers first turning white,then blue,then red with a burning,throbbing pain.The nurse suspects that she is experiencing:
A)Lymphedema.
B)Raynaud disease.
C)Deep-vein thrombosis.
D)Chronic arterial insufficiency.
Q3) During an assessment,the nurse uses the profile sign to detect:
A)Pitting edema.
B)Early clubbing.
C)Symmetry of the fingers.
D)Insufficient capillary refill.
Page 22
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Chapter 21: Abdomen
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Sample Questions
Q1) During an abdominal assessment,the nurse tests for a fluid wave.A positive fluid wave test occurs with:
A)Splenomegaly.
B)Distended bladder.
C)Constipation.
D)Ascites.
Q2) The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen.Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
A)"We need to determine the areas of tenderness before using percussion and palpation."
B)"Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation."
C)"Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination."
D)"Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."
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Chapter 22: Musculoskeletal System
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Sample Questions
Q1) A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms.The nurse should suspect:
A)Crepitation.
B)Rotator cuff lesions.
C)Dislocated shoulder.
D)Rheumatoid arthritis.
Q2) When reviewing the musculoskeletal system,the nurse recalls that hematopoiesis takes place in the:
A)Liver.
B)Spleen.
C)Kidneys.
D)Bone marrow.
Q3) The nurse is assessing a patient's ischial tuberosity.To palpate the ischial tuberosity,the nurse knows that it is best to have the patient:
A)Standing.
B)Flexing the hip.
C)Flexing the knee.
D)Lying in the supine position.
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Chapter 23: Neurologic System
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Sample Questions
Q1) The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes.When testing her ability to feel the vibrations of a tuning fork,the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally,but she is able to feel vibrations on both patellae.Given this information,what would the nurse suspect?
A)Hyperalgesia
B)Hyperesthesia
C)Peripheral neuropathy
D)Lesion of sensory cortex
Q2) While obtaining a health history of a 3-month-old infant from the mother,the nurse asks about the infant's ability to suck and grasp the mother's finger.What is the nurse assessing?
A)Reflexes
B)Intelligence
C)CNs
D)Cerebral cortex function
Q3) During the assessment of deep tendon reflexes,the nurse finds that a patient's responses are bilaterally normal.What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+
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Page 25
Chapter 24: Male Genitourinary System
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Sample Questions
Q1) When performing a genital assessment on a middle-aged man,the nurse notices multiple soft,moist,painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis.These lesions are characteristic of:
A)Carcinoma.
B)Syphilitic chancres.
C)Genital herpes.
D)Genital warts.
Q2) When performing a genitourinary assessment on a 16-year-old male adolescent,the nurse notices a swelling in the scrotum that increases with increased intra-abdominal pressure and decreases when he is lying down.The patient complains of pain when straining.The nurse knows that this description is most consistent with a(n)______ hernia.
A)Femoral
B)Incisional
C)Direct inguinal
D)Indirect inguinal
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Chapter 25: Anus,Rectum,and Prostate
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Sample Questions
Q1) A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH).He has a friend who just died from cancer of the prostate.He is concerned this will happen to him.How should the nurse respond?
A)"The swelling in your prostate is only temporary and will go away."
B)"We will treat you with chemotherapy so we can control the cancer."
C)"It would be very unusual for a man your age to have cancer of the prostate."
D)"The enlargement of your prostate is caused by hormonal changes, and not cancer."
Q2) The mother of a 5-year-old girl tells the nurse that she has noticed her daughter "scratching at her bottom a lot the last few days." During the assessment,the nurse finds redness and raised skin in the anal area.This finding most likely indicates:
A)Pinworms.
B)Chickenpox.
C)Constipation.
D)Bacterial infection.
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Chapter 26: Female Genitourinary System
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Sample Questions
Q1) A nurse is assessing a patient's risk of contracting a sexually transmitted infection (STI).An appropriate question to ask would be:
A)"You know that it's important to use condoms for protection, right?"
B)"Do you use a condom with each episode of sexual intercourse?"
C)"Do you have a sexually transmitted infection?"
D)"You are aware of the dangers of unprotected sex, aren't you?"
Q2) A 22-year-old woman is being seen at the clinic for problems with vulvar pain,dysuria,and fever.On physical examination,the nurse notices clusters of small,shallow vesicles with surrounding erythema on the labia.Inguinal lymphadenopathy present is also present.The most likely cause of these lesions is:
A)Pediculosis pubis.
B)Contact dermatitis.
C)HPV.
D)Herpes simplex virus type 2.
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Chapter 27: The Complete Health Assessment: Adult
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Sample Questions
Q1) A patient states,"Whenever I open my mouth real wide,I feel this popping sensation in front of my ears." To further examine this,the nurse would:
A)Place the stethoscope over the temporomandibular joint, and listen for bruits.
B)Place the hands over his ears, and ask him to open his mouth "really wide."
C)Place one hand on his forehead and the other on his jaw, and ask him to try to open his mouth.
D)Place a finger on his temporomandibular joint, and ask him to open and close his mouth.
Q2) A patient is unable to shrug her shoulders against the nurse's resistant hands.What cranial nerve is involved with successful shoulder shrugging?
A)VII
B)IX
C)XI
D)XII
Q3) Which of these is included in an assessment of general appearance?
A)Height
B)Weight
C)Skin color
D)Vital signs
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Page 29
Chapter 28: The Complete Physical Assessment: Infant,
Child, and Adolescent
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Sample Questions
Q1) When assessing the neonate,the nurse should test for hip stability with which method?
A)Eliciting the Moro reflex
B)Performing the Romberg test
C)Checking for the Ortolani sign
D)Assessing the stepping reflex
Q2) A female patient tells the nurse that she has four children and has had three pregnancies.How should the nurse document this?
A)Gravida 3, para 4
B)Gravida 4, para 3
C)This information cannot be documented using the terms gravida and para.
D)"The patient seems to be confused about how many times she has been pregnant."
Q3) Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup?
A)Testing for Ortolani sign
B)Assessment for stereognosis
C)Blood pressure measurement
D)Assessment for the presence of the startle reflex
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Chapter 29: Bedside Assessment of the Hospitalized Patient
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Q1) At the beginning of rounds when entering the room,what should the nurse do first?
A)Check the intravenous (IV) infusion site for swelling or redness.
B)Check the infusion pump settings for accuracy.
C)Make eye contact with the patient, and introduce him or herself as the patient's nurse.
D)Offer the patient something to drink.
Q2) During an assessment,the nurse is unable to palpate pulses in the left lower leg.What should the nurse do next?
A)Document that the pulses are nonpalpable.
B)Reassess the pulses in 1 hour.
C)Ask the patient turn to the side, and then palpate for the pulses again.
D)Use a Doppler device to assess the pulses.
Q3) During an assessment of a hospitalized patient,the nurse pinches a fold of skin under the clavicle or on the forearm to test the:
A)Mobility and turgor.
B)Patient's response to pain.
C)Percentage of the patient's fat-to-muscle ratio.
D)Presence of edema.
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Chapter 30: The Pregnant Woman
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Q1) A female patient has nausea,breast tenderness,fatigue,and amenorrhea.Her last menstrual period was 6 weeks ago.The nurse interprets that this patient is experiencing __________ signs of pregnancy.
A)Positive
B)Possible
C)Probable
D)Presumptive
Q2) A woman who is 28 weeks' pregnant has bilateral edema in her lower legs after working 8 hours a day as a cashier at a local grocery store.She is worried about her legs.What is the nurse's best response?
A)"You will be at risk for development of varicose veins when your legs are edematous."
B)"I would like to listen to your heart sounds. Edema can indicate a problem with your heart."
C)"Edema is usually the result of too much salt and fluids in your diet. You may need to cut down on salty foods."
D)"As your baby grows, it slows blood return from your legs, causing the swelling. This often occurs with prolonged standing."
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Chapter 31: Functional Assessment of the Older Adult
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Q1) When beginning to assess a person's spirituality,which question by the nurse would be most appropriate?
A)"Do you believe in God?"
B)"How does your spirituality relate to your health care decisions?"
C)"What religious faith do you follow?"
D)"Do you believe in the power of prayer?"
Q2) When using the various instruments to assess an older person's ADLs,the nurse needs to remember that a disadvantage of these instruments includes:
A)Reliability of the tools.
B)Self or proxy reporting of functional activities.
C)Lack of confidentiality during the assessment.
D)Insufficient details concerning the deficiencies identified.
Q3) The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to:
A)Observe the patient's ability to perform the tasks.
B)Ask the patient's wife how he does when performing tasks.
C)Review the medical record for information on the patient's abilities.
D)Ask the patient's physician for information on the patient's abilities.
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