NCLEX Practice questions based on Health and Physical Assessment of the Adult Client Part-5

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Prior concept = Clinical judgement; Health promotion

KEY POINTS TO REMEMBER
  • Types of the Health and Physical Assessments:
    • Complete Assessment
    • Focused Assessment
    • Episodic Assessment/ Follow-up Assessment
    • Emergency Assessment
  • To test skin turgor, pinch a large fold of skin and assess the ability of the skin to return to its palce when released. Poor turgor occurs in severe dehydration or extreme weight loss.
  • Neck movements are never performed if the client has sustained a neck injury or if a neck injury is suspected
  • The first slide on the Ishihara chart is one that everyone can discriminate; failure to identify numbers on this slide suggests a problem with performing the test, not a problem with color vision.
  • Before performing an otoscopic exam and inserting the speculum, check the auditory canal for foreign bodies. Instruct the client not to move the head during the examination to avoid damage to the canal and tympanic membrane.
  • The otoscope is never introduced blindly into the external canal because of the risk of perforating the tympanic membrane
  • When auscultating breath sounds, instruct the client to breathe through the mouth and monitor the client for dizziness.
  • When performing an abdominal assessment, the specific order for assessment techniques is inspection, auscultation, percussion, and palpation.
  • Brudzinski’s sign is tested with the client in the supine position. It is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
  • Kernig’s sign is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended.
  • Dorsiflexion of the great toe and fanning of the other toes (Babinski’s sign) after firmly stroking the sole of the foot, is abnormal in anyone older than 2 years and indicates the presence of central nervous system disease

PRACTICE QUESTIONS:

  1. A Spanish speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?
    1. Have one of the client’s family members interpret
    2. Have the Spanish-speaking triage receptionist interpret
    3. Page an interpreter from the hospital’s interpreter services
    4. Obtain s Spanish-English dictionary and attempt to triage the client.
  2. The nurse is performing a neurological assessment on a client and notes a positive Romberg’s test. The nurse makes this determination based on which observation?
    1. An involuntary rhythmic, rapid, twitching of the eyeballs
    2. A dorsiflexion of the great toe with fanning of the other toes
    3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed
    4. A lack of normal sense of the position when the client is unable to return extended fingers to a point of reference
  3. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?
    1. Rhythmic respirations with periods of apnea
    2. Regular rapid and deep, sustained respirations
    3. Totally irregular respiration in the rhythm and depth
    4. Irregular respirations with pauses at the end of inspiration and expiration
  4. A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?
    1. A defect in the cochlea
    2. A defect in cranial nerve VIII
    3. A physical obstruction to the transmission of sound waves
    4. A defect in the sensory fibers that lead to the cerebral cortex
  5. While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?
    1. Lub-dub sounds
    2. Scratchy, leathery heart noise
    3. A blowing or swooshing noise
    4. Abrupt, high-pitched snapping noise
  6. The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?
    1. Test the corneal reflexes
    2. Test the 6 cardinal positions of gaze
    3. Test visual acuity, using a Snellen eye chart
    4. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin
  7. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam?
    1. After a shower or bath
    2. While standing to void
    3. After having a bowel movement
    4. While lying in bed before arising
  8. The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski’s sign. Which finding did the nurse observe?
    1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet
    2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended
    3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column
    4. The client’s upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated
  9. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?
    1. Stridor
    2. Crackles
    3. Wheezes
    4. Diminished
  10. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.
    1. Auscultating lung sounds
    2. Obtaining the client’s temperature
    3. Assessing the strength of peripheral pulses
    4. Obtaining information about the client’s respirations
    5. Performing a musculoskeletal and neurological examination
    6. Asking the client about a family history of any illness or disease

ANSWERS

  1. 3
  2. 3
  3. 1
  4. 3
  5. 3
  6. 2
  7. 1
  8. 3
  9. 3
  10. 1,2,4

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