Chapter 28: The Complete Health Assessment: Adult
Jarvis: Physical Examination and Health Assessment, 8th Edition
MULTIPLE CHOICE
1. A hospitalized patient does not require a full neurologic examination during every shift
assessment. What is a method of assessing the neurologic status of a patient without
performing a full neurological examination?
a.
Palpate the carotid pulse.
b.
Offer the patient a glass of water.
c.
Look at the significant other throughout the examination.
d.
Assign the nursing assistant to ask the patient questions and report the findings.
2. The examiner is assessing the extraocular muscles. Which of the following tests would be
inappropriate?
a.
Confrontation test
b.
Corneal light reflex
c.
Six cardinal positions of gaze
d.
Cranial nerve III, IV, and VI testing
3. What should the examiner do during auscultation of breath sounds?
a.
Listen with the bell of the stethoscope.
b.
Compare sounds on the left and right sides.
c.
Listen only to the posterior chest for adventitious sounds.
d.
Instruct the patient to breathe in and out through the nose.
4. In which situation should the examiner auscultate for carotid bruits?
a.
Middle-aged or older patient
b.
Pregnant patient with gestational diabetes
c.
Patient that reports abdominal pain
d.
Patient with enlarged, tender cervical lymph nodes
5. When standing with their eyes closed, feet together, and arms at their sides, a patient sways
and starts to fall. How should the nurse document this finding?
a.
Positive Romberg sign
b.
Positive Babinski sign
c.
Positive Ortolani sign
d.
Positive modified Allen test
6. The nurse is conducting a hearing screening. Which technique will the nurse use during the
whisper test?
a.
The nurse pulls the pinna up and back.
b.
The nurse covers their lips to obscure them from view.
c.
The nurse asks the patient to repeat 3 letters or numbers.
d.
The nurse stands 4 feet away from the patient and whispers three different words.
7. When auscultating heart sounds, which technique should the nurse use?
a.
Listen with the bell.
b.
Listen with the diaphragm.
c.
Listen with both the diaphragm and bell working from apex to base in a Z pattern.
d.
Listen with both the bell and diaphragm comparing sides of the heart as progress
from apex to base.
8. The nurse is assessing the cranial nerves. To assess cranial nerve XII, what should the nurse
ask the patient to do?
a.
Say “ahh”.
b.
Stick out tongue.
c.
Smile and then frown.
d.
Follow the nurses fingers through the six cardinal positions of gaze.
9. When performing a health history, the nurse would note immunizations under which
category?
a.
Family history
b.
Personal history
c.
Past medical history
d.
History of present illness
10. While conducting a musculoskeletal assessment the nurse stands behind the patient and has
the patient bend over and touch his or her toes. What is the nurse assessing?
a.
Balance
b.
The spine
c.
Cervical range of motion
d.
External rotation of hips
11. The nurse is preparing to perform an examination of the eyes. Which test will the nurse
conduct to assess the patient’s vision?
a.
Weber test
b.
Snellen test
c.
Confrontation test
d.
Corneal light reflex
12. Which statement is true regarding the recording of data from the history and physical
examination?
a.
Use long, descriptive sentences to document findings.
b.
Record the data as soon as possible after the interview and physical examination.
c.
The examiner should avoid taking any notes during the history and examination
because of the possibility of decreasing the rapport with the patient.
d.
If the information is not documented, then it can be assumed that it was done as a
standard of care.
MULTIPLE RESPONSE
1. When gathering information relative to a complete health assessment, the nurse should
include which in the decision-making process? (Select all that apply.)
a.
Treat the health assessment as a legal document.
b.
Use line drawings to explain and record pertinent findings.
c.
Do not document findings on the computer while the patient is present.
d.
Gather needed equipment before the start of the health assessment.
e.
Write down “word for word” what the patient says as evidence of reliable
documentation.