WorksheetsFoundations of Nursing Assessment
Total questions: 65
Worksheet time: 33mins
What is Evidence-Based Practice (EBP)?
The use of only clinical expertise to make healthcare decisions
The integration of the best research evidence with clinical expertise and patient values to make healthcare decisions
The use of patient values only to make healthcare decisions
The use of outdated research to make healthcare decisions
Fill in the blank: First-level priorities in nursing assessment refer to __________ issues (e.g., airway, breathing, circulation).
Life-threatening
Psychosocial
Chronic
Nutritional
Which of the following is an example of a second-level priority in nursing assessment?
Knowledge deficit
Airway obstruction
Mental status change
Mobility issues
Third-level priorities in nursing assessment are:
Life-threatening issues
Urgent problems requiring prompt intervention
Important health problems that are not urgent, but require intervention
Problems that can be ignored
Spirituality is best defined as:
An organized system of beliefs, practices, and rituals shared by a group
A broad concept focusing on a person's search for meaning, purpose, and connection with a higher power or the universe
A dietary practice
A family role
Religion is:
A broad concept focusing on a person's search for meaning
An organized system of beliefs, practices, and rituals shared by a group
A communication pattern
A type of nonverbal behavior
Fill in the blank: Cultural Assessment is a systematic examination of the cultural values, beliefs, and practices of an individual or group to provide __________ care.
culturally competent
universal
technical
financial
Which of the following is NOT one of the ten traps of interviewing?
Providing false assurance
Using authority
Asking 'why' questions
Using open-ended questions
Open-ended questions require more than a 'yes' or 'no' answer to encourage patients to share detailed information.
True
False
When interviewing special needs patients, you should:
Use jargon
Adapt your approach for individuals with specific needs
Ignore communication barriers
Ask only 'yes' or 'no' questions
Fill in the blank: Nonverbal behaviors such as posture, gestures, and eye contact significantly impact __________.
communication
nutrition
transportation
mathematics
Interviewing the older adult requires considerations such as:
Pacing the interview
Allowing for more time
Being aware of potential sensory deficits or cognitive changes
All of the above
What is the purpose of collecting a health history?
To collect subjective data about a person's health state to form a comprehensive picture of their past and present health.
To diagnose diseases without any further tests.
To prescribe medication immediately.
To perform surgical procedures.
Subjective data is what the person says about themselves, while objective data is what you observe through measurement, inspection, palpation, percussion, and auscultation.
True
False
Which of the following is an example of objective data?
I have a headache.
Blood pressure reading
I feel tired.
My stomach hurts.
Functional assessment measures a person's self-care ability in areas of general physical health or absence of illness.
True
False
When a patient reports an allergy, what is crucial to ask?
What kind of reaction occurs (e.g., rash, difficulty breathing).
How long the allergy has existed.
If the allergy is common in their family.
Whether they have traveled recently.
You are legally required to report suspected cases of abuse and neglect (child, elder, or vulnerable adult) and domestic violence in some jurisdictions.
True
False
What is the diaphragm of a stethoscope used for?
Used for high-pitched sounds like breath, bowel, and normal heart sounds.
Used for low-pitched sounds like heart murmurs.
Used to measure blood pressure directly.
Used to amplify electrical signals from the heart.
The bell of a stethoscope is used for which type of sounds?
High-pitched sounds
Low-pitched sounds
All sounds
No sounds
A Doppler device is used to detect peripheral pulses or blood pressure when they are difficult to palpate or auscultate.
True
False
The general survey is a study of the whole person, covering their general health state and any obvious physical characteristics.
True
False
Radial pulse is assessed for which of the following?
Rate (beats per minute)
Rhythm (regular or irregular)
Force (strength)
Temperature
What are Korotkoff sounds?
The sounds heard during blood pressure measurement. A two-step BP procedure helps avoid an auscultatory gap.
A type of heart murmur heard during systole.
The sounds produced by the lungs during inspiration.
A type of nerve impulse recorded in EEG.
Factors affecting blood pressure can include age, stress, race, medications, and the cuff size used for measurement.
True
False
What are the expected breath sounds you should know the location for?
Bronchial, bronchovesicular, and vesicular sounds.
Tracheal, alveolar, and pleural sounds.
Laryngeal, diaphragmatic, and pericardial sounds.
Cardiac, gastric, and intestinal sounds.
Which of the following are considered adventitious breath sounds?
Crackles
Wheezes
Rhonchi
All of the above
How is chest expansion assessed?
By placing hands on the posterior chest wall and observing for symmetric movement as the patient breathes.
By measuring the circumference of the chest with a tape measure during inspiration only.
By asking the patient to cough and observing for chest movement.
By palpating the anterior chest for tenderness only.
What age-related change may be observed in the chest expansion of older adults?
Decreased chest expansion and a more rigid thoracic cage.
Increased chest expansion and a more flexible thoracic cage.
No change in chest expansion or thoracic cage flexibility.
Decreased chest expansion and a more flexible thoracic cage.
Light palpation is used to assess for which of the following?
Surface characteristics and tenderness
Underlying organs and masses
Fluid in the abdomen
Cognitive impairment
Deep palpation is used to assess underlying organs and masses.
True
False
What is the purpose of pain assessment in the abdomen?
To assess the location, quality, and severity of abdominal pain.
To determine the patient's blood pressure.
To evaluate lung function.
To check for vision problems.
What is a fluid wave test used to detect?
Ascites (free fluid in the abdominal cavity).
Appendicitis.
Gallstones.
Peptic ulcer disease.
Which components are included in a mental status exam?
Appearance, Behavior, Cognition, and Thought processes (A-B-C-T).
Vital signs, Reflexes, Sensation, and Coordination.
Blood pressure, Heart rate, Respiratory rate, and Temperature.
Vision, Hearing, Smell, and Taste.
Which tool is used to screen for depression?
Mini-Cog
PHQ-2
CAGE
AUDIT
The Mini-Cog is a quick screening tool for cognitive impairment that involves three-item recall and a clock-drawing test.
True
False
What should you be aware of when assessing at-risk drinking?
The number of drinks per week that constitutes at-risk drinking for men and women.
The type of alcoholic beverage consumed.
The time of day alcohol is consumed.
The location where drinking occurs.
Name two screening tools used to screen for alcohol use disorder.
CAGE and AUDIT.
MMSE and PHQ-9.
GAD-7 and HAM-D.
MoCA and DAST.
Certain lab values such as GGT and AST can indicate heavy alcohol use.
True
False
Differentiate between acute, chronic (persistent), neuropathic, and breakthrough pain. ______ pain is a type of pain that is persistent over time.
Chronic
Acute
Neuropathic
Breakthrough
For dementia patients, what type of pain scale should be used for those who cannot verbally communicate their pain?
Observational pain scales (like the PAINAD scale)
Numeric rating scale
Visual analog scale
Verbal descriptor scale
Which of the following may be a physiologic response to acute pain?
Bradycardia
Tachycardia
Low blood pressure
Hypothermia
What does the ABCDEF skin assessment screen for?
Suspicious lesions (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Elevation/Evolution, Funny looking)
Nutritional deficiencies (Anemia, B12, Calcium, Vitamin D, Electrolytes, Folate)
Common skin infections (Bacterial, Fungal, Candida, Dermatophytes, Eczema, Folliculitis)
Allergic reactions (Angioedema, Blisters, Contact dermatitis, Erythema, Flushing, Hives)
How should you perform a lymph node assessment?
Use a gentle, circular motion with the finger pads to palpate lymph nodes, comparing sides for symmetry.
Use firm, deep pressure with your knuckles to palpate lymph nodes quickly.
Tap the lymph nodes lightly with your fingertips to check for tenderness.
Only inspect the lymph nodes visually without touching them.
What is gynecomastia?
Benign breast tissue growth in males.
Malignant tumor in the liver.
Inflammation of the prostate gland.
Excessive hair growth in females.
What should you assess during a pupil assessment?
Size, shape, and reaction to light and accommodation.
Color, temperature, and moisture.
Movement, strength, and coordination.
Hearing, speech, and balance.
The extraocular muscle (EOM) assessment is used to assess for parallel tracking of the eyes using which test?
The diagnostic positions test (six cardinal positions of gaze)
The Snellen chart test
The cover-uncover test
The pupillary light reflex test
What is the Snellen chart used to measure?
Visual acuity
Blood pressure
Hearing ability
Lung capacity
Which age-related change is described as a decreased ability to accommodate for near vision?
Presbyopia
Cataract
Glaucoma
Macular degeneration
What is a gray-white arc around the cornea, which is a common degenerative change, called?
Arcus Senilis
Kayser-Fleischer ring
Pterygium
Cataract
A clouding of the lens is known as:
Cataracts
Glaucoma
Conjunctivitis
Astigmatism
For an adult, how should you straighten the S-shaped curve of the ear canal during an ear canal assessment?
Pull the pinna up and back.
Pull the pinna down and back.
Push the tragus inward.
Pull the earlobe up and forward.
What is presbycusis?
Age-related hearing loss, particularly of high-frequency sounds.
A condition causing loss of vision in old age.
A degenerative joint disease common in elderly.
A type of memory loss associated with aging.
What is a common age-related change in the ear involving earwax?
Increased cerumen (earwax) buildup.
Decreased cerumen (earwax) production.
Complete absence of cerumen (earwax).
Change in cerumen (earwax) color to blue.
What is the grading of tonsils based on in Tonsil Assessment?
How much they obstruct the airway (1+ to 4+).
The color of the tonsils.
The presence of pain.
The age of the patient.
What is dysphagia?
Difficulty swallowing.
Difficulty breathing.
Difficulty hearing.
Difficulty seeing.
How do you assess nasal patency?
By having the person sniff inward through one nostril at a time.
By asking the person to open their mouth wide.
By checking the color of the lips.
By tapping lightly on the bridge of the nose.
What changes in the nasal mucosa indicate allergies or infection?
Pale or swollen mucosa indicates allergies; other changes may indicate infection.
Red and dry mucosa always indicates allergies.
Thick and crusty mucosa is a sign of allergies only.
Bright red mucosa is a sign of infection only.
Where is the Point of Maximal Impulse (PMI) typically located?
At the 5th intercostal space, midclavicular line.
At the 2nd intercostal space, right sternal border.
At the 4th intercostal space, left sternal border.
At the 6th intercostal space, midaxillary line.
What is the difference between a thrill and a murmur?
A thrill is a palpable vibration; a murmur is an auscultated blowing/swooshing sound.
A thrill is an audible sound; a murmur is a visible pulsation.
A thrill is a type of heart valve; a murmur is a type of blood vessel.
A thrill is a type of arrhythmia; a murmur is a type of chest pain.
Which tool is used to assess bruits?
The bell of the stethoscope.
A reflex hammer.
A tuning fork.
An otoscope.
What does Jugular Venous Distention (JVD) indicate?
Right-sided heart failure.
Left-sided heart failure.
Pulmonary embolism.
Hypertension.
How is pitting edema assessed?
On a 4-point scale based on the depth of the pit and how long it remains.
By measuring the circumference of the limb only.
By checking for color changes in the skin.
By asking the patient about their pain level.
Which of the following is a characteristic of arterial insufficiency?
Brownish skin discoloration and edema
Pale, cool skin and intermittent claudication
Shallow ulcers with irregular borders
None of the above
What is the formula for the Ankle-Brachial Index (ABI)?
Ankle Systolic Pressure divided by Brachial Systolic Pressure.
Brachial Systolic Pressure divided by Ankle Systolic Pressure.
Ankle Diastolic Pressure divided by Brachial Diastolic Pressure.
Brachial Diastolic Pressure divided by Ankle Diastolic Pressure.
