HEALTH ASSESSMENT (LECTURE) FINAL EXAMINATION NAME: ________________________________________________ PERMIT NO.

________________ SCORE: __________ DIRECTION: Select the best answer. Final answers must be written on the answer sheet provided. 1. A client who is unconscious needs frequent mouth care. When performing a mouth care, the best position of a client is: a. Fowlers position b. Side lying c. Supine d. Trendelenburg 2. The nurse administers cleansing enema. The common position for this procedure is a. Sims left lateral b. Dorsal Recumbent c. Supine d. Prone 3. Which of the following statements about Chest X-ray is false? a. No contradictions exist for this test b. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist c. A signed consent is not required d. Eating, drinking, and medications are allowed before this test 4. The most appropriate time for the nurse to obtain a sputum specimen for culture is: a. Early in the morning b. After the patient eats a light breakfast c. After aerosol therapy d. After chest physiotherapy 5. The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml? a. 5 gtt/minute b. 13 gtt/minute c. 25 gtt/minute d. 50 gtt/minute 6. 22. Among the following statements, which should be given the HIGHEST priority? A. Client is in extreme pain B. Clients blood pressure is 60/40 C. Clients temperature is 40 deg. Centigrade D. Client is cyanotic 7. The sequence in examining the quadrants of the abdomen is: A. RUQ,RLQ,LUQ,LLQ B. RLQ,RUQ,LLQ,LUQ C. RUQ,RLQ,LLQ,LUQ D. RLQ,RUQ,LUQ,LLQ 8. In inspecting the abdomen, which of the following is NOT DONE? A. Ask the client to void first B. Knees and legs are straighten to relax the abdomen C. The best position in assessing the abdomen is Dorsal recumbent D. The knees and legs are externally rotated 9. Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a Correct preparation before the procedure? A. Provide the necessary draping to ensure privacy B. Open the windows, curtains and light to allow better illumination C. Pour warm water over the ophthalmoscope to ensure comfort D. Darken the room to provide better illumination 10. If the client is female, and the doctor is a male and the patient is about to undergo a vaginal and cervical examination, why is it necessary to have a female nurse in attendance? A. To ensure that the doctor performs the procedure safely B. To assist the doctor C. To assess the clients response to examination D. To ensure that the procedure is done in an ethical manner 11. In palpating the clients breast, Which of the following position is necessary for the patient to assume before the start of the procedure? A. Supine B. Dorsal recumbent C. Sitting D. Lithotomy

12. When is the best time to collect urine specimen for routine urinalysis and C/S? A. Early morning B. Later afternoon C. Midnight D. Before breakfast 13. Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity? A. Use a clean container B. Discard the first flow of urine to ensure that the urine is not contaminated C. Collect around 30-50 ml of urine D. Add preservatives, refrigerate the specimen or add ice according to the agencys protocol 14. 73. In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing? A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen B. The nurse discards the Friday 9:00 A M urine of the client C. The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection D. The nurse added preservatives as per protocol and refrigerates the specimen 15. Who collects Blood specimen? A. The nurse C. Physician

B. Medical technologist D. Physical therapist

16. The best position for any procedure that involves vaginal and cervical examination is A. Dorsal recumbent B. Side lying C. Supine D. Lithotomy 17. When palpating the clients neck for lymphadenopathy, where should the nurse position himself? A. At the clients back B. At the clients right side C. At the clients left side D. In front of a sitting client 18. In assessing the clients chest, which position best show chest expansion as well as its movements? A. Sitting B. Prone C. Sidelying D. Supine 19. Nurse Ron performed mantoux skin test today (Monday) to a male adult client. Which statement by the client indicates that he understood the instruction well? a. I will come back later b. I will come back next month c. I will come back on Friday d. I will come back on Wednesday, same time, to read the result 20. Which is the primary characteristic lesion of syphilis? a. Sore eyes b. Sore throat c. Chancroid d. Chancre 21. When is the best time in performing breast self examination? a. 7 days after menstrual period b. 7 days before menstrual period c. 5 days after menstrual period d. 5 days before menstrual period 22. Which of the following should be given the highest priority before performing physical examination to a patient? a. Preparation of the room b. Preparation of the patient c. Preparation of the nurse d. Preparation of environment 23. Myrna a pregnant client reports that her last menstrual cycle is July 11, her expected date of birth is a. November 4 b. November 11 c. April 4 d. April 18 24. The nurse prepares to palpate a clients maxillary sinues. For this procedure, where should the nurse place the hands? a. On the bridge of the nose b. below the eyebrows c. below the cheekbones d. over the temporal area 25. A closed, saclike structure that contains fluid, gas, or semisolid material and is not a normal part of the tissue where it is located.

a. macule c. plaque 26. Non-palpable flat lesion with skin color change a. macule c. plaque 27. A broad, raised area on the skin. a. macule c. plaque 28. A small fluid-filled blister. a. macule c. plaque

b. vesicles d. cyst

b. vesicles d. cyst

b. vesicles d. cyst

b. vesicles d. cyst

29. They are benign tumors on the surface of the skin which are commonly caused by papilloma virus a. papules b. wheal c. warts d. vesicles 30. They may open when scratched and become crusty and infected a. papules b. wheal c. warts d. vesicles 31. A raised, itchy area of skin that is almost always an overt sign of allergy a. papules b. wheal c. warts d. vesicles 32. An induration of 10 or more millimeters is considered a positive reaction for the following people, except: a. People born in areas of the world where TB is common (foreign-born persons) b. People who inject illicit drugs but who are known to be HIV negative c. People with chest x-ray findings suggestive of previous TB disease d. Low-income groups with poor access to health care 33. The use a viewing tube to evaluate a patient's lung and airways including the voice box and vocal cord. a. Bronchography b. Chest X-Ray c. Fluoroscopy d. Bronchoscopy 34. It is used to diagnose or treat patients by displaying the movement of a body part a. Bronchography b. Chest X-Ray c. Fluoroscopy d. Bronchoscopy 35. A radiographic (x-ray) examination of the interior passageways of the lower respiratory tract which may become visible on x-ray film after contrast dye is instilled. a. Bronchography b. Chest X-Ray c. Fluoroscopy d. Bronchoscopy 36. A test that records the electrical activity of the heart. a. Electrocardiogram b. Echocardiogram c. Stress Test d. Electroencephalogram 37. used in the evaluation of brain disorders a. Electrocardiogram c. Stress Test

b. Echocardiogram d. Electroencephalogram

38. Helps a doctor find out how well your heart handles work a. Electrocardiogram b. Echocardiogram c. Stress Test d. Electroencephalogram 39. A painless test that uses sound waves to create pictures of your heart. a. Electrocardiogram b. Echocardiogram c. Stress Test d. Electroencephalogram 40. a. supine position b. lithotomy position

c. sims position d. dorsal recumbent position 41. a. supine position b. lithotomy position c. sims position d. dorsal recumbent position

42.

a. supine position b. lithotomy position c. sims position d. dorsal recumbent position

43.

a. knee chest position b. orthopneic position c. high fowlers position d. none of the above

44. Thoracentesis is the removal of ____. a. CSF for laboratory analysis c. fluid from the peritoneal cavity 45. inability to retract the skin of the penis a. phismosis c. hypospadia 46. ventral location of the meatus a. phismosis c. hypospadia

b. fluid from the pleural cavity d. fluid from a joint space

b. paraphimosis d. cryptorchidism

b. paraphimosis d. cryptorchidism

47. inability of the foreskin of the penis to return to its original position a. phismosis b. paraphimosis c. hypospadia d. cryptorchidism 48. Undescended testes a. phismosis c. hypospadia 48. Name the pattern of respiration:

b. paraphimosis d. cryptorchidism a. Tachypnea b. Eupnea c. Bradypnea d. Hyperventilation a. Tachypnea b. Eupnea c. Bradypnea d. Hyperventilation a. Tachypnea b. Eupnea c. Bradypnea d. Hyperventilation a. Tachypnea b. Eupnea c. Bradypnea d. Hyperventilation

49. Name the pattern of respiration:

50. Name the pattern of respiration:

51. Name the pattern of respiration:

52. Complete blood count is a preoperative test to ensure both adequate carbon dioxide carrying capacity and homeostasis. a. True b. False c. I dont know d. Tralse

53. Perfusion scans evaluate ventilation, or the movement of air into and out of the bronchi and bronchioles. a. True b. False c. I dont know d. Tralse 54. The squatting position gives a greater increase of pressure in the pelvic cavity with minimal muscular effort. a. True b. False c. I dont know d. Tralse 55. Patients who are on tube feedings are typically placed in the High-Fowler's position a. True b. False c. I dont know 56. All of the following are purposes of physical examination, except: a. To obtain endline data about the clients functional activities b. To obtain data that will help exclude nursing diagnosis and plan of care c. all of the above d. none of the above 56. Bluish discoloration of the skin a. jaundice c. cyanosis

d. Tralse

b. pallor d. erythema

57. Usual color of the skin or body due to liver cirrhosis. a. jaundice b. pallor c. cyanosis d. erythema 58. Abnormal color of the skin associated with anemia. a. jaundice b. pallor c. cyanosis d. erythema 59. a skin condition characterized by redness or rash a. jaundice c. cyanosis 60. deep pitting edema a. + 2 c. +4

b. pallor d. erythema

b. +1 d. +3

61. An induration of 5 or more millimeters is considered a positive reaction for the following people. a. People with HIV infection b. Close contacts of people with infectious TB c. People with chest x-ray findings suggestive of previous TB disease d.All of the above 62. a. macule b. papule c. plaque d. vesicles

63.

a. macule b. papule c. plaque d. vesicles

64.

a. macule b. papule c. plaque d. vesicles

65.

a. macule b. papule c. plaque d. vesicles

66. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the clients vital sign hereafter. What phrase of nursing process is being implemented here by the nurse? a. Assessment b. Diagnosis c. Planning d. Implementation 67. It is best describe as a systematic, rational method of planning and providing nursing care for individual, families, group and community a. Assessment b. Nursing Process c. Diagnosis d. Implementation 68. Which of the following is the most important purpose of handwashing a. To promote hand circulation b. To prevent the transfer of microorganism c. To avoid touching the client with a dirty hand d. To provide comfort 69. Which of the following technique involves the sense of sight? a. Inspection b. Palpation c. Percussion d. Auscultation 70. Palpating the midclavicular line is the correct technique for assessing a. Baseline vital signs b. Systolic blood pressure c. Respiratory rate d. Apical pulse ESSAY: Answer briefly the following questions: (30 points). Write your answers at the back of the answer sheet. 1. Discuss the physical examination done when assessing the skin of the patient. Please include the techniques, normal and abnormal findings. (10 points)

2. State as many as you can the listed general principles in the Care of clients undergoing diagnostic tests. (10 points)

3. Why do you think nursing process is called the Heart of Nursing (10 points)