Question

A nurse is obtaining a history from a 30-year-old female client. Which of the following questions would you ask to assess health promotion act?

Answer 1

Correct Answers:

"Do you have annual breast examinations?"

Rationale :

🔶 This question focuses on preventive health behavior, which is key in assessing health promotion.

🔶 Annual breast exams help detect early signs of breast cancer, fulfilling a health promotion goal.

🔶 Asking about annual exams aligns with primary prevention strategies in nursing.

🔶 It evaluates whether the patient participates in regular screening, a component of health promotion.

🔶 It supports nursing goals of education, risk reduction, and early detection.

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Answer 2

Correct Answers:

Hypothalamus controls temperature and regulates sleep

Rationale :

🔷 The hypothalamus plays a major role in homeostasis, especially temperature regulation.

🔷 It also controls circadian rhythms that influence the sleep-wake cycle.

🔷 This region also manages appetite, thirst, and emotional responses.

🔷 It is anatomically part of the diencephalon in the brain structure.

🔷 Its dysfunction may present as temperature instability or sleep disorders.

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Answer 3

Correct Answers:

Stereognosis.

Rationale :

🟢 Stereognosis is the ability to recognize an object by touch with eyes closed.

🟢 It tests parietal lobe and sensory pathway function.

🟢 It helps assess higher cortical sensory function and proprioception.

🟢 It distinguishes between tactile agnosia and normal recognition.

🟢 Loss may indicate a lesion in sensory cortex or posterior column pathway.

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Answer 4

Correct Answers:

Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.

Rationale :

🔸 Pain expression is culturally influenced, and not all patients react the same.

🔸 Verbal and non-verbal cues vary among cultures and individuals.

🔸 Nurses must perform a culturally competent pain assessment.

🔸 This acknowledges that pain perception and expression are subjective experiences.

🔸 Proper pain management requires personalized care, not assumptions.

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Answer 5

Correct Answers:

When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said
As the patient says a long "ee-ee-ee sound, the examiner also hears a long "ee-ee-ee" sound.
Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice

Rationale :

🟠 Indicates normal bronchophony where sound is heard but not clearly understood.

🟠 Normal egophony presents with same "ee" sound, indicating healthy lung tissue.

🟠 Whispered pectoriloquy is faint or inaudible in normal lungs; louder in consolidation.

🟠 All these reflect air-filled lungs with no consolidation.

🟠 They help rule out conditions like pneumonia or pleural effusion.

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Answer 6

Correct Answers:

Herniated nucleus pulposus.

Rationale :

🔴 The positive straight leg raise test and radiating pain suggest sciatica due to herniation.

🔴 Herniated discs often compress spinal nerve roots, causing leg pain.

🔴 Lateral tilting reflects spinal alignment compensation.

🔴 It’s common in the lumbar region, especially after strain or injury.

🔴 Confirmed with MRI or CT scan, but physical exam gives critical clues.

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Answer 7

Correct Answers:

Positive Babinski sign, which is abnormal for adults.

Rationale :

🟡 Toes fanning and dorsiflexion in adults signals a neurological abnormality.

🟡 Normal adult response is toe flexion or no movement.

🟡 Indicates upper motor neuron lesion in conditions like stroke, MS.

🟡 Babinski is normal only in infants under 2 years.

🟡 Part of routine neurologic assessment in altered mental states.

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Answer 8

Correct Answers

Pulse 68 bpm [ Objective ]
7 x 4 cm scar on the left lower abdomen. [ Objective ]
Blood pressure 148/92 [ Objective ]
History of allergies [ Subjective ]
Last menstrual period [ Subjective ]
Shortness of breath [ Subjective ]
Pain 8/10 [ Subjective ]
Brawny edema in lower extremities. [ Objective ]
Temperature 101 SF [ Objective ]
Use of medications at home [ Subjective ]

Rationale :

🟣 Objective = observed or measured (e.g., vitals, visible signs)

🟣 Subjective = patient-reported symptoms or history

🟣 Clear distinction helps guide nursing documentation and care

🟣 Promotes accurate diagnosis and prioritization

🟣 Both forms together form a complete nursing assessment

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Answer 9

Correct Answers:

Health-related beliefs

Rationale :

🟤 Cultural health assessments explore beliefs and practices affecting care.

🟤 This includes views on illness, treatment, healing.

🟤 Helps avoid cultural imposition or misunderstandings.

🟤 Aligns care with client values and preferences.

🟤 Important for holistic, culturally sensitive nursing.

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Answer 10

Correct Answers:

6

Rationale :

⚫ The Glasgow Coma Scale measures eye, verbal, and motor responses.

⚫ Scores range from 3 (deep coma) to 15 (fully alert).

⚫ A score of 6 or less indicates coma and requires emergency intervention.

⚫ This helps monitor LOC and neurological status over time.

⚫ GCS is a critical tool in trauma and neuro assessments.

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options	Subjective	Objective
Pulse 68 bpm
7 x 4 cm scar on the left lower abdomen.
Blood pressure 148/92
History of allergies
Last menstrual period
Shortness of breath
Pain 8/10
Brawny edema in lower extremities.
Temperature 101 SF
Use of medications at home

RN Nurs~220 Health Assessment Exam 1

No.

1 :
A nurse is obtaining a history from a 30-year-old female client. Which of the following questions would you ask to assess health promotion act?

2 :
Which of the following statements is true regarding the function of the brain?

3 :
During an assessment of the neurological system, a nurse places a key in the hand of a client, and he identifies it as a key. The nurse would describe this finding as

4 :
The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?

5 :
The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)

6 :
During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, the patient complains of a pain going down his buttock into his leg. The nurse suspects:

8 :
The nurse is performing a physical assessment on a newly admitted patient.

Correct Answers

9 :
While conducting a cultural health assessment a nurse should include which of the following?

10 :
The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

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RN Nurs~220 Health Assessment Exam 1

No.

1 : A nurse is obtaining a history from a 30-year-old female client. Which of the following questions would you ask to assess health promotion act?

2 : Which of the following statements is true regarding the function of the brain?

3 : During an assessment of the neurological system, a nurse places a key in the hand of a client, and he identifies it as a key. The nurse would describe this finding as

4 : The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?

5 : The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)

6 : During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, the patient complains of a pain going down his buttock into his leg. The nurse suspects:

8 : The nurse is performing a physical assessment on a newly admitted patient.

Correct Answers

9 : While conducting a cultural health assessment a nurse should include which of the following?

10 : The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

1 :
A nurse is obtaining a history from a 30-year-old female client. Which of the following questions would you ask to assess health promotion act?

2 :
Which of the following statements is true regarding the function of the brain?

3 :
During an assessment of the neurological system, a nurse places a key in the hand of a client, and he identifies it as a key. The nurse would describe this finding as

4 :
The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?

5 :
The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)

6 :
During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, the patient complains of a pain going down his buttock into his leg. The nurse suspects:

8 :
The nurse is performing a physical assessment on a newly admitted patient.

9 :
While conducting a cultural health assessment a nurse should include which of the following?

10 :
The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?