HEALTH ASSESSMENT (CHAPTER 1)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

Situation: Mrs. Martha Jacobs is a 70-year-old female who tripped at home 2 weeks
ago and suffered a sprain in her right ankle. Her initial treatment included an Ace
bandage wrap, ice, and s nonsteroidal anti-inflammatory drug (NSAID) for discomfort.
She was instructed to elevate the extremities for 3 days and to increase weight-bearing
activity gradually. She is being seen in a follow-up visit and reports that her ankle is
feeling much better, but she has abdominal discomfort.
When question about the problem, she stated, “My stomach has been kind of
achy and it really started a couple of days ago”. She replied to further questioning
saying, “I’ve only had one or two little hard bowel movements in the last five days”.
She denied having problem with bowel elimination in the past and stated, “I usually go
once a day and it’s soft”. In response to further questions she stated that she has been
“essentially, just sitting around, because I’m afraid to put too much weight on my
ankle. I have been eating as usual, but I haven’t been drinking so much because I hate
to have to get up to use the bathroom.”
A physical examination was conducted and the following were found: Bowel
sounds were present in all quadrants, percussion revealed dullness in the LLQ, the
abdomen was softly distended and non-tender, and there were dry feces in the rectum.

Questions:
1. Identify the findings as objective or subjective data.

2. After identifying the assessment data, formulate nursing diagnosis using a two-
part statement nursing diagnosis.
HEALTH ASSESSMENT (CHAPTER 2)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

I. Identification

1. __________________________It describes a state of life that is balanced, personally

satisfying, and characterized by the ability to adapt and to participate in activities that
enhance quality of life.

2. __________________________It refers to those action used to increase health or well

being and the improvement of the health of individuals, families and communities.

3. __________________________Theorist that defined wellness for the individual as an

integrated method of functioning that is oriented toward maximizing the potential of
which the individual is capable.

4. __________________________Level of prevention that implies health and a high level of

wellness for the individual.

5. __________________________ It refers to activity in which the oxygen is metabolized to

produce energy.

II. Matching Type

LEADING HEALTH INDICATORS

A. Biology
B. Social Environment
C. Physical Environment
________6. It consists of all the things that are experienced through the individual’s
senses and some harmful elements such as radiation, ozone and radon.
________7. It refers to interactions between individuals and others as well as the
institutions in an individual’s community, including churches, schools,
transportations system and protective services.
________8. It includes genetic background, gender, race and ethnicity, family history,
and problems occurring throughout life.

SLEEP REQUIREMENTS ACROSS THE AGE SPAN

1. 0 to 2mos a. 13 to 15hrs
2. 2 to 12mos b. 10.5 to 18.5hrs
3. 12 to 18mos c. 14 to 15hrs
 4. 18 to 3years d. 12 to 14hrs
5. 3 to 5 years e. 11 to 13hrs
6. 5 to 12 years f. 9 to 11hrs
7. Adults g. 7 to 9 hrs

HEALTH ASSESSMENT (CHAPTER 3)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

I. Multiple choice
___________1.It follows the oral phase and continues through about 3 years of age.
a. Oral phase b. anal phase c. phallic d. latency
___________2.Adie focuses energy on intellectual and physical pursuits and derives
pleasure from peer and adult relationships and school.
a. Oral phase b. anal phase c. phallic d. latency
___________3.It occurs during the 1st year of life when the mouth is the center of
pleasure.
a. Oral phase b. anal phase c. phallic d. latency
___________4.It covers the period from puberty through adulthood.
a. Oral phase b. anal phase c. phallic d. genitals
___________5. Phase that have a complex known as the Oedipus and Elektra.
a. Oral phase b. anal phase c. phallic d. latency
II. Matching Type
1. Birth to 1 year old a. generativity vs. stagnation
2. 1 to 2 years old b. integrity vs. despair
3. 2 to 6 years old c. intimacy vs. isolation
4. 6 to 12 years old d. identity vs. role confusion
5. 12 to 18 years old e. industry vs. inferiority
6. 19 to 40 years old f. initiative vs. guilt
7. 40 to 65 years old g. autonomy vs. shame and doubt
8. 65 years to death h. trust vs. mistrust

9. Fifteen months a. can pull pants up and down for

toileting
10. Eighteen months b. walks independently, creeps upstairs
11. Two and a half years c. runs, climbs, pull toys, and throws
12. Three years d. can stand on one foot for atleast 1
second
13. Two years e. tries to jump, can walk up and down stairs

III. Enumeration
 14-17. Identify the factors that influence growth and development
18-20. Give three principles of growth and development

HEALTH ASSESSMENT (CHAPTER 4)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

1. Define the following:

• Cultural Competence-

• Culture-

• Race-

• Ethnicity-

• Ethnocentrism-

• Diversity-

• Assimilation-
 2. Give the factors that affect the cultural aspects in healthcare.

HEALTH ASSESSMENT (CHAPTER 5)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

I. Identification

______________________1. Defined as being mentally, emotionally, socially, and spiritually

well.

______________________2. This includes hereditary characteristics or those related

to genetic makeup.

______________________3. Reflect the individual’s relationship with a higher power

that the person sees as larger than self that gives meaning to life.

______________________4. The individual’s capacity to identify and fulfill the societal

expectations related to the variety of roles assumed in a lifetime.

______________________5. The person’s who developed the use of HOPE questions

to use as a formal spiritual assessment in the client interview.

______________________6. The way a person thinks about physical appearance, size and
body functioning.

______________________7. A very complex system that includes knowledge, beliefs,

morals and customs that provide a pattern for living.

______________________8. This includes the individual’s personality, sense of self,

and role as a member of a larger society.

______________________9. The individual’s physical and emotional response to

psychosocial or physical treats or the “stressors”.

______________________10. Scale used for spiritual well-being measurement that

consists of 20 items and is written on English and Spanish language.

II. Essay Type

 11-15. Enumerate the 3 internal factors that influence the psychosocial health and
define each.

16-20. Enumerate the 4 external factors that influence the psychosocial health and
define each.

HEALTH ASSESSMENT (CHAPTER 6)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

I. Multiple Choice
A. Plexor F. Direct Percussion

B. Tuning Fork G. Auscultation

C. Fremitus H. Duration

D. Tape measure I. Flatness

E. Light Palpation J. Johannes Doppler

_____________________1. Vibratory tremors felt through the chest wall.

_____________________2. Derived from the Greek word “plexis” or a hammer or

tapping finger used to strike an object.

_____________________3. A type of percussion that is used to examine the thorax of

an infant and to assess the sinuses of an adult.

_____________________4. This refers to the length of time of the produced percussion

sound.

_____________________5. Is a high-pitched, very soft and lasts in a very short period

of time. This occurs over solid tissue such as muscle or bone.

_____________________6. Measures the circumference of the head, abdomen, and

extremities of the client.
 _____________________7. The skill of listening to sounds produced by the body.

_____________________8. This equipment measures the auditory function and vibratory

sensation.

_____________________9. Type of palpation used to assess surface characteristics,

such as skin texture, pulse, or a tender, inflamed area near the surface of the skin.

_____________________10. An Australian physicist that discovered the principle that

pitch of a sound varies in relation to the distance between the source and the
listener.

11-20. Enumerate the 5 percussion sounds. Define and write the specific locations of each.
(2 points each)

HEALTH ASSESSMENT (CHAPTER 7)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

1. What are the 5 cardinal signs or vital signs?

2. What are the 6 factors that affect the body temperature? Explain each.

3. Identify the routes for measuring the body temperature and give the advantages and
disadvantages of each.
 4. Draw a table that indicates the age and the normal respirations per minute.

5. Draw the Wong- Baker “FACES’ pain rating scale.

HEALTH ASSESSMENT (CHAPTER 8)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

I. Matching Type
______1) Mild to severe pain A. Acute Pain

______2) Vital signs normal B. Chronic Pain

______3) Client reports pain C. Both A and B

______4) Diaphoresis

______5) Client crying, rubbing or holding area

______6) Continues beyond healing

______7) Client appears depressed and withdrawn

______8) Pain behavior often absent

______9) Client appears restless and anxious

______10) Dilated pupils

II.
11-20) Define pain in terms of its duration, origin, location and etiology. (2 points each)

Duration Origin Location Etiology

1. ACUTE PAIN 1. CUTANEOUS PAIN 1. RADIATING PAIN 1. INTRACTABLE PAIN

2. CHRONIC PAIN 2. DEEP SOMATIC PAIN 2. REFERRED PAIN 2.NEUROPATHIC PAIN

3. VISCERAL PAIN 3. PHANTOM PAIN

HEALTH ASSESSMENT (CHAPTER 9)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

1. Define nutritional health.

2. Outline risk factors that affect nutritional health status.

3. Discuss the focus areas described in Healthy People 2010 in relation to nutrition.
4. Identify physical and laboratory parameters utilized in a nutrition assessment.

5. Identify components of a diet history and techniques for gathering diet history data.

HEALTH ASSESSMENT (CHAPTER 10)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

1. Discuss the purpose of the nursing health history.

2. Describe communication skills used by the professional nurse when conducting a

health history.

3. Identify barriers to effective nurse-client communication.

4. Discuss the phases of the client interview.

5. Describe the components of the nursing health history.

HEALTH ASSESSMENT (CHAPTER 11)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

1. Identify the anatomy and physiology of the skin, hair, and nails.

2. Develop questions to be used when completing the focused interview.

3. Explain client preparation for assessment of the skin, hair, and nails.
4. Differentiate normal from abnormal findings in physical assessment.

5. Describe developmental, psychosocial, cultural, and environmental variations in

assessment techniques and findings.

HEALTH ASSESSMENT (CHAPTER 12)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

1. Identify the anatomy and physiology of the structures of the head and neck.

2. Describe the techniques required for assessment of the head and neck.

3. Differentiate normal from abnormal findings in physical assessment of the head,

neck, and related structures.
4. Describe developmental, psychosocial, cultural, and environmental variations in
assessment techniques and findings.

5. Discuss the focus areas related to the overall health of the head, neck, and related
lymphatics as presented in Healthy People 2010.

HEALTH ASSESSMENT (CHAPTER 18)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

Direction: Write the answer on the space provided.

______1. A client is recovering from a cardiac catheterization where the right femoral
artery was accessed. Which of the following pulses can the nurse use to assess the
patency of this artery?

a. Radial b. Ulnar c. Anterior tibial d. Brachial

______2. The nurse assesses ankle edema in a client. What can the nurse say to the
client about this edema?

a. It’s caused by a blood clot. c. It’s caused by an infection.

b. It’s caused by blood pooling in the legs. d. It’s caused by tight

stockings.

______3. The neonatal nurse obtains a newborn’s blood pressure as being 76/40 mm Hg.
Which of the following should the nurse do with this information?

a. Write it down. This is a normal neonatal blood pressure.

b. Ask another nurse to check the blood pressure because it is low.

c. Call for help as the baby is going to cardiac arrest.

d. Call the physician.

______4. An eight-month-pregnant client is worried about all of the swollen veins she
has developed. What can the nurse tell the client about these veins?

a. It’s too bad that your legs look like that.

b. It’s because of the uterus causing blood to back up.

c. Maybe you should see a vascular surgeon.

d. Nothing. Phone the physician and report the finding.

______5. During the assessment of a client’s blood pressure, the nurse notices the client
starting to cry. What should the nurse do?

a. Nothing. c. Begin talking about the weather as a distraction to the

client.

b. Offer a paper tissue. d. Stop taking the blood pressure.

______6. A client tells the nurse, “My legs are always cold.” What significance does this
information have to the nurse?

a. The client smokes. c. The client has stasis ulcers.

b. The client has edema. d. The client might have arterial insufficiency.

_____7. A 47-year-old female tells the nurse, “I’m sorry for my hairy legs. I shaved a few
days ago and didn’t have time this morning to do it again.” What does this information
mean to the nurse?

a. The client has good peripheral extremity blood flow.

b. The client needs to plan more time for self-care in the morning.

c. The client has personal hygiene issues.

d. The client needs instruction on safe hair removal.

_____8. A client tells the nurse, “My legs really hurt when I walk.” What can the nurse
say to this client in response?

a. Maybe you shouldn’t walk as much and see if it improves.

b. Does the pain go away when you stop walking?

c. Maybe you have a lymph node infection in your groin.

d. That means you have to walk more.

_____9. A 33-year-old female client comes into the clinic with an edematous left calf
that is painful to the touch, feels warm, and is red. Which of the following should be
included in the focused interview of this client?

a. Have you had any facial swelling? c. What medications are you
taking?
b. Are you experiencing any emotional upset? d. How long have you had varicose
veins?

______10. The nurse wants to further assess a client’s radial pulse. What can be done to
do this assessment?

a. Conduct the Allen’s test. c. Conduct the manual compression

test.

b. Conduct the Trendelenburg’s test. d. Conduct the Babinski test.

______11. A client’s blood pressure is 158/90 mm Hg. What does this reading suggest to
the nurse?

a. This client has prehypertension. c. This client has stage 1 hypertension.

b. This blood pressure is normal. d. This client has stage 2 hypertension.

______12. A client’s fingertips are large and very round. How can this data be
documented?

a. Fingertips large and round c. Edematous finger tips

b. Oversized hands d. Possible clubbing and “turkey drumstick”

appearance of fingertips

______13. A client tells the nurse she has calf pain. Which of the following should the
nurse do?

a. Ask the client to walk around the examination room.

b. Walk with the client and ask her to rate the pain.

c. Call the physician and prepare for a heparin infusion.

d. Pull up on the client’s toes to see if there’s more pain.

______14. A 68-year-old client has lower extremity edema and thick skin discolored to a
dark brown. The client complains of his legs “feeling full.” Which of the following does
this information suggest to the nurse?

a. The client might have venous insufficiency.

b. The client has a deep vein thrombosis.

c. The client might have an arterial blood clot.

d. The client has varicose veins.

______15. Using the Healthy People 2010 recommendations for blood pressure and
stroke, the nurse wants to include actions for both of these conditions in the next staff
inservice. Which of the following actions would be appropriate for both of these
conditions?

a. Warning signs
b. Annual blood pressure screening

c. Exercise

d. Smoking cessation

HEALTH ASSESSMENT (CHAPTER 19)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

Direction: Write the answer on the space provided.

______1. A client tells the nurse, “I have a stomachache almost every day.” Which of the
following could the nurse respond to this client?

a. That’s not a good sign. c. I would see a surgeon if I were you.

b. That’s too bad. d. Maybe we can talk about your diet

______2. The nurse learns a client takes more than three times the recommended
amount of an over the counter pain reliever on a daily basis and is concerned about his
liver. What is the reason for this concern?

a. The patient is altering the body’s ability to produce insulin.

b. The patient is altering the body’s ability to digest fats.

c. Maybe the client would benefit from a prescribed pain reliever.

d. The liver might become damaged.

______3. The nurse is preparing to examine a client’s abdomen. Which of the following
landmarks could be considered a thoracic structure?

a. Umbilicus c. Pubic bone

b. Iliac crests d. Xiphoid process

______4. The nurse wants to assess bowel sounds on a client with abdominal pain.
Where would the nurse hear those sounds the best coming from the stomach?

a. RUQ c. LLQ

b. RLQ d. LUQ

______5. The nurse is planning to palpate a client’s bladder. Which area of the abdomen
should this palpation be done?

a. RLQ c. Left lumbar region

b. Right hypochondriac region d. Hypogastric region

______6. The mother of an 18-month-old child tells the nurse, “I can see his belly
rumbling. Is this normal?” Which of the following can the nurse respond to this client?

a. No. This is not normal.

b. This means his gallbladder is digesting fats.

c. There is a good pediatric gastroenterologist that I know who can help you.

d. The muscles of the abdomen are thin in babies. So you will see this.

______7. The 79-year-old female tells the nurse, “I don’t drink as much water as I should
because it makes me have to go to the bathroom.” What is this client prone to
developing?

a. Constipation c. Acid indigestion

b. Diarrhea d. Hemorrhoids

______8. An overweight client tells the nurse, “I was raised to eat everything on my
plate.” What can the nurse say to help with this client’s weight problem?

a. There are some small changes that you can make to help with your weight problem.
b. I was raised the same way.

c. Nothing. This is none of the nurse’s business.

d. I know; it’s not worth the effort to fight a losing battle.

______9. After inspecting a client’s abdomen, which assessment technique should the
nurse use next?

a. Percussion c. Palpation

b. Nothing. The assessment is complete. d. Auscultation

______10. A client comes to the hospital with nausea, vomiting, and ongoing sciatic
pain. Which of the following should be included in the focus interview with this client?

a. Review of other chronic diseases c. Blood pressure levels

b. Bowel habits d. Use of pain medication

______11. A client tells the nurse, “I get stomach burning when I drink wine.” Of what is
this information an indication?

a. Stomach bleeding c. Gastrointestinal irritation

b. Gallstones d. Intestinal ulcerations

______12. The client tells the nurse, “I’ve had diarrhea ever since my mother was
admitted to the hospital with a heart attack.” What can the nurse say to the client
about this information?

a. Are you having any other problems?

b. How’s your mother doing now?

c. What hospital is your mother in?

d. Stress can cause the bowels to act up.

______13. After assessing a client, the nurse writes “striae present bilateral costal
margins.” What should the nurse do with this information?

a. Ask the client if they’ve experienced any recent emotional events.

b. Notify the physician.

c. Suggest the client see a general surgeon.

d. Nothing. This is a normal finding.

______14. The nurse auscultates borborygmi on a client. What does this finding indicate
to the nurse?

a. The client had a full breakfast

b. The client is anorexic.

c. The client is hungry.

d. The client is obese.

______15. A 70-year-old male client comes into the clinic with weight loss and difficulty
swallowing. Which of the following should the nurse document for this client?

a. Dysphagia

b. Aphasia

c. Odynophagia

d. Bulimia

HEALTH ASSESSMENT (CHAPTER 20)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

Direction: Write the answer on the space provided.

______1. A client has been diagnosed with a kidney stone, lodged within the medulla of
the right kidney. Which of the following will this stone most effect?

a. The filtration of blood c. The removal of lymph

b. The collection of urine d. The clearance of toxins

______2. During the abdominal assessment of a male client, the nurse palpates large
round mass in the hypogastric region. Which of the following could explain what this
nurse has palpated?
a. The client has a tumor in his small intestines. c. The client has a distended or
full bladder.

b. The client is constipated. d. The client has kidney stones.

______3. During the assessment of a client’s urinary system, the nurse finds a location
on the client’s back. What landmark is this?

a. Umbilicus c. Costovertebral angle

b. Symphysis pubis d. Rectus abdominis muscle

______4. A client three weeks postpartum comes into the clinic with the complaints of
urinary frequency and burning with urination. Which of the following can the nurse
explain to this client about these symptoms?

a. Your bladder is stretched and it will feel funny.

b. Your kidneys are working fine.

c. This is normal after having a baby.

d. After having a baby, your bladder has less sensation and you could get an infection.

______5. A client says to the nurse, “I wish I could have a complete night’s sleep without
having to get up every two hours to go to the bathroom.” The nurse realizes this client
is experiencing:

a. Polyurea c. Benign prostatic hypertrophy

b. Nocturia d. Oliguria

______6. A client with urinary incontinence tells the nurse, “I haven’t been to the senior
center for weeks.” Which of the following would be an appropriate response for the
nurse to make to this client?

a. Are you getting enough rest?

b. Are you having problems eating?

c. Can you tell me why you haven’t gone to the senior center?

d. Are you having problems getting to the senior center?

______7. A 68-year-old female tells the nurse, “Since the hysterectomy, I can’t seem to
hold my water.” Which of the following can the nurse explain to this client?

a. That can happen after the kind of surgery you had.

b. Maybe the surgeon hurt your bladder with the surgery.

c. There’s always adult continence pads you could use.

d. That’s an odd complaint.

______8. A client asks the nurse, “What does having diabetes have to do with
urinating?” Which of the following would be an appropriate response to make to this
client?

a. You are asking too many questions. c. Diabetes can hurt the kidneys.

b. The doctors say it’s important. d. It doesn’t really.

______9. A client with long-standing renal disease comes into the clinic with the
complaint of “itchiness.” The nurse realizes this as being:

a. A drug reaction c. Potential urea build up

b. A nervous reaction d. Caused by an allergy

______10. The mother of a two-year-old child tells the nurse that the baby was born
deaf. Which of the following should the nurse do at this time?

a. Assess how well the baby sleeps. c. Assess the baby’s appetite.

b. Assess the mother’s level of rest. d. Assess the baby’s urine output.

______11. The nurse wants to assess the renal arteries. Where should the stethoscope
be placed to do this assessment?

a. Costovertebral angle

b. Epigstric region

c. Extended midclavicular line

d. Hypogastric region

______12. A client comes into the clinic with excruciating pain in his scrotum. Which of
the following should the nurse do?

a. Prepare to examine the kidneys.

b. Ask the client if he’s recently experienced trauma.

c. Offer him an over the counter analgesic.

d. Call an ambulance to take him to the emergency room.

______13. During the assessment of a client’s kidneys, the nurse is unable to palpate
the organs from the back of the client. What does this finding suggest to the nurse?
a. The client’s kidneys are misplaced.

b. The client’s kidneys are misshaped.

c. The client’s kidneys have atrophied.

d. Nothing. This is normal.

______14. A 79-year-old client on pain medication for spinal stenosis tells the nurse,
“Now I can’t make it to the bathroom and I’m wetting myself while I sleep.” The nurse
realizes this client is describing:

a. Functional incontinence

b. Urge incontinence

c. Total incontinence

d. Reflex incontinence

______15. The mother of a four-year-old male child tells the nurse, “I can’t believe he’s
still wetting the bed.” Which of the following can the nurse instruct this mother?

a. I’m sure he’s embarrassed.

b. He can wet the bed until eight or nine years old.

c. Wait for a few more months and see if stops. Let us know if it doesn’t.

d. Wait for a few more months and see if stops. Let us know if it doesn’t.

HEALTH ASSESSMENT (CHAPTER 21)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

Direction: Write the answer on the space provided.

______1. A 16-year-old male client tells the nurse, “I’m worried because I think I have
misshaped private parts.” Upon examination, the nurse learns the client is concerned
about his scrotum. Which of the following can the nurse explain to this client?

a. Well, your left testicle is lower than your right.

b. You are right. I think you should talk with the doctor.

c. You are right. The testicles should be even.

d. This is completely normal.

______2. A 32–male-client has been diagnosed with an infection of his epididymis. Which
of the following would be appropriate for the nurse to instruct this client?

a. It’s best if you wash at least three times a day.

b. This is unusual.

c. You might not be able to have children.

d. This is a common infection.

______3. A 45-year-old male is concerned because of the diagnosis of indirect hernia.

Which of the following would be an appropriate response for the nurse to make to

a. You can have severe pain with this hernia.

b. This is a medical emergency.

c. It’s rare but can occur.

d. This is the most common type of hernia.

______4. The mother of a two-month-old male infant says to the nurse, “I think there’s
something wrong. His scrotum looks so big.” Which of the following can the nurse say
in response to this mother?

a. I’m sure there’s nothing to worry about.

b. How many diapers does he use a day?

c. If it’s the size of a water balloon you should be concerned.

d. It can appear oversized.

______5. A 48-year-old male tells the nurse, “I have a good wife, but I’m just not
interested in sex anymore.” Which of the following would be appropriate for the nurse
to respond?

a. How is your job?

b. How is your appetite?

c. When was the last time you took a vacation?

d. Are you using any recreational drugs?

______6. The father of a 15-year-old male adolescent is concerned because he heard his
son “was touching another boy’s private parts in the shower at school.” Which of the
following can the nurse respond to this father?
a. Has he said anything to you about it?

b. Experimentation is common at his age and doesn’t mean he will be a homosexual.

c. He might be homosexual.

d. What does he do with his friends after school?

______7. The nurse with a history of sexual abuse has difficulty in assessing clients’ sex-
related organs. Which of the following can be done to support this nurse’s discomfort?

a. Only assign the nurse to clients without these healthcare issues.

b. Assist this nurse to find ways to work through her own feelings.

c. Suggest she see a therapist.

d. Discipline the nurse for incompetent care.

______8. A male client tells the nurse that he is concerned because his wife hasn’t been
able to get pregnant even though they’ve been trying for six months. What should the
nurse say in response to this client?

a. Are your sexual needs being filled?

b. Don’t give up. It hasn’t even been a year yet.

c. Did you have mumps as a child?

d. How many sexual partners have you had in your lifetime?

______9. A male client says to the nurse, “I’m so embarrassed. When I’m erect, my
penis isn’t straight. Is there some kind of surgery to fix this or something?” What can
the nurse respond to this client?

a. If you have surgery then you would be infertile.

b. There is a condition where the penis is bent when erect.

c. Surgery would make it worse.

d. That sounds pretty bad.

______10. In response to the nurse’s recommendation that he do a monthly testicular

examination, a male client says to the nurse, “We don’t touch our private parts where I
come from.” Which of the following should the nurse do with this information?

a. Change the subject of conversation.

b. Explain the reasons why a testicular examination should be done monthly.

c. Document “client refuses to conduct self-testicular examination.”

d. End the focused interview.

______11. The nurse is having difficulty during the focused interview of an adolescent
male’s sexual activity. Which of the following should the nurse do at this time?

a. Ask if he was sexually abused as a child.

b. Offer information on pregnancy, birth control, and STDs.

c. Change the subject.

d. Ask the adolescent’s parents to talk with him.

______12. During the inspection of a male client’s genitalia, the nurse notes a white
cheesy substance on the glans penis. What should the nurse document about this
finding?

a. Smegma present

b. Obvious STD discharge present

c. Sero-sanguinous drainage present

d. Purulent discharge on glans penis

______13. During the physical examination of a male client’s scrotum, the nurse
palpates a mass. What should the nurse do next with this information?

a. Perform transillumination to further assess the finding.

b. Ask the client how long he’s had a tumor in his testicle.

c. Document mass palpated, left testicle.

d. Nothing. This is a normal finding.

______14. During the assessment of a client’s prostate gland, the nurse notes multiple
varicose veins around the anal opening. Which of the following should be done with this
information?

a. Ask the client to sit for a few minutes before proceeding.

b. Ask for assistance to complete the prostate exam.

c. Note the characteristics of the varicosities and proceed with the exam.

d. Stop the examination.

______15. A 51-year-old male has never had a prostate examination. Which of the
following should be done for this client?

a. Encourage him to continue with monthly self-testicular examination.

b. Instruct him in the need for prostate examinations after the age of 50.

c. Schedule him for this examination as soon as possible.

d. Nothing.

HEALTH ASSESSMENT (CHAPTER 22)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

Direction: Write the answer on the space provided.

______1. Prior to the client having a gynecological examination, the client says, “How
can you see my uterus this way?” An appropriate response for the nurse to make would
be:

a. The uterus can be seen this way.

b. This exam is to check your vagina and cervix.

c. It’s to check your bladder muscle wall.

d. The fallopian tubes attach here.

______2. A woman in her third trimester of pregnancy tells the emergency room nurse,
“I was okay and then I had a big wad of bloody mucus come out of me and horrible
pain.” The nurse realizes this client is describing:

a. The Goodell’s sign

b. The Chadwick’s sign

c. The water breaking

d. The bloody show

______3. A 38-year-old female client tells the nurse, “I have no interest in sexual activity
since my husband died last year.” Which of the following does the nurse realize this
client is demonstrating?

a. Feelings of betrayal

b. Grief over the loss of a relationship

c. Fear of sexual intimacy

d. Free from worry of unwanted pregnancy

______4. During the focused interview, the nurse learns that a client had the onset of
menarche at age 10. Which of the following can the nurse surmise from this
information?

a. This is a little early.

b. This means the client has an endocrine malfunction.

c. This is late.

d. This is normal.

______5. A client tells the nurse, “I had an abortion years ago,” and proceeds to cry.
Which of the following should the nurse do to support this client?

a. Ask if she has any other children now.

b. Offer a tissue.

c. Ask how the client has she been emotionally since the abortion.

d. Change the subject.

______6. A teenage client comes into the clinic with the complaint of “itching and a
gross thick discharge” from her vaginal area. The nurse realizes this client is most likely
describing:

a. A yeast infection

b. Contact dermatitis

c. A syphilitic chancre sore

d. A herpes infection

______7. The nurse learns that a client does not perform self-examination of her
genitalia. What can the nurse do to instruct this client?

a. Instruct in the ways to conduct this examination and the reasons why it should be
done monthly.

b. Assure her that even though it’s unpleasant, it needs to be done.

c. Suggest she make a monthly appointment at the clinic for the nurse to examine this
area.

d. Ask her why she doesn’t do it.

______8. A 45-year-old female tells the nurse, “Confidentially, I’ve never had an orgasm
with a man.” Which of the following should the nurse respond to this client?

a. I’m sorry to hear that.

b. Have you talked with your partner about this?

c. So you’re saying you are never sexually aroused?

d. I don’t have any suggestions for you.

______9. During the focused interview, the nurse learns that a postmenopausal client
has “pain with sex” and is “hot almost all of the time.” Which of the following is this
client describing?

a. Symptoms of pending menstruation

b. Sexual arousal

c. Sexual inhibition

d. Menopausal symptoms of dyspareunia and hot flashes

______10. A college student comes into the clinic to be “checked” because she recently
“wasn’t careful” and is fearful of pregnancy. Which of the following should the nurse
respond to this client?
a. Were you date raped?

b. Do you know who the father might be?

c. What did you do?

d. Was illicit drug use involved?

______11. After the examination of a client, the nurse writes “labia majora symmetrical
and smooth, without lesions.” Which of the following does this information imply?

a. Nothing. This is a normal finding.

b. The client has a chancre sore on her labia majora.

c. The client’s majora are inflamed.

d. The client has a yeast infection.

______12. During the gynecological examination of a 19-year-old female, the nurse

notes a thin layer of skin within the vagina. This finding suggests:

a. This client has had multiple wounds to the vagina.

b. This client had forceful sex.

c. Nothing. This is normal in all females.

d. This client has never had sexual intercourse.

______13. During the palpation of a client’s vaginal walls, the nurse feels a bulging
along the posterior wall. This finding suggests to the nurse:

a. A prolapsed uterus

b. A cystocele

c. A rectocele

d. Nothing. This is a normal finding.

______14. During the gynecological examination of a client, an erosion is seen on the

surface of the cervix. Which of the following should be done?

a. Ask the client if she’s had traumatic intercourse.

b. Explain to the client that a biopsy will need to be done.

c. Nothing. This is a normal finding.

d. Ask the client if she’s ever had a surgical abortion.

______15. A 65-year-old female client asks the nurse, “When can I stop having these
Pap smears?” An appropriate response for the nurse to make to this client would be:

a. At least once every three years.

b. Never. They are needed annually.

c. After age 70 if you’ve had three years of normal results.

d. At least once per year.

HEALTH ASSESSMENT (CHAPTER 23)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

1. How to test for muscle strength of the wrist and fingers?

 2. Enumerate and explain the different abnormalities of the spine.

HEALTH ASSESSMENT (CHAPTER 24)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

1. What are the 12 cranial nerves? Give its function and corresponding activity.
 2. Explain the following problems related to motor function.

• Ataxic Gait

• Scissors Gait

• Steppage Gait

• Festination Gait

• Fasciculation

• Tic

• Tremor
• Athetoid Movement

• Dystonia

• Myoclonus

HEALTH ASSESSMENT (CHAPTER 25)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

1. What are the primitive reflexes of early childhood?

2. How to elicit these reflexes?

3. When will it disappear?

HEALTH ASSESSMENT (CHAPTER 26)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: _____________________________

1. Draw the external female genitalia.

 2. Give common complications in pregnancy, with description and assessment findings.

• First trimester

• Second and Third trimester

HEALTH ASSESSMENT (CHAPTER 27)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: __________________________
 Situation: Mary and Lou have recently had their first child. Mary tearfully tells her
primary caregiver that Lou has refused any parenting responsibilities. He has told
Mary that the baby is hers and she should take care of him. Recently, Lou has also
been coming home late from work with alcohol on his breath. Fill in the appropriate
elements of the care plan for this client in the boxes below.

I. ASSESSMENT

II. DIAGNOSIS

III. PLANNING AND

IMPLEMENTATION

IV. EVALUATION

HEALTH ASSESSMENT (CHAPTER 13)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: __________________________

ACTIVITY: PENCIL AND PAPER TEST (15 points)

INSTRUCTION: Identify the cranial nerves involve when these disruption of function
results is present.
______________ 1. Inability to move eye upward or temporally
______________ 2. Inability to move eye down or nasally
______________ 3. Inability to move eye temporally
______________ 4. Inability to move eye upward temporally
______________ 5. Inability to move eye down ward or temporally
______________ 6. Inability to move eye nasally

Matching type: Identify the eye abnormalities; write the letter of your choice in the
blank before the number.

_____ 7. Is the normal refractive condition of the eye a. Hyperopia

in which light rays are brought into sharp focus b.
Emmetropia
retina. c. Myopia
_____ 8. An inherited condition in which the eye d. Astigmatism
is shorter than normal. The light rays focus behind e.
Strabismus
the retina. F. Acute glaucoma
_____9.Is generally inherited and occurs when the eye is g.
Cataract
longer than normal. h. Conjunctiva
_____10.Is often a familial condition in which the refraction i. Chalazion
of light is spread over a wide area rather than in j.
Hordeolum (Stye)
a distinct point of the retina.
_____11. Is a result of a staphylococcal infection of hair follicle
on the margin of the lids.
_____12. Is an infection of the conjunctiva usually due to
bacteria or virus but which may result from chemical
exposure.
_____13. Is a firm, nontender molecules on the eyelid, arising
from infection of the meibomian gland.
_____14. Is an opacity in the lens, usually occurs in aging.
_____15. Is a result of sudden increase in intraocular pressure
resulting from blocked flow of fluid from anterior
chamber.
HEALTH ASSESSMENT (CHAPTER 14)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: __________________________

INSTRUCTION: Encircle T if true and F for false. (15 points)

1. The outer ear funnels sound T F

2. Cerumen is made in the ear canal T F

3. The eardrum separates the outer and inner ear T F

4. The Eustachian tube helps equalize pressure in the ear T

F

5. Structures of the ear regulate balance T F

6. Epistaxis is a nosebleed T F

7. Sinusitis is inflammation of sinuses following an upper respiratory infection T

F

8. Rhinitis is a nasal inflammation usually not a cause of viral infection or allergy

T F

9. Nasal polyps are pale, round, firm, non-painful overgrowth of nasal mucosa T
F

covered by allergic rhinitis

10. Sight in growth of the lower nasal septum is called Deviated Septum
T F

11. Inflammation of gums is gingivitis T F

12. Black hairy tongue results as a permanent condition by the inhibition of

normal bacteria, growth of fungus on the papillae of the tongue T

F

13. Gingival hyperplasia is atrophy of the gums T

F

14. Tonsillitis is inflammation of the tonsils T

F
 15. A condition as a result of Vit. B and iron deficiency is called Smooth Tongue
T F

HEALTH ASSESSMENT (CHAPTER 15)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: __________________________

ILLUSTRATION (20 points)

ACTIVITY: ILLUSTRATE THE FOLLOWING NORMAL AND ABNORMAL RESPIRATORY
RATES AND PATTERNS IN THE SPACE.
I NORMAL FINDINGS:
EUPNEA
Even depth, regular pattern
Inspiration = expiration; occasional sigh
EUPNEA with sigh

II ABNORMAL FINDINGS:
A.TACHYPNEA
Slow, regular respirations,
Rate>24
Precipitating factors:
fever,fear,exercise,pneumonia,pleuritic
pain,alkalosis
B.BRADYPNEA
Slow,regular respiration,
Rate<10
Precipitating factors: diabetic, coma, drug-
induced respirator depression, increased
Intracranial pressure
C.HYPERVENTILLATION
Irregular, shallow respiration,
Rate>24
Precipitating factors: extreme exertion,
fear, diabetic ketoacidosis
(kussmauls),hypoxia, Hypoglycemia
D.HYPOVENTILLATION
Irregular, shallow respiration
Rate<10
Precipitating factors: narcotic overdose,
anesthetics, prolong bed rest, chest
eplenting
E.CHEYNE-STOKES
Periods of deep breathing alternating with
periods of apnea, regular pattern
Precipitating factors: normal children and
aging, heart failure, uremia, brain
damage, drug-induced respiratory
depression
F.BIOT’S (Ataxic) Respirations
Shallow, deep respirations with periods of
apnea,
Irregular pattern
Precipitating factors: respiratory
depression, brain damage
G.SIGHING
Frequent sighs
Precipitating factors: hyperventilation
syndrome, nervousness. Causes: dyspnea,
dizziness

H.OBSTRUCTIVE BREATHING
Prolong expiration
Precipitating factors: COPD, asthma,
chronic bronchitis
HEALTH ASSESSMENT (CHAPTER 16)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: __________________________

ACTIVITY: ACTUAL DEMONSTRATION (female to female student/male to

male student)
TEACHING SELF BREAST EXAMINATION (60 points)

1. Teach the client to observe her breast in front of a mirror and in good lighting. Tell
her to observe her breast in four positions.
a. With her arms relaxed and at her sides.
b. With her arms lifted over her head.
c. With her hands pressed against her hips
d. With her hands pressed together at the waist, leaning forward.
Instruct her to look at each breast individually, and then to compare them. She
should observe for any visible abnormalities, such as lumps, dimpling, deviation,
recent nipple retraction, irregular shape, edema, discharge or asymmetry.

2. Teach the client to palpate breast while standing or sitting with one hand behind her
head. Tell her that many women palpate their breast in shower because water and
 soap make the skin slippery and easier to palpate all areas of her breast, using the
concentric circles technique. Tell her to press the breast tissue gently against the
chest wall and to be sure to palpate the axillary tail.

3. Instruct the client to palpate her breast again while lying down, as described in step
2. Suggest that she place a folded towel under the shoulder and back on the side to
be palpated. The arm on the examining side should be over her head, with her hand
under the head.

4. Teach the client to palpate the areolae and nipples next. Show her to compress the
nipple to check for discharge.

5. Remind the client to use a calendar to keep a record of when she performs SBE.
Teach her to perform SBE at the same time each month, usually 5 days after the
onset of menses, when there is less hormonal influence on tissues.

6. Remind clients who are post menopausal to continue monthly SBE. They should
perform the exam at the same time each month.

HEALTH ASSESSMENT (CHAPTER 17)

Name: ________________________________ Score: ____________________

Section: _______________________________ Date:
_____________________
Instructor: __________________________

Identification:

_________________1. Narrowing of the left mitral valve.

Etiology: Rheumatic Fever of cardiac infection
Findings: Murmur heard at the apical area with the client in left
lateral position
_________________ 2. Narrowing of the aortic valve
Etiology: Congenital bicuspid valves, Rheumatic heart disease,
atherosclerosis
Findings: Murmur of aortic area, RSB 2nd ICS
_________________ 3. Backflow of blood from the left ventricle in the left atrium
Etiology: Rheumatic fever, myocardial infarction, rupture of chordae
tendinae
 Findings: Murmur at apex, sound is transmitted to (L) axillae
_________________ 4. Narrowing of the opening between the pulmonary artery and the
right ventricle
Etiology: Congenital
Findings: Murmur at pulmonic area radiates to neck. Thrill in (L) 2nd
and 3rd IC
_________________ 5. Narrowing or stricture of the tricuspid valve of the heart
Etiology: Rheumatic heart disease, congenital defect, right atrial
myxoma
Findings: Murmur heart with the bell of the stethoscope over the
tricuspid area
_________________ 6. Redundancy of the mitral valve, Leaflets so they prolapsed into the
left atrium
Etiology: May occur with pectus excavatum often unknown
Findings: (L) lower sterna border in position
_________________ 7. Backflow of blood from the aorta into the left ventricle
Etiology: Rheumatic heart disease, endocarditis, Marfan’s Syndrome,
syphilis
Findings: Murmur with client leaning forward. Click in 2nd ICS
_________________ 8. Regurgitation occurs through the defect resulting in a holosystolic
murmur
_________________ 9. Regurgitation occurs through the fdefefct resulting in a harsh, loud,
high-pitched murmur heard at the LSB 2nd ICS
_________________ 10. Aorta is severely narrowed in the region inferior to the left
subclavian artery.
 ACTIVITY AND
WORKBOOK
IN
HEALTH
ASSESSMENT

By:
Odette Macarubbo, RN (Chapter 1-4)
Ma. Jessica Ahorro, RN (Chapter 5-8)
Melody Gatdula, RN (Chapter 9-12)
Zenaida Evangelista, RN (Chapter 13-17)
Don Xavier Gancia, RN (Chapter 18-22)
Lhorlit Dela Pena, RN (Chapter 23-27)