Health Assessment Denver School of Nursing
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Free Health Assessment Denver School of Nursing Questions
The nurse is assessing a client who has swelling in the lower extremities. Which of the following findings would most likely indicate lymphedema rather than general edema
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The swelling is graded at a 3 in both lower extremities.
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The swelling is pitting and feels firm to the touch.
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The swelling improves with elevation of the affected limb.
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The swelling gradually develops and feels hard and lumpy.
Explanation
Correct Answer D: The swelling gradually develops and feels hard and lumpy.
Explanation:
Lymphedema is caused by impaired lymphatic drainage, leading to the accumulation of lymph fluid in tissues. It typically presents as non-pitting, chronic swelling that feels hard, lumpy, or fibrotic, especially in advanced stages. The condition often develops gradually and does not improve significantly with elevation.
Why the other options are incorrect:
A) The swelling is graded at a 3 in both lower extremities:
This describes pitting edema grading, common in venous insufficiency or heart failure, not lymphedema.
B) The swelling is pitting and feels firm to the touch:
Pitting edema is more associated with fluid overload or venous disease, not with lymphedema, which is usually non-pitting.
C) The swelling improves with elevation:
Edema from venous insufficiency or heart failure typically improves with elevation; lymphedema does not respond significantly to elevation.
During a cardiac assessment, the nurse palpates the point of maximal impulse (PMI). Which of the following best describes the normal location of the PMI
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At the midclavicular line, fifth intercostal space, left side of the chest
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At the midclavicular line, second intercostal space, left side of the chest
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At the left sternal border, fourth intercostal space
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At the anterior axillary line, sixth intercostal space, right side of the chest
Explanation
Correct Answer A: At the midclavicular line, fifth intercostal space, left side of the chest
Explanation:
The point of maximal impulse (PMI) is typically found at the fifth intercostal space, along the left midclavicular line. This is where the apex of the heart touches the chest wall during contraction and is most easily felt. A displaced PMI may indicate an enlarged heart or other cardiac abnormalities.
Why the other options are incorrect:
B) Second intercostal space:
This is the aortic or pulmonic area, not the PMI.
C) Left sternal border, fourth intercostal space:
This is the tricuspid area, not where the PMI is normally felt.
D) Right side, anterior axillary line:
The PMI is not found on the right side of the chest; this would suggest abnormal anatomy or a documentation error.
The nurse is assessing a client's capillary refill during a physical exam. Which of the following findings would require further investigation
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Capillary refill of 2 seconds in the right hand and 2 seconds in the left hand.
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Capillary refill of less than 2 seconds in the fingers and toes.
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Capillary refill greater than 5 seconds in the fingers and toes.
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Capillary refill of 2 seconds in both hands, but 1 second in both feet.
Explanation
Correct Answer C: Capillary refill greater than 5 seconds in the fingers and toes.
Explanation:
Normal capillary refill is less than 2 seconds. A refill time greater than 5 seconds suggests impaired peripheral perfusion, which may be due to conditions like shock, hypothermia, or vascular disease. This finding requires further evaluation and possible intervention.
Why the other options are incorrect:
A) 2 seconds in both hands:
This is normal and symmetric—no concern.
B) Less than 2 seconds in fingers and toes:
Also normal and indicates good perfusion.
D) 2 seconds in hands, 1 second in feet:
Both are within normal limits, and although there’s a slight variation, it’s not clinically significant.
The nurse is auscultating a client's heart sounds and hears a soft, blowing sound between heartbeats. Which of the following is the most likely cause of this sound
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Splitting of heart sounds
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Pericardial friction rub
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Normal heart sound
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Heart murmur
Explanation
Correct Answer D: Heart murmur
Explanation:
A heart murmur is a soft, blowing, or whooshing sound heard between heartbeats, caused by turbulent blood flow through the heart valves or chambers. Murmurs may be innocent or indicate underlying conditions like valve stenosis or regurgitation.
Why the other options are incorrect:
A) Splitting of heart sounds:
This refers to a normal variation in timing between the aortic and pulmonic valves closing, usually heard during inspiration—not a blowing sound.
B) Pericardial friction rub:
This produces a high-pitched, scratchy or grating sound, not soft or blowing, and is associated with pericarditis.
C) Normal heart sound:
Normal heart sounds (S1 and S2) are "lub-dub" sounds, not soft blowing; any blowing sound between them is abnormal.
An elderly client expresses concern about getting short of breath more easily during daily activities. The client asks the nurse, "Am I getting sick, or is this just old age?" Which therapeutic response by the nurse is most appropriate
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It's likely due to anxiety. Try to stay calm and breathe slowly.
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Some shortness of breath can be normal as we age because the lungs become less elastic.
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That doesn't sound normal. You should avoid activity until the provider can assess you.
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You probably just need to rest more often
Explanation
Correct Answer B: Some shortness of breath can be normal as we age because the lungs become less elastic.
Explanation:
This response provides a therapeutic and educational answer that addresses the client’s concern without dismissing it. It acknowledges that age-related changes, such as decreased lung elasticity and reduced respiratory muscle strength, can cause mild shortness of breath during exertion. However, it also opens the door for further assessment if the symptoms worsen or are unusual.
Why the other options are incorrect:
A) It's likely due to anxiety
Assumes a cause without proper assessment and may dismiss a potentially serious concern.
C) That doesn't sound normal. You should avoid activity
Discourages activity prematurely and may cause unnecessary worry without further evaluation.
D) You probably just need to rest more often.
Minimizes the client’s concern and doesn’t address the potential underlying causes.
An elderly client is recovering from hip replacement surgery. Shortly after being assisted out of bed, the client becomes anxious and restless. The nurse notes that the client's skin is pale and cool to the touch, and the client is short of breath. Which action should the nurse take first
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Check the client's oxygen saturation
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Apply supplemental oxygen via nasal cannula
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Use therapeutic communication to reduce the client's anxiety
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Assess the client's orthostatic vital signs
Explanation
Correct Answer A: Check the client's oxygen saturation
Explanation:
The client is showing signs of possible hypoxia, such as anxiety, restlessness, shortness of breath, and cool, pale skin. The first priority is to assess oxygen saturation using a pulse oximeter. This provides critical data to guide immediate interventions such as oxygen administration.
Why the other options are incorrect:
B) Apply supplemental oxygen via nasal cannula:
This may be necessary, but the nurse must first assess oxygen levels to determine the need and appropriate flow rate.
C) Use therapeutic communication to reduce anxiety:
While helpful, addressing the physiological cause of anxiety (potential hypoxia) takes precedence.
D) Assess orthostatic vital signs:
This is not the priority action in an acute respiratory situation and would delay necessary oxygen assessment and treatment.
A nurse is assessing a client who presents with ear pain, fever, and a feeling of fullness in the ear. The client also reports difficulty hearing. Upon examination, the nurse notes that the ear canal is clear and there is no redness or swelling. The tympanic membrane is red, bulging, and there is fluid behind the ear drum. Based on these findings, which condition does the nurse most likely suspect
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Otitis media
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Otitis externa
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Sinusitis
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Mastoiditis
Explanation
Correct Answer A: Otitis media
Explanation:
Otitis media is an infection or inflammation of the middle ear. It is commonly characterized by:
Ear pain (otalgia)
Fever
Sensation of fullness
Hearing difficulty
Red, bulging tympanic membrane
Presence of fluid behind the eardrum
In this case, the clear ear canal and bulging red tympanic membrane with fluid behind it are classic signs of acute otitis media.
Why the other options are incorrect:
B) Otitis externa:
Also known as "swimmer’s ear," this is an inflammation of the external auditory canal, often presenting with redness, swelling, and tenderness of the canal itself, which is not present here.
C) Sinusitis:
Sinusitis involves inflammation of the sinuses, not the ear. While it can cause referred ear pressure or pain, it does not involve tympanic membrane changes.
D) Mastoiditis:
A complication of untreated otitis media, mastoiditis involves infection of the mastoid bone behind the ear. It typically presents with swelling and tenderness over the mastoid process, which is not noted in this case.
The nurse is performing a cardiac health assessment. Which of the following findings during inspection would suggest a potential abnormality in the client's cardiovascular system
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The client's skin appears pink, warm, and dry with no cyanosis or edema.
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The chest appears symmetrical, with no visible pulsations.
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The nurse observes a visible apical impulse at the 5th ICS at the left sternal border.
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The client's jugular veins are not distended when sitting at a 45-degree angle.
Explanation
Correct Answer C: The nurse observes a visible apical impulse at the 5th ICS at the left sternal border.
Explanation:
A visible apical impulse at the 5th intercostal space (ICS) at the left sternal border is not in the normal location. The normal point of maximal impulse (PMI) should be at the 5th ICS at the midclavicular line. A PMI at the left sternal border may suggest cardiac enlargement or displacement, which is abnormal.
Why the other options are incorrect:
A) Skin pink, warm, dry, no cyanosis or edema:
These are all normal findings indicating adequate perfusion.
B) Chest symmetrical, no visible pulsations:
This is normal; visible pulsations elsewhere may suggest aneurysm or other abnormalities.
D) Jugular veins not distended at 45-degree angle:
This is a normal finding; jugular vein distention at this angle could indicate right-sided heart failure or elevated central venous pressure.
The nurse is assessing heart sounds in a client and is using the stethoscope to detect a split S2. What part of the stethoscope should the nurse use for this client
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The diaphragm is best for detecting high-pitched sounds, such as a split S2.
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The diaphragm is best for detecting low-pitched sounds, such as a split S2.
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The bell is best for detecting high-pitched sounds, such as a split S2.
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The bell is best for hearing low-pitched sounds, such as a split S2.
Explanation
Correct Answer A: The diaphragm is best for detecting high-pitched sounds, such as a split S2.
Explanation:
The split S2 (second heart sound) is a high-pitched sound that occurs when the aortic and pulmonic valves close at slightly different times. The diaphragm of the stethoscope is designed to detect high-pitched sounds such as S1, S2, splits, and most murmurs. It should be pressed firmly against the chest.
Why the other options are incorrect:
B) The diaphragm is best for detecting low-pitched sounds:
Incorrect — low-pitched sounds like S3 and S4 are best heard with the bell, not the diaphragm.
C) The bell is best for detecting high-pitched sounds:
Incorrect — the bell is used for low-pitched sounds.
D) The bell is best for hearing low-pitched sounds, such as a split S2:
Incorrect — while the bell is for low-pitched sounds, the split S2 is high-pitched and best heard with the diaphragm.
A nurse is assessing a client with a pressure injury on the sacral area. The wound is deep, showing full-thickness skin loss but does not expose underlying muscle or bone. There is visible subcutaneous tissue, and the wound appears to have some slough. Based on this description, which of the following stages best describes this pressure injury
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Stage IV
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Stage I
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Stage II
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Stage III
Explanation
Correct Answer D: Stage III
Explanation:
Stage III pressure injuries involve full-thickness skin loss, where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough (yellowish dead tissue) may be present but does not obscure the depth of tissue loss. These wounds may include undermining or tunneling, and the injury extends through the dermis into the subcutaneous tissue.
Why the other options are incorrect:
A) Stage IV:
Involves exposed bone, muscle, or tendon. Since the wound described does not expose these deeper structures, it is not a Stage IV.
B) Stage I:
Characterized by non-blanchable redness of intact skin. There is no open wound or tissue loss, so this does not apply.
C) Stage II:
Involves partial-thickness skin loss with exposed dermis. The wound is usually shallow with no visible fat or slough, so the injury described is too deep to be classified as Stage II.
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