Phsical Assessement Exam 2

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Sample questions from Phsical Assessement Exam 2

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.During a home visit, a 76-year-old client with hypertension reports new dizziness when standing. The client's supine BP is 146/82 mm Hg and standing BP is 112/68 mm Hg; pulse rises from 78 to 96/min. Which action should the nurse take first?

   • A.Assist the client to sit or lie down and assess for injury or symptoms
   • B.Document the finding as an expected effect of aging
   • C.Teach the client to restrict fluids to reduce blood pressure
   • D.Ask the client to walk to determine whether the dizziness resolves

   Rationale: The substantial orthostatic BP drop with dizziness creates an immediate fall risk, so the client should be positioned safely and assessed. Fluid restriction could worsen volume depletion, and walking increases the chance of a fall. Orthostatic changes are not an inevitable or harmless consequence of aging and require follow-up.

2. 2.In an outpatient clinic, a 52-year-old client says, "My headache came on all at once, and it is the worst pain I have ever felt." The client is alert, with BP 174/96 mm Hg and no history of similar headaches. Which response is the priority?

   • A.Ask the client to keep a headache diary for the next month
   • B.Recommend an over-the-counter analgesic and reassessment tomorrow
   • C.Schedule a routine appointment with the primary care provider
   • D.Arrange immediate emergency evaluation for a possible intracranial event

   Rationale: A sudden, severe, first-time headache is a red flag that requires urgent evaluation for a potentially life-threatening cause. Routine follow-up, a diary, or self-treatment could delay time-sensitive assessment. The elevated BP adds concern but does not establish the cause.

3. 3.At change of shift on a medical-surgical unit, a 68-year-old client with pneumonia has the following chart findings. Refer to the client's chart. Which findings require the nurse to notify the rapid response team or provider immediately? Select all that apply.

   • A.New confusion documented at 1000
   • B.Heart rate 92/min at 0800
   • C.SpO2 88% on 2 L/min nasal cannula at 1000
   • D.Respiratory rate 30/min at 1000
   • E.Temperature 37.8 C at 0800

   Rationale: The SpO2 decline to 88%, new confusion, and RR of 30/min are signs of worsening oxygenation and possible acute deterioration requiring prompt escalation. A temperature of 37.8 C warrants monitoring but is not the most urgent finding by itself. The HR of 92/min at 0800 is not concerning in isolation.

4. 4.A charge nurse is assigning clients on a rehabilitation unit. Which client is most appropriate to assign to an experienced practical nurse?

   • A.A client returning from surgery who needs initial postoperative assessment
   • B.A newly admitted client with chest pain requiring an initial assessment
   • C.A stable client needing a scheduled dressing change for a healing wound
   • D.A client with a sudden decrease in level of consciousness

   Answer and rationale are in the full material.

5. 5.On a pediatric unit, a 7-year-old's parent asks why the nurse needs to listen to the child's lungs before giving a bronchodilator. Which response is best?

   • A."The assessment is mainly to document the medication was given."
   • B."I will compare breath sounds and work of breathing before and after the medication."
   • C."The medication is given on schedule, so an assessment is not needed."
   • D."I need to listen only if your child says the chest hurts."

   Answer and rationale are in the full material.