Ch 8 - Ch 20

The nurse is assessing the characteristics and positioning of the client's uvula, which deviates asymmetrically when the nurse has the client say aaah. This finding should prompt the nurse to focus on which of the following during subsequent assessment?

B) The client's neurological status

A nurse is reviewing a colleague's documentation of a client assessment. The nurse reads that the client's radial pulse was 2+. How should the nurse interpret this assessment finding?

B) The client's radial pulse occluded with moderate pressure.

The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate?

B) The cuff is placed about 1 inch above the antecubital area.

The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system?

A) Endocrine

The nurse is assessing a client who has been admitted with signs and symptoms that are consistent with malnutrition. Which of the following physiological phenomena would the nurse recognize as an early indicator of malnutrition?

A) Protein stores are lower than normal

A nurse is assessing the eyes of a 3-year-old child. Which finding would the nurse document as normal?

A) Pseudostrabismus

A woman reports a sudden onset of spontaneous nipple discharge. Which of the following would be the nurse's most appropriate action?

A) Refer the client for cytologic study of the discharge.

The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next?

A) Refer the client immediately for further evaluation.

A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?

A) Referral for further assessment of thyroid function

Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. Which of the following nursing diagnoses would be the nurse's priority?

A) Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination

A group of students is reviewing information about the salivary glands and their secretions. The students demonstrate understanding of the information when they identify which of the following as components of saliva? Select all that apply.

A) Salts D) Mucus E) Amylase

The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age- related changes?

A) Slight kyphosis

When assessing whispered pectoriloquy, the nurse should instruct a client to do which of the following?

A) Softly repeat the words one-two-three.

The nurse's assessment reveals that a client is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate?

A) Teaching the client muscle-building exercises

The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first?

A) Temperature

The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test?

A) The client has unilateral hearing loss.

A client has sustained a brain stem injury and is being treated in the intensive care unit. Which of the following would the nurse need to consider when assessing this client's respiratory status?

A) The client will have a loss of involuntary respiratory control.

A nurse at an ambulatory clinic is preparing to begin the collection of objective assessment data from a female client. After meeting the client and bringing her into the examination room, what instruction should the nurse provide?

B) Please have a seat on the edge of the exam table.

The nurse is using an ophthalmoscope to examine a client's inner eye structures. What action should the nurse perform in order to accurately examine the client's optic disc?

B) Position the scope close to the client's eye and look through the pupil at a 15- degree angle.

The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next?

B) Refer the client to a primary care provider for medication.

When examining the mouth of an adult client with recent cognitive changes, the nurse notes a distinct bluish-black line along the client's gum line. Which action should be the nurse's priority?

B) Referring the client for further evaluation

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?

B) Stage II

A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation?

B) Sternal notch

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?

B) Sternomastoid

When taking a health history for a female client, which factor should the nurse identify as placing the client at increased risk for breast cancer?

B) The client had her first child at age 38

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale?

B) The client is consistently incontinent of urine.

The nurse's assessment of an 81-year-old client's hearing has corroborated her recent history of hearing loss. The nurse questions the client about her use of hearing aids, to which the client responds, I've got enough frustration in my life without having to fiddle with those. The nurse should suspect which of the following?

B) The client may have had a negative experience with hearing aids in the past.

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

B) The client's ability to change position

The nurse is providing care for a client with a history of chronic heart failure. The client is in bed with the head of her bed at 45 degrees, and the nurse is assessing the client's neck veins. What assessment finding would be most consistent with a nursing diagnosis of fluid volume excess related to chronic heart failure?

B) The client's jugular veins are clearly visible and firm to palpation.

A hospital nurse is performing a nutritional assessment of a 39-year-old obese client who has been recently diagnosed with type 2 diabetes. The nurse has completed the collection of subjective data and is preparing to proceed with objective data collection. Which principle should guide the nurse's subsequent actions?

B) The nurse should be aware that the client may find assessment embarrassing.

While using an otoscope to assess the ears of an 8-year-old boy, the nurse observes white spots on the boy's tympanic membrane. The nurse also observes that no redness is present. Which action would be most appropriate?

C) Ask the mother whether the child has had numerous ear infections.

The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. How should the nurse respond to this assessment finding?

C) Assess the client's pulse at the carotid site.

The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform?

C) Auscultate the client's thyroid.

A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae?

C) C7

The nurse is preparing to perform a nutritional assessment of a newly admitted client. Which of the following questions would be most appropriate to use when initiating the assessment?

C) Can you tell me what you've eaten in the last 24 hours?

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. Which of the following would be most appropriate for the nurse to include?

C) Thoroughly chew small amounts of food with each mouthful.

The nurse is assessing a client's breasts. When assessing the area of the breast most vulnerable to breast cancer, where should the nurse to assess?

C) Upper outer quadrant

A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing?

C) Wearing ear protection when in the work environment

When obtaining the nutritional health history from a female client, which of the nurse's questions would best elicit information about the client's knowledge of her own health status?

C) What are your height and usual weight?

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. During which of the following components of the assessment should the nurse wear gloves?

C) When palpating lesions on the client's skin

A client's recent complaints of polyuria have prompted a full diagnostic work-up for diabetes mellitus, including a nutritional assessment. To determine the client's body mass index (BMI), the nurse must know which of the following assessment parameters? Select all that apply.

C, E C) Weight E) Height

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse consequently ask?

D) Do you take steroid medications on a regular basis?

The nurse is completing the assessment of a client who takes a beta-adrenergic blocker and a diuretic. Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents?

D) Evaluating for orthostatic hypotension

A nurse is conducting an assessment of a client's eyes and vision and has completed the positions test. Following this test, the nurse will be able to document data that address what aspects of eye health? Select all that apply.

D) Eye muscle strength E) Cranial nerve function

A client has sought care because she states that she has begun to see halos around headlights and streetlights when she is out at night. The nurse should recognize the need to refer the client for further assessment related to what health problem?

D) Glaucoma

The nurse is performing an assessment of a hospital client at the beginning of a shift. When assessing the client's heart rate, the nurse will most likely palpate what artery?

D) Radial artery

The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. Which of the following would the nurse expect to find?

D) Red and scaling on the areola

The results of a client's Rinne test suggest that bone conduction and air conduction are both reduced. Which of the following would be most appropriate?

D) Refer the client for further evaluation.

Which of the following factors should a nurse include when discussing risk factors about breast cancer for a group of women?

A) Early menarche

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available?

D) Cup of water

A nurse is preparing to assess an adult client's body temperature. At which time of the day would the nurse expect to obtain the lowest body temperature?

A) Early morning

A nurse is performing an eye assessment of an 81-year-old male client. Which of the following would the nurse document as a normal finding?

A) Ectropion

Assessment of a client's breasts reveals tenderness on palpation and diffuse redness. What collaborative problem is most clearly suggested by these data?

D) RC: Infection

During a new client's nutritional assessment, the nurse asks the client's height and usual weight. The client states that he has no idea how much he weighs. How should the nurse respond?

A) Do you feel like your weight has increased, decreased, or stayed the same lately?

The nurse should prioritize assessments related to overhydration for a client experiencing which of the following health problems?

A) Early congestive heart failure

A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following?

A) "How would you describe your pain? Is it sharp? Is it an ache?"

The nurse is beginning the inspection of a young adult client's breasts. The client states, "My left breast has always been a bit bigger than the right." How should the nurse best respond to the client's statement?

A) "Many women have this, and it's rarely a sign of a health problem."

The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure?

A) 44 mm Hg

In which of the following male clients would gynecomastia be considered to be an expected assessment finding?

A) A 14-year-old boy who began puberty last year

A nurse who works at an outpatient ophthalmic clinic has a large number of clients. Which client would be at the highest risk for developing cataracts?

A) A 55-year-old female client

A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal?

A) Acromegaly

During a prenatal class, a participant says that she was told that her breasts are not large enough to breastfeed. When responding to this client, the nurse should understand that the functional capacity of the breast is primarily determined by which of the following variables?

A) Amount of glandular tissue

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an itching rash. Which question would be most important for the nurse to ask?

A) Are you allergic to foods, medications, or other substances?

A 55-year-old client is being evaluated for a suspected hearing impairment. Which of the nurse's health interview questions is most likely to yield relevant data?

A) Are you having difficulty hearing high-frequency sounds?

The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The nurse knows that a normal breathing rate is between approximately 10 and 20 breaths per minute, but the client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding?

A) Ask the client if she has recently exerted herself.

A nurse is assessing an adult client's eyes and vision. When performing the cover test, the nurse would cover one of the client's eyes and then do which of the following?

A) Ask the client to focus on a distant object, looking for movement in the other eye.

The nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding?

A) Auscultate the client's apical pulse.

The nurse is auscultating a client's blood pressure and identifies the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds. This is known as which of the following?

A) Auscultatory gap

A nurse is observing the red reflex in a client during an eye assessment. During this component of the assessment, the client states, I hope you can see it because I have cataracts. What finding should the nurse expect?

A) Black spokes pointing inward

A nurse has performed the corneal light reflex test during a client's eye examination. During this test, the nurse held a penlight 1 foot from the client's eyes and appraised the client's eye alignment in which of the following ways?

A) By comparing the reflection of the light on the client's eye surface

A nurse observes the posture of a male client and finds him leaning forward and bracing himself while sitting on the exam table. Which of the following would the nurse most likely suspect?

A) Chronic obstructive pulmonary disease

A client weighs 106 pounds and is 5 feet 5 inches tall. As a result, her ideal body weight is 120 pounds. After determining the client's percentage of ideal body weight, which of the following should the nurse conclude?

A) Client is mildly malnourished.

A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. Which of the following assessment findings should the nurse anticipate along with this condition?

A) Crepitus over the maxillary sinuses

Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following?

A) Discrete

The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test?

A) Far, then near

A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. The nurse has lowered the client's arm and observed how long it takes for venous filling, then raised the same arm and watched how long it takes to empty. After determining that venous filling and emptying each take approximately 10 seconds, the nurse should perform further assessments related to what health problem?

A) Fluid volume deficit

The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What might the nurse expect to hear when auscultating the lungs of a client with this fluid volume deficit?

A) Friction rub

The nurse is assessing an older adult client whose health problems include receding gums. The nurse notes gum ischemia and worn tooth surfaces. Which question would be most important for the nurse to ask?

A) Have you lost any teeth recently?

The nurse analyzes the data obtained from a client's nutritional assessment and develops a health promotion diagnosis related to nutrition for a client. Which of the following would be the best example?

A) Health-seeking behaviors related to desire and request to alter amount of food intake

When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. Which of the following should the nurse examine first?

A) Hearing acuity

When evaluating nutrition in an adult female client, which laboratory value would most concern the nurse?

A) Hemoglobin A1c of 9%

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?

A) History of allergies

The nurse is assessing a client who enjoys good health overall but who has brought a complaint of chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize?

A) How often do you use over-the-counter nasal sprays?

A client has a history of emphysema. During the respiratory assessment, the nurse percusses the client's chest, expecting to find which of the following?

A) Hyperresonance

The nurse has completed a focused ear and hearing assessment and gathered the following data: the client speaks very softly, denies hearing loss, and has never had and cannot afford additional hearing tests; the client fails the whisper test. Which nursing diagnosis would be most appropriate?

A) Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing

A group of students is preparing for a quiz on breast assessment and the assessment findings that are associated with breast cancer. The students demonstrate understanding of the material when they identify which of the following? Select all that apply.

A) Irregular, firm lumps C) Dimpling and nipple retraction D) Orange peel-like appearance

After teaching a group of students about the external and internal structures of the eye, the instructor determines that the teaching was successful when the students identify which of the following as external structures? Select all that apply.

A) Lacrimal apparatus B) Conjunctiva F) Caruncle

The nurse is preparing to auscultate the client's thorax. Which of the following actions is the priority during this component of assessment?

A) Listen at each site for at least one complete respiratory cycle.

A nurse has completed the assessment of a client's breasts. The nurse should suspect that the client has fibroadenomas based on which findings?

A) Lobular, ovoid, or round lesions

A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency?

A) Monthly

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities?

A) Nodularity

A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which of the following actions?

A) Observing the eye's reaction when a light is shone into the opposite eye

The nurse's assessment of an older adult client's ears and hearing suggests the possible presence of conductive hearing loss. Which of the following is the most likely etiology of this abnormal assessment finding?

A) Otitis media

During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches?

A) Pain radiating from eye to temporal region

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

A) The right lung has three lobes, while the left lung has two lobes.

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which of the following assessment findings would be indicative of a stage I pressure ulcer?

A) There is a nonblanching reddened area on the client's coccyx region.

A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection (thrush). On inspection of the patient's tongue, the nurse should anticipate what appearance?

A) Thick, white plaques on the tongue surface

During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem?

A) Trigeminal neuralgia

A community health nurse is conducting a home visit to a client who requires wound care. The nurse observes that the client is diaphoretic and wishes to measure the client's temperature. The nurse asks if the client has a thermometer in her home, and she states that she owns an ear thermometer. What principle should guide the nurse's use of a tympanic thermometer?

A) Tympanic temperature is slightly higher than oral temperature.

The nurse is preparing to palpate the breasts of a female client. Which technique should the nurse utilize during this aspect of assessment?

A) Use the flat pads of three fingers.

The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon?

A) Vasoconstriction

The nurse is assessing a dark-skinned client whose forearms are hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?

A) Vitiligo

A nurse health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients how to clean their ears, what action should the nurse recommend?

A) Washing with a warm, moist washcloth

A client asks why cerumen is important, stating, It just clogs up the ears anyway. How should the nurse best describe the purpose of cerumen?

B) It helps to keep the ear drum soft and functioning well.

During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition?

B) Iron deficiency anemia

A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first?

C) Inspect the client's external ear canal.

A nurse is presenting a class to a local community group about vision and eye health. As part of the presentation, the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation?

B) It begins with light rays striking the retina.

A 42-year-old female client says she does not perform breast self-examination because she believes that mammograms are more thorough. Which response by the nurse would be most appropriate?

B) "Be sure to have your breasts checked by a doctor and have a mammogram every year."

28. The nurse is palpating the axillary lymph nodes of a client who has been experiencing recent malaise. The nurse should consider a lymph node to be enlarged if its diameter exceeds what size?

B) 1 cm

A nurse weighs a client today and finds that the client's weight has increased 2.2 lbs from the previous day. The nurse interprets this finding as suggesting a fluid gain of which amount?

B) 1.0 liters

During an initial prenatal visit, the nurse is performing a nutritional assessment of a woman who has just learned that she is pregnant for the first time. The nurse has determined that the client has an average stature and is 5 feet, 3 inches tall. What is this client's ideal body weight?

B) 115 lbs.

Due to a change in the client's level of consciousness, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4∫F. Which finding would the nurse interpret as corresponding most closely to the client's previous temperature?

B) 97.4 F

The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve?

B) Accessory (XI)

Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following?

B) Acute illness

The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his history of environmental allergies, the client states, I'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies. How can the nurse begin to identify the specific allergens that cause the man's symptoms?

B) Ask the client about the timing of his allergy symptoms.

The nurse has completed the assessment of a client's breast and lymphatic system. The nurse has ended the assessment by offering to teach the client how to perform breast self-examination (BSE). The client states, "That's alright. I already know how to do that." What should the nurse do next?

B) Ask the client to demonstrate BSE.

A client tells the clinic nurse that she has sought care because she has been experiencing excessive tearing of her eyes. Which assessment should the nurse next perform?

B) Assess the nasolacrimal sac.

A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. During assessment using the mnemonic ABCDE, which finding would the nurse identify as being most suggestive of melanoma?

B) Asymmetric, irregular borders

Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies?

B) Bacterial infection

During the health interview, the nurse asks a middle-aged client at what age she began menstruating. This question addresses a risk factor for what health problem?

B) Breast cancer

A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status?

B) Brittle hair

A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, Do you wear sunglasses during exposure to the sun? the nurse is addressing a known risk factor for what health problem?

B) Cataracts

During a nutritional assessment, the client asks the nurse for suggestions to improve her diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to desire to improve diet. Which of the following suggestions would be most appropriate?

B) Choose low-fat versions of milk products such as yogurt.

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

B) Compressing the arteries bilaterally

A 12-year-old boy has been brought to the emergency department after being hit in the head with a pitch during a baseball game. The emergency department nurse's comprehensive assessment includes examination of the boy's ears with an otoscope. What assessment finding would suggest trauma to the middle ear or inner ear?

B) Dark red or bluish tympanic membrane

The nurse is admitting a client to surgical daycare and is assessing the client's vital signs. When obtaining the client's oral temperature, where should the nurse insert the thermometer?

B) Deep in the posterior sublingual pocket

A nurse is assessing a client for possible fluid overload. Which of the following assessment findings is most consistent with this diagnosis?

B) Distended neck veins with head elevated at 45 degrees

When examining a child who complains of a sore throat, the nurse notes swelling on either side of the child's oropharynx. The nurse would include which of the following when documenting this finding?

B) Enlarged palatine tonsils

A client's history suggests a need to assess eye muscle strength and cranial nerve function. What assessment should the nurse consequently perform?

B) Eye positions test

Which of the following, if obtained during the health history, would alert the nurse to a possible risk factor for ear-related problems?

B) Frequent use of cotton-tipped applicators inside the ear

A nurse is completing a comprehensive health history of a 69-year-old woman who is a new client of the clinic. Which of the nurse's interview questions most directly addresses the client's risk for developing cataracts?

B) Have you ever been tested for diabetes?

The nurse is completing the general survey of a client and determines that the client's temperature is 102∞F. Which of the following would the nurse also expect to find?

B) Heart rate greater than 100 bpm

During a health screening event, the nurse is assessing a client's risk factors for lung cancer. When addressing the most significant risk factor for lung cancer, the nurse should question the client about which of the following?

B) History of tobacco use

26. A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction?

B) I'm going to put my fingers in front of your ears and ask you to open your mouth wide.

A nurse is performing an otoscopic exam of a client's right tympanic membrane. At which location would the nurse document seeing the cone of light if it were in the appropriate place?

B) In the 5 o'clock position

A nurse is teaching an older adult client about breast self-examination. The nurse includes teaching on expected changes in the client's breasts due to aging. Which of the following would the nurse include?

B) Increase in fatty tissue

A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic?

B) Increased thinness

The nurse is performing an ear assessment of an adult client. Which of the following actions constitutes the correct procedure for using an otoscope when examining the client's ears?

B) Inserting the speculum down and forward into the ear canal

A review of a client's history reveals cranial nerve IV paralysis. Which of the following findings would the nurse expect to assess?

C) The eye cannot look down when turned inward.

An obese teenage boy from a culture that values increased body mass has been referred to the clinic. The nurse is assessing him for malnutrition based on his electronic health record and current health complaints. His mother questions the nurse's rationale, stating, Anyone can see he's not malnourished. Just look at the size of him! How should the nurse best respond?

B) It's actually very possible for a person to be overweight but have inadequate nutrition.

The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow-up?

B) Leukoplakia

A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which of the following principles?

B) Many clients have an additional (third) thyroid lobe.

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following?

B) Narcotic use

The nurse inspects a client's mouth and notes the presence of a bifid uvula. The nurse understands that this finding is most common in which ethnic group?

B) Native Americans

The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. The nurse should document this as which of the following?

B) Normal expansion

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

B) On each side between the top of the ear and the eye

The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first?

B) On the client's mastoid process

When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. The nurse would document this as which of the following?

B) Optic disc

A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect which of the following health problems?

B) Otitis externa

A client has presented with a terrible head cold, and the nurse is assessing for signs and symptoms of sinusitis. The nurse should utilize what assessment techniques? Select all that apply.

B) Palpation D) Percussion E) Transillumination

A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the presence of which of the following?

B) Papule

A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably stooped posture. How should the nurse best follow up this abnormal assessment finding?

B) Perform a focused assessment of the client's musculoskeletal system

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following should the nurse do next?

B) Perform a random blood sugar test.

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?

B) Petechiae

A nurse is conducting a focused ear and hearing assessment of an adult client who has a history of mild hearing loss. When performing the whisper test, what instruction should the nurse begin with?

B) Please cover your ear that has the weakest hearing.

A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which of the following would the nurse describe?

B) The size and shape of children's eustachian tubes makes them vulnerable.

A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates correct technique for this assessment?

B) Use of two middle fingers lightly applied to wrist area along the thumb side

A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax?

B) Vertebral line

An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess?

B) Vesicle

A client has sought care at the clinic, telling the nurse, This ringing in my ears has gone on for weeks, and it's driving me crazy. The patient denies exposure to excessive noise levels. The nurse recognizes the likely presence of tinnitus and should follow up with which of the following questions?

B) What medications are you currently taking?

A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify? Select all that apply.

B, C B) Hyoid bone C) Cricoid cartilage

The nurse is assessing an adult client's areolas and nipples. What assessment finding would most clearly warrant referral?

C) The patient's nipple has recently become inverted.

The nurse has asked a female client if she has noticed any lumps or swelling in her breasts. After the client responds "yes," which question should the nurse ask next?

C) "Does the lump change over the course of your menstrual cycle?"

A woman appears restless and is wringing her hands prior to having a clinical breast examination performed. Which statement by the nurse would be most appropriate?

C) "You seem to be anxious. Can you tell me what you are thinking?"

The nurse is inspecting a client's tonsils and notes that they make contact with the client's uvula. The nurse would document this finding as which of the following?

C) 3+

A nurse in the intensive care unit is calculating an acutely ill client's 24-hour fluid balance. The nurse should include insensible fluid losses of what volume when performing this assessment?

C) 800 to 1000 mL

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis?

C) A sound of turbulent blood flow in the thyroid

When assessing a client for possible oral cancer, the nurse should most closely inspect which area?

C) Area under the tongue

Which of the following would the nurse expect to assess when examining the eyes of a client who reports a history of severe allergies?

C) Areas of dryness

A client has presented for care to the clinic, stating, "I'm pretty sure that I feel a new lump in my breast." After confirming the presence of a lump, what action should the nurse take?

C) Arrange for a prompt referral to her primary care provider.

A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next?

C) Arrange for worker to be promptly assessed by an eye specialist.

The nurse is assessing the skin condition and color of an African-American client. Which of the following would the nurse document as an abnormal finding?

C) Ashen gray skin color

During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. Which of the following would be most important for the nurse to assess?

C) Checking for a deviated nasal septum

Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would recognize this as a tripod position and suspect the presence of which of the following medical problems?

C) Chronic obstructive pulmonary disease

After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative?

C) Client maintains the position during the test

A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following?

C) Consensual response

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which of the following findings should the nurse attribute to age-related physiological changes?

C) Decreased strength of temporal artery pulsations

A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer?

C) Do you use tobacco, whether smoking or chewing?

An older adult client has a body mass index of 15.5 and is consequently considered to be underweight. The client lives alone and states that she has never been a heavy eater. How can the nurse most accurately assess the client's nutritional habits?

C) Elicit the client's 24-hour food recall.

The nurse is preparing to examine a client's skin. Which of the following actions would be most important for the nurse to do?

C) Expose only the body part that is being examined.

The nurse is assessing a client whose electronic health record notes a diagnosis of esotropia. When examining this client, the nurse should expect what finding?

C) Eye turning inward

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause?

C) Falls prevention

When percussing the scapula of a client, which of the following would the nurse expect to hear?

C) Flatness

A client has large, pendulous breasts. Which of the following would be most appropriate to ensure better access while examining the client's breasts for retraction and dimpling?

C) Have the client sit and then lean forward

When palpating a female client's axillae, which of the following actions is most appropriate?

C) Hold the client's elbow of the side being examined with one hand.

The nurse is conducting the health interview of an adult client who has sought care because of a wicked cough leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask?

C) How long have you been experiencing your cough?

In the course of the nurse's health interview, a client reports an occasional blockage in the upper portion of his nasal passage. What is the most pronounced effect that this will have on the client?

C) Impaired sense of smell

A nurse is caring for a patient whose diagnosis of cystic fibrosis results in the production of large amounts of sticky mucus. The client has a history of repeated hospital admissions for complications of his disease and receives daily treatments to mobilize the secretions. When planning the care of this client, what nursing diagnosis is most plausible?

C) Ineffective Airway Clearance related to respiratory secretions

Which of the following would be most important for the nurse to do when assessing a client's blood pressure?

C) Inflate the cuff 30 mm Hg above where the radial pulse disappears.

A client's electronic health record states that he has been diagnosed with sensorineural hearing loss. Which condition should the nurse most likely identify as a cause?

C) Inner ear problem

While assessing a woman's breasts, the nurse notes a pronounced and asymmetric pattern of veins on the client's breasts. Follow-up care is ordered because the nurse should suspect which of the following?

C) Malignancy

The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. Which of the following would the nurse most likely assess?

C) Masklike expression

The nurse needs to obtain the height of a client who is unable to stand. Which of the following would the nurse do?

C) Measure from client's arm span using one of his arms outstretched.

A nurse is assessing a client's skeletal muscle mass in the context of a comprehensive nutritional assessment. Which measurement would yield the most valid and reliable data?

C) Mid-arm circumference

During a health history, a 62-year-old male client reveals that he occasionally sees spots before his eyes. The nurse interprets this finding as the result of which of the following?

C) Normal findings for client's age

While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following?

C) Normal tympanic membrane

An older adult client has been admitted to the medical unit after suffering an exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following should the nurse do to assess the depth of the client's respirations?

C) Observe the client's chest expansion bilaterally.

A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about which of the following assessment findings related to the client's sputum?

C) Pink and frothy

25. Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?

C) RC: Cushing's syndrome

Assessment of a client's mouth reveals a lesion on the client's buccal membrane that is approximately 0.5 cm in diameter. On further questioning, the client states that the lesion has been present for 3 months and that it bleeds intermittently. How should the nurse follow up this assessment finding?

C) Refer the client to her primary care provider promptly.

The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem?

C) Risk for aspiration related to decreased swallowing ability

A nurse is reviewing the laboratory test results of an adult client who has numerous chronic health challenges. Which assessment result would alert the nurse to potential malnutrition?

C) Serum albumin of 2.6 g/dL

The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position?

C) Slightly above the clavicle

Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment?

C) Smokeless tobacco use

An adult client has been diagnosed with bronchitis. Which of the following would the nurse most likely hear on auscultation?

C) Sonorous wheezes

When preparing to assess a client's thoracic cage, the nurse should locate which landmark when determining where to begin the assessment of the ribs and intercostal spaces?

C) Sternal angle

A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding?

C) Tender

When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment?

C) Tender tragus

A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the client's blood pressure reading in light of what principle?

C) The client's blood pressure will be slightly lower than standing readings.

An 84-year-old man has been admitted to the emergency department from an extended care facility. Facility staff suspect that the client has pneumonia, and his malaise, productive cough, shortness of breath, and adventitious breath sounds are consistent with this diagnosis. However, the nurse's assessment of the client's vital signs yields an oral temperature of 97.5∞F. How should the nurse best interpret this assessment finding?

C) The client's normothermic temperature does not rule out the presence of an infection.

The nurse is examining a client's breasts and notes the presence of pronounced dimpling. How should the nurse best respond to this assessment finding?

D) Promptly refer the client for further medical assessment.

A client describes her frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines?

D) Do you have any visual changes before the headache?

The nurse is performing a respiratory assessment of a client who is palliative due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate?

D) Cheyne-Stokes

On inspection, the nurse observes a line across the tip of an 8-year-old client's nose. The nurse should consequently focus on which area of assessment?

D) Chronic allergies

An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess?

D) Circulatory

During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide?

D) Cover one of your eyes and then read out the letters on the chart, starting from the top.

An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following?

D) 28

An experienced nurse is aware that receding gums are an expected finding in some clients whereas in other clients this finding is abnormal. In which of the following clients would the nurse identify receding gums as an expected assessment finding?

D) A 77-year-old man who describes himself as being healthy

A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers?

D) A smoking cessation program

A nurse is assessing a client who is suspected to have optic atrophy. Which of the following assessment findings is most consistent with this diagnosis?

D) A white appearance of the optic disc

Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding?

D) Acute otitis media

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process?

D) Air passing through constricted passageways

After teaching a group of young women about breast self-examination, the nurse determines that the teaching was successful when the women state that they will palpate their breasts using which pattern?

D) An up-and-down pattern

An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

D) Are you currently taking any diuretic medications?

A nurse is completing a general survey of a client's health and is beginning by measuring the client's vital signs. What assessment question constitutes the fifth vital sign?

D) Are you having any pain right now?

The nurse has assisted a 74-year-old woman from a chair to the examination table during an assessment, and the nurse observes that the client moves particularly slowly and stiffly. The nurse should question the client regarding a possible history of what health problem?

D) Arthritis

While examining a client's mouth, the nurse notes the presence of fasciculations (fine tremors) of the client's tongue. How should the nurse best respond to this assessment finding?

D) Assess the client's cranial nerve function.

A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands?

D) Behind the tip of the client's mandible

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document which of the following?

D) Bronchial breath sounds

The nurse is conducting an assessment of an older adult client who has a diagnosis of chronic heart failure. How can the nurse best assess the effects of the client's stroke volume?

D) Calculate the difference between the diastolic and systolic pressures.

A nursing instructor is discussing cultural variations in the size of the thorax and impact on lung capacity. Which group would the instructor identify as typically having a larger thorax?

D) Caucasians

While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. Which of the following actions should the nurse do first?

D) Have the client cough, then listen again.

A nurse is assessing an adult client's neck. Which of the following would be most appropriate when auscultating the client's thyroid gland for bruits?

D) Have the client hold his or her breath.

A clinic client's primary complaint is earache (otalgia). Consequently, the nurse's assessment is focusing on potential causes of the client's pain. What question should the nurse include in the health interview?

D) Have you been swimming lately?

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment?

D) Having bad sunburns when you're a child puts you at risk for skin cancer later in life.

The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states, It shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker. The nurse should recognize the need to teach the client about what topic?

D) Health risks of secondhand smoke

During the health interview, a client tells the nurse that he can't breathe all that well at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for which of the following health problems?

D) Heart failure

A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion?

D) Illuminate the area using a Wood's light.

While performing an elderly client's admission assessment, the nurse notes the presence of deep tongue fissures. Which of the following responses should take priority?

D) Intravenous fluid replacement

The nurse is completing an initial assessment of a client who is new to the ambulatory clinic. Before assessing the client's blood pressure, a nurse asks him what his usual blood pressure is. The nurse bases this action primarily on what rationale?

D) It indicates the client's involvement in his health care.

A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. Which of the following conclusions is suggested if the client has no reaction?

D) It may be immunosuppression resulting from undernourishment.

When assessing an older adult client with osteoporotic thinning and vertebral collapse, which of the following findings would the nurse expect to identify?

D) Kyphosis

When palpating a female client's axillae, which finding would the nurse document as normal?

D) Nodes are discrete.

A nurse is performing an eye and vision assessment on a client who has an inner ear disorder. This disorder may contribute to what finding during the client's eye positions test?

D) Nystagmus

The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis?

D) Oral mucosa

The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis?

D) Pain on percussion

A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?

D) Percussion

In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds?

D) Peripheral vascular disease

The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which of the following findings would a nurse interpret as being normal?

D) Pinkish, spongy soft palate

During a client's eye assessment, the nurse is testing for consensual pupillary constriction. Which technique should the nurse implement?

D) Place a barrier between the client's eyes.

The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique?

D) Place the diaphragm on the client's posterior chest wall.

While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment?

D) Please say the number 'ninety-nine' for me.

A nurse has taught a group of older adults about the high incidence and prevalence of macular degeneration. What health promotion and prevention activity should the nurse encourage these clients to perform?

D) Post an Amsler grid in their home and perform the test on a regular basis

A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis?

D) Presbycusis

A 2-year-old girl has been brought to the ambulatory clinic by her mother who states, She's put a pea in her ear, and I think she did it 2 days ago because that was the last time we ate them. The nurse's otoscopic examination confirms the presence of this foreign body in the girl's middle ear. How should the nurse best respond to this assessment finding?

D) Refer the girl to her primary care provider for prompt removal of the pea.

The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse must assess which lobe anteriorly?

D) Right middle lobe

The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. During health promotion, the nurse should focus education on which of the following topics?

D) Risks of sun exposure

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

D) Sebum production

The nurse is preparing to inspect a woman's breasts for retraction and dimpling. Which position would be most appropriate?

D) Sitting

The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following should the nurse assess next?

D) Spinal column

The nurse is collecting data from a client about his nutrition. Which of the following would the nurse document as objective data?

D) Tenting of client's skin observed upon skin pinch.

The nurse is completing a comprehensive nutritional assessment and has assessed and documented the client's triceps skin fold thickness (TSF) using calipers. This assessment finding allows the nurse to determine which of the following?

D) The amount of the client's subcutaneous fat stores

An 18-year-old woman complains because one breast is larger than the other. What additional interview data would suggest a need for referral?

D) The client states that this represents a sudden change in her breast size.

A client has presented for care because of frequent sinus headaches. During transillumination of the frontal sinuses, a red glow is noted. The nurse should anticipate which of the following?

D) The headaches are most likely not from a sinus infection.

A nurse is preparing for an assessment by reviewing a new client's electronic health record, which documents the presence of macules on the client's left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions?

D) The lesions will not be palpable.

During a Weber test, the client reports lateralization of sound to the good ear. How should the nurse interpret this assessment finding?

D) There is a sensorineural hearing impairment.

The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health?

D) Vision

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

D) XII