health assessment III (nursing assessment of physical systems)

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A variation that looks split or partially severed and may be associated with a submucous cleft palate

Bifid uvula

Touch the uvula

Grade 3 tonsils

Method used to assess the internal nose

Inspection using otoscope with short wide tip attachment

Common site of nasal bleeding

Kiesselbach's area

Normal variation that occurs in the crease between the upper and lower lip

Lip pits

Methods used to test for sinus tenderness

Palpation and percussion

Bony protuberance in the midline of the hard palate

Torus palatinus

. While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 1 cm. The nurse documents this as a a. plaque. b. macule. c. papule. d. patch.

. While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of a. macules. b. papules. c. plaques. d. bulla.

. While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of a. hypoxia. b. trauma. c. anemia. d. infection.

The nurse is planning to inspect an adult client's mouth, using a tongue depressor. The nurse should plan to a. depress the tongue blade slightly off center. b. depress the tongue blade as close to the center as possible. c. ask the client to keep the mouth partially open. d. insert the tongue blade at the back of the client's tongue.

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should a. position the client 20 feet away from the chart. b. ask the client to remove his glasses. c. ask the client to read each line with both eyes open. d. instruct the client to begin reading from the bottom of the chart.

The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to a. position the handle of the otoscope to one side. b. tip the client's head as far back as possible. c. direct the otoscope tip quickly back and down the nostril. d. position the handle of the otoscope straight and up.

A client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his right eye. The nurse should a. examine the area of head trauma. b. refer the client to an ophthalmologist. c. assess the client for double vision. d. ask the client if he sees "halos."

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to a. ask the client to raise the chin. b. approach the client posteriorly. c. turn the client's neck slightly backward. d. place the fingers above the cricoid cartilage.

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to a. inhale deeply. b. swallow a small sip of water. c. cough deeply. d. flex the neck to each side.

While assessing an adult client's skull, the nurse observes that the client's skull bones are acorn-shaped and enlarged. The nurse should refer the client to a physician for possible a. Cushing's syndrome. b. scleroderma. c. Paget's disease. d. Parkinson's

To assess an adult client's skin turgor, the nurse should a. press down on the skin of the feet. b. use the dorsal surfaces of the hands on the client's arms. c. use the fingerpads to palpate the skin at the sternum. d. use two fingers to pinch the skin under the clavicle.

While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's earlobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an a. enlarged thyroid. b. lymph node abscess. c. neurologic disorder. d. parotid gland enlargement.

While assessing the ears of an adult client, the nurse observes bloody drainage in the client's ear. The nurse should a. document the finding in the client's chart. b. determine whether a foreign body is present in the ear. c. assess the client for further signs of otitis media. d. refer the client to a physician.

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's a. eyelid reflexes. b. refractory mechanism. c. lacrimal reflexes. d. corneal reflexes.

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible a. cancerous lesions. b. arterial occlusion. c. inner ear disease. d. trigeminal neuralgia.

Absence of a red glow with transillumination

Sinus filled with fluid or pus:

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's a. nailbeds. b. oral mucosa. c. sclera. d. palms.

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears a. greenish. b. ashen. c. bluish. d. olive.

. The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's a. nodules. b. bullae. c. vesicles. d. wheals.

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the a. ethmoidal sinuses. b. laryngeal sinuses. c. maxillary sinuses. d. sphenoidal sinuses.

A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should a. document the results in the client's record. b. ask the client to read a handheld vision chart. c. ask the client to return in 2 weeks for another examination. d. refer the client to an optometrist.

The clavicles extend from the acromion of the scapula to the part of the sternum termed the a. body. b. xiphoid process. c. angle. d. manubrium.

Match the terms. 1. Promotes the strongest stimulus to breathe 2. Orthopnea 3. Crepitus 4. Pectus excavatum 5. Pectus carinatum 6. Pleural friction rub 7. Wheeze (sibilant) 8. Wheeze (sonorous) 9. Crackles (fine) 10. Crackles (coarse) a. High-pitched, short, popping sounds b. Forward protrusion of the sternum c. High-pitched musical sounds d. An increase in carbon dioxide in the blood e. Low-pitched, bubbling, moist sounds f. Low-pitched snoring or moaning sounds g. Difficulty breathing when lying supine h. Markedly sunken sternum and adjacent cartilage i. Low-pitched, dry, grating sounds j. A "crackling" sensation

1. d 2. g 3. j 4. h 5. b 6. i 7. c 8. f 9. a 10. e

Match the terms. 1. Skene's glands 2. Bartholin's glands 3. Os 4. Libido 5. Pediculosis pubis 6. Chadwick's sign 7. Mons pubis 8. Menopause 9. Amenorrhea 10. Menorrhagia 11. Dysmenorrhea 12. Dysuria a. Painful menstruation b. Cessation of menstruation c. "Crabs" d. Heavy menstruation e. Secrete mucus to aid in lubrication during intercourse f. Desire for sexual activity g. Secrete mucus to lubricate and maintain moist vaginal environment h. Cervix appears blue rather than pink i. Painful urination j. Absence of menstruation k. Opening in center of cervix l. Round firm pad of adipose tissue that covers the symphysis pubis

1. g 2. e 3. k 4. f 5. c 6. h 7. l 8. b 9. j 10. d 11. a 12. i

Controls lateral eye movements

Abducens

Contains sensory fibers for hearing and balance

Acoustic

Determines the patency of the radial and ulnar arteries

Allen's test

Darkly pigmented area surrounding the nipple of the mammary gland

Areola

Usually occur on tips of toes, metatarsal heads, and lateral malleoli; ulcers have pale ischemic base, welldefined edges, and no bleeding

Arterial ulcer

Rigid peripheral blood vessels; occurs more commonly in older adults

Arteriosclerosis

Groups of lymph nodes located under the arm (the axilla)

Axillary lymph nodes

The time it takes for color to return to the nail beds after they have been blanched by pressure; a good measure of peripheral perfusion and cardiac output

Capillary refill time

Red oval ulcerations caused by syphilis

Chancres

Cracking at the corner of the lips seen in riboflavin deficiency

Cheilosis

Diffuse enlargement of terminal phalanges

Clubbing

Endoscopic examination of the colon, either transabdominally during laparotomy or transanally by colonoscopy

Colonoscopy

Infrequent hard stool

Constipation

Fibrous glands extending vertically from the breast surface to attach on the chest wall muscles

Cooper's ligaments

Displacement of the urinary meatus to the dorsal surface of the penis

Corona

Undescended testicle

Cryptorchidism

Frequent loose stools

Diarrhea

Used to detect a weak peripheral pulse to monitor blood pressure in infants or children and to measure blood pressure in a lower extremity; it magnifies pulse sounds from the heart and blood vessels

Doppler ultrasound probe

Swelling caused by excess fluid

Edema

A solution introduced into the rectum to promote evacuation of feces

Enema

Displacement of the urinary meatus to the dorsal surface of the penis

Epispadias

T or F? It is best to integrate the rectal examination with the abdominal examination.

T or F? The Mental Status Exam should be performed after examining all other body systems.

Contracts eye muscles to control eye movement, constricts pupils, and elevates eyelids

Facial

Contains sensory fibers for taste on posterior one third of the tongue; responsible for "gag reflex" when stimulated

Glossopharyngeal

Painless flabby papules due to varicose veins; two types, external or internal

Hemorrhoids

Protrusion of bowel through weakened muscles

Hernia

Calf pain elicited when the calf muscle is compressed against the tibia or when the foot is sharply dorsiflexed against the calf

Homans' sign (positive)

Contains sensory fibers for taste on anterior two thirds of the tongue and stimulates secretions from the salivary glands and tears from lacrimal glands

Hypoglossal

Displacement of the urinary meatus to the ventral surface of the penis

Hypospadias

Deficient supply of oxygenated arterial blood to a tissue; caused by obstruction of a blood vessel

Ischemia

Ducts conveying the milk secreted by the lobes of the breast to and through the nipples

Lactiferous duct

Reservoirs for storing milk, located behind the nipple

Lactiferous sinus

Medicines that loosen the bowel contents and encourage evacuation

Laxatives

Specialized gland of the skin of females, which secretes milk for nourishment of the young

Mammary gland

Roentgenography of the breast to detect any underlying mass

Mammography

Surgical removal of breast tissue

Mastectomy

Inflammation of the breast

Mastitis

Pigmented projection at the tip of each breast, which allows passage of milk from the breast

Nipple

Contracts eye muscles to control eye movement, constricts pupils, and elevates eyelids

Oculomotor

Carries smell impulses from nasal mucous membrane to brain

Olfactory

Carries visual impulses from the eye to the brain

Optic

Erythematous scaling lesion of the breast, involving the nipple and areola unilaterally, and associated with an underlying malignancy

Paget's disease

Retracted foreskin that cannot be returned to cover the glans

Paraphimosis

Lymphatic obstruction, causing edema, which thickens the skin, exaggerates the hair follicles, and gives the breast an orange peel or pigskin look

Peau d'orange

A tight foreskin that cannot be retracted

Phimosis

A hair containing cyst located in the midline over the coccyx or lower sacrum

Pilonidal cyst

Method used to palpate frontal sinuses

Press up on brow on each side of nose

Method used to palpate maxillary sinuses

Press up with thumbs on sinuses

Examination of the rectum and sigmoid colon with the sigmoidoscope

Proctosigmoidoscopy

Blood test to detect prostate cancer

Prostate-specific antigen (PSA) test

A vasospastic disorder, primarily affects the hands, characterized by color change from pallor, to cyanosis, to rubor; attacks precipitated by cold or emotional upset and relieved by warmth

Raynaud's disease

Most common site of tongue cancer

Side of tongue

Significance of a red glow with transillumination

Sinus filled with air

Innervates neck muscles that promote movement of the shoulders and head rotation

Spinal accessory

Excessive fat in the stool

Steatorrhea

Openings found on buccal mucosa across from second upper molars

Stensen's ducts

T or F? Assessment of cranial nerve I (olfactory) may be performed during examination of the nose, mouth, and throat.

T or F? Assessment of the posterior and lateral chest should be completed before assessing the anterior chest.

T or F? Examination of the legs should include assessment of lower peripheral vascular status.

Inflammation of a vein associated with thrombus formation

Thrombophlebitis

Method used to test for fluid in the sinuses

Transillumination

Carries sensory impulses of pain, touch, and temperature from the face to the brain

Trigeminal

Contracts one eye muscle to control inferomedial eye movement

Trochlear

Carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal tract, and abdominal viscera

Vagus

Client holds the breath and bears down

Valsalva maneuver

Three semilunar transverse folds within the rectal interior

Valves of Houston

Swollen, distended, and knotted veins; occur most commonly in the legs

Varicose veins

Usually occur on medial malleoli; ulcers have bleeding uneven edges

Venous ulcer

Openings found on either side of the frenulum of the floor of the mouth

Wharton's ducts

A 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should a. tell the client that these often occur with aging. b. refer the client to an ophthalmologist. c. re-examine the client in 2 weeks. d. assess the client for signs of diabetes.

A 45-year-old male client tells the nurse that he has had problems in having an erection for the last couple of weeks but is "doing better now." The nurse should explain to the client that a. transient periods of erectile dysfunction are common. b. impotence in males should be investigated. c. transient impotence may be indicative of prostate enlargement. d. inguinal hernias have been associated with transient impotence.

A 53-year-old client tells the nurse that she thinks she is starting the menopausal phase of her life. The nurse should instruct the client that she may experience a. hot flashes. b. increased appetite. c. vaginal discharge. d. urinary frequency.

A bony ridge located at the point where the manubrium articulates with the body of the sternum is termed the sternal a. angle. b. notch. c. space. d. prominens.

A client visits the clinic and complains of pain in his knees. The nurse explains that a ballottement test will be performed. To perform the ballottement test, the nurse should a. place the left thumb and index finger on either side of the patella. b. use the ball of the hand to firmly stroke the medial side of the knee. c. press the lateral side of the knee and inspect for swelling. d. palpate for tenderness 10 cm above the patella.

A client visits the clinic and tells the nurse that he has not been feeling very well. The nurse observes that the client's speech is slow, the client has a disheveled appearance, and he maintains poor eye contact with the nurse. The nurse should further assess the client for a. depression. b. delirium. c. hallucinations. d. schizophrenia.

A client visits the clinic and tells the nurse that his stools have been pale for the past 2 days and his skin has been itching. The nurse should refer the client to a physician for possible a. biliary disease. b. cancer. c. gastrointestinal infection. d. hemorrhoids.

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for a. lymphedema. b. Raynaud's disease. c. poor peripheral pulses. d. bruits over the radial artery.

A client visits the clinic and tells the nurse that she has had "runny diarrhea" for 2 days. The nurse should assess the client for a. gastrointestinal infection. b. fecal impaction. c. constipation. d. hemorrhoids.

A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of a. arthritis. b. osteoporosis. c. carpal tunnel syndrome. d. a neurologic disorder.

A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of a. stomach ulcers. b. pancreatic cancer. c. decreased gastric motility. d. abdominal tumors.

A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says a. "I can decrease the constipation if I eat foods high in fiber and drink water." b. "I should cut down on the number of iron tablets I am taking each day." c. "Constipation should decrease if I take the iron tablets with milk." d. "I should discontinue the iron tablets and eat foods that are high in iron."

A female client has scheduled a physical examination, including a Pap smear. The nurse should instruct the client to a. refrain from douching 48 hours before the examination. b. bring in a urine sample for testing. c. drink a large volume of fluid before the examination. d. refrain from using talcum powder after her shower.

A female client visits the clinic and tells the nurse that she began menarche at the age of 16 years. The nurse should instruct the client that she is at a higher risk for a. osteoporosis. b. osteomyelitis. c. rheumatoid arthritis. d. lordosis.

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a a. migraine headache. b. cluster headache. c. tension headache. d. tumor-related headache.

A male client tells the nurse that he has received a diagnosis of hernia. He visits the clinic because he is nauseated and has extreme tenderness on the left side. The nurse should a. refer the client to an emergency room. b. try to push the mass into the abdomen. c. assess for a mass on the right side. d. assess the client's vital signs.

A male client visits the clinic and tells the nurse that he has had a white discharge from hispenis for the past few days. The nurse should refer the client to a physician for possible a. urethritis. b. gonorrhea. c. herpes infection. d. syphilis.

A nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. The nurse should a. refer the client for further evaluation. b. document the presence of herpes simplex. c. ask the client if his gums bleed. d. document the presence of a canker sore.

An adult client tells the nurse that he eats sardines every day. The nurse should instruct the client that a diet high in purines can contribute to a. gouty arthritis. b. osteomalacia. c. bone fractures. d. osteomyelitis.

An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible a. glaucoma. b. increased intracranial pressure. c. bacterial infection. d. migraine headaches.

An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart disease is a. high serum level of low-density lipoproteins. b. low-carbohydrate diets. c. high serum level of high-density lipoproteins. d. diets that are high in antioxidant vitamins.

An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should document the presence of a. cluster headaches. b. migraine headaches. c. tension headaches. d. tumor-related headaches.

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for a. symptoms of stress. b. recent radiation therapy. c. pigmentation irregularities. d. allergies to certain foods.

An older adult client visits the clinic and tells the nurse that she has had shooting pains in both of her legs. The nurse should assess the client for signs and symptoms of a. herniated intervertebral disc. b. rheumatoid arthritis. c. osteoporosis. d. metastases.

An older adult client visits the clinic complaining of urinary incontinence. The nurse should explain to the client that this is often due to a. decreased urethral elasticity. b. atrophy of the vaginal mucosa. c. change in the vaginal pH. d. decreased estrogen production.

An older adult client visits the clinic for a gynecologic examination. The client tells the nurse that she has been told that she has uterine prolapse. The nurse should further assess the client for a. stress incontinence. b. cystocele. c. a retroverted uterus. d. diastasis recti.

At puberty, the female breasts enlarge in response to estrogen and a. progesterone. b. aldosterone. c. lactogen. d. prolactin.

Before beginning the examination of the genitalia of an adult male client, the nurse should a. ask the client to empty his bladder. b. tell the client that he will remain in a supine position. c. ask the client to leave his shirt in place. d. tell the client that he may leave his underwear in place.

Bones contain yellow marrow that is composed mainly of a. fat. b. protein. c. cartilage. d. carbohydrates.

Cultural factors play an important role in the development of prostate cancer in men. Which culture has the highest prostate cancer rate? a. African-American. b. White American. c. Italian. d. Japanese.

During a gynecologic examination, the nurse observes that the client has a yellow-green frothy vaginal discharge. The nurse should plan to test the client for possible a. Trichomonas vaginalis infection. b. bacterial vaginosis. c. atrophic vaginitis. d. Chlamydia trachomatis infection.

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing a. venous insufficiency. b. arterial occlusive disease. c. venous ulcers. d. ankle edema.

Examination of the skin should be a. integrated throughout the head-to-toe examination. b. completed at the beginning of the physical assessment before proceeding to other parts of the exam. c. performed at the very end of the physical assessment. d. integrated and completed only with the musculoskeletal examination.

Skeletal muscles are attached to bones by a. tendons. b. cartilage. c. fibrous connective tissue. d. ligaments.

Squamous cell carcinoma is associated with a. overall amount of sun exposure. b. intermittent exposure to ultraviolet rays. c. precursor lesions. d. an increase in the rates of melanoma.

The P-wave phase of an electrocardiogram (ECG) represents a. conduction of the impulse throughout the atria. b. conduction of the impulse throughout the ventricles. c. ventricular repolarization. d. ventricular polarization.

The anterior chest area that overlies the heart and great vessels is called the a. precordium. b. epicardium. c. myocardium. d. endocardium.

The bicuspid, or mitral, valve is located a. between the left atrium and the left ventricle. b. between the right atrium and the right ventricle. c. at the beginning of the ascending aorta. d. at the exit of each ventricle near the great vessels.

The colon originates in this abdominal area: the a. right lower quadrant. b. right upper quadrant. c. left lower quadrant. d. left upper quadrant.

The corpora spongiosum extends distally to form the acorn-shaped a. glans. b. frenulum. c. corona. d. scrotum.

The external sphincter of the anus is a. composed of smooth muscle. b. composed of skeletal muscle. c. composed of striated muscle. d. under involuntary control.

The fourth heart sound, S4, is a/an a. low-frequency sound best heard with the bell of the stethoscope. b. abnormal finding in trained athletes. c. sound that can be heard in the absence of atrial contraction. d. sound that may increase during expiration.

The inguinal canal in a male client is located a. just above and parallel to the inguinal ligament. b. anteriorly above the symphysis pubis. c. anterior to the external inguinal ring. d. posterior to the superior iliac ring.

The lymph nodes that are responsible for drainage from the arms are the a. lateral lymph nodes. b. central lymph nodes. c. anterior lymph nodes. d. posterior lymph nodes.

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible a. chronic bronchitis. b. atelectasis. c. renal failure. d. congestive heart failure.

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent a a. reduction of the blood supply to the brain. b. rapid rise in the client's pulse rate. c. premature ventricular heart sound. d. decreased pulse pressure.

The nurse detects paradoxical pulses in an adult client during an examination. The nurse should explain to the client that paradoxical pulses are usually indicative of a. obstructive lung disease. b. left-sided heart failure. c. premature ventricular contractions. d. aortic stenosis.

The nurse has assessed the respiratory pattern of an adult client. The nurse determines thatthe client is exhibiting Kussmaul's respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates a. diabetic ketoacidosis. b. central nervous system injury. c. drug overdose. d. congestive heart failure

The nurse has discussed the risks for breast cancer with a group of high school seniors. The nurse determines that one of the students needs further instructions when the student says that one risk factor is a. having a baby before the age of 20 years. b. a family history of breast cancer. c. consumption of a high-fat diet. d. late menopause.

The nurse has instructed a 55-year-old male client about the need for a stool test for occult blood. The nurse determines that the client understands the instructions when he says the test should be performed every a. year. b. 2 years. c. 3 years. d. 4 years.

The nurse is assessing a client who has been taking antibiotics for an infection for 10 days. The nurse observes whitish curd-like patches in the client's mouth. The nurse should explain to the client that these spots are most likely a. Candida albicans infection. b. Koplik's spots. c. leukoplakia. d. Fordyce spots.

The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of a. a great degree of cyanosis. b. a mild degree of cyanosis. c. lupus erythematosus. d. hyperthyroidism.

The nurse is assessing the mouth of an older adult and observes that the client appears to have poorly fitting dentures. The nurse should instruct the client that she may be at greater risk for a. aspiration. b. malocclusion. c. gingivitis. d. throat soreness.

The nurse is assessing the neurologic system of an adult client. To test the client's motor function of the facial nerve, the nurse should a. ask the client to purse the lips. b. ask the client to open the mouth and say "ah." c. note the presence of a gag reflex. d. observe the client swallow a sip of water.

The nurse is caring for a client during the immediate postoperative period after abdominal surgery. While performing a "neuro check" the nurse should assess the client's a. sensation in the extremities. b. deep tendon reflexes. c. ability to speak. d. recent memory.

The nurse is performing a speculum examination on an adult woman. The nurse is having difficulty inserting the speculum because the client is unable to relax. The nurse should ask the client to a. bear down. b. hold her breath. c. use imagery to relax. d. take a deep breath.

The nurse is planning a presentation to a group of high school students about the risk factors for oral cancer. Which of the following should be included in the nurse's plan? a. Diets low in fruits and vegetables are a possible risk factor for oral cancer. b. About 40% of all cancers occur in the lips, mouth, and tongue. c. The incidence of oral cancers is higher in women than in men. d. Most oral cancers are detected in people in their 70s.

The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should a. ask the client to empty his bladder. b. place the client in a side-lying position. c. ask the client to hold his breath for a few seconds. d. tell the client to raise his arms above his head.

The nurse is planning to auscultate a female adult client's carotid arteries. The nurse should plan to a. ask the client to hold her breath. b. palpate the arteries before auscultation. c. place the diaphragm of the stethoscope over the artery. d. ask the client to breathe normally.

The nurse is preparing to assess the cardiovascular system of an adult client with emphysema. The nurse anticipates that there may be some difficulty palpating the client's a. apical pulse. b. breath sounds. c. jugular veins. d. carotid arteries.

The nurse is preparing to percuss a client's reflexes in his arms. To use the reinforcement technique, the nurse should ask the client to a. clench his jaw. b. stretch the opposite arm. c. hold his neck toward the floor. d. straighten his legs forward.

The nurse is preparing to use a Doppler ultrasound probe to detect blood flow in the femoral artery of an adult client. The nurse should a. apply K-Y jelly to the client's skin. b. place the client in a supine position with the head flat. c. place the tip of the probe in a 30-degree angle to the artery. d. apply gel used for ECG to the client's skin.

The nurse observes an orange-peel appearance, or peau d'orange, of the areolae of a client's breasts. The nurse should explain to the client that this is most likely due to a. blocked lymphatic drainage. b. fibrocystic breast disease. c. fibroadenomas. d. radiation therapy.

The outermost layer of the vaginal wall is composed of a. pink squamous epithelium and connective tissue. b. the vascular supply, nerves, and lymphatic channels. c. smooth muscle and connective tissue. d. connective tissue and the vascular network.

The popliteal artery can be palpated at the a. knee. b. great toe. c. ankle. d. inguinal ligament.

The primary function of the gallbladder is to a. store and excrete bile. b. aid in the digestion of protein. c. produce alkaline mucus. d. produce hormones.

The prostate gland consists of two lobes separated by the a. median sulcus. b. rectovesical pouch. c. anorectal junction. d. valves of Houston.

The semilunar valves are located a. at the exit of each ventricle at the beginning of the great vessels. b. between the right atrium and the right ventricle. c. between the left atrium and the left ventricle. d. at the beginning of the ascending aorta.

The sinoatrial node of the heart is located on the a. posterior wall of the right atrium. b. anterior wall of the right atrium. c. upper intraventricular system. d. anterior wall of the left atrium.

The skin folds of the labia majora and the labia minora form a boat-shaped area termed the a. vestibule. b. corpus. c. Skene's glands. d. urethral meatus.

The thin double-layered serous membrane that lines the chest cavity is termed a. parietal pleura. b. pulmonary pleura. c. visceral pleura. d. thoracic pleura.

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's a. right upper quadrant. b. right lower quadrant. c. left upper quadrant. d. left lower quadrant.

When the nurse moves a client's leg upward, the nurse is performing a. supination. b. external rotation. c. eversion. d. internal rotation.

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible a. umbilical hernia. b. ascites. c. intraabdominal bleeding. d. pancreatitis.

While assessing an adult client's feet for fungal disease using a Wood's light, the nurse documents the presence of a fungus when the fluorescence is a. blue. b. red. c. yellow. d. purple.

While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible a. pneumonia. b. pleuritis. c. bronchitis. d. asthma

While assessing the abdominal sounds of an adult client, the nurse hears high-pitched tingling sounds throughout the distended abdomen. The nurse should refer the client to a physician for possible a. intestinal obstruction. b. gastroenteritis. c. inflamed appendix. d. cirrhosis of the liver.

While assessing the anus of an adult client, the nurse detects the presence of small nodules. The nurse should refer the client to a physician for possible a. polyps. b. anorectal fistula. c. hemorrhoids. d. rectocele.

While assessing the cervix of an adult client, the nurse observes a yellowish discharge from the cervix. The nurse should further assess the client for a/an a. infection. b. abnormal lesion. c. positive pregnancy test result. d. polyp.

While assessing the ears of an adult client, the nurse observes that the tympanic membrane is completely immobile. The nurse should further assess the client for signs and symptoms of a. infection. b. skull injury. c. vestibular disorders. d. healed perforations.

While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for a. arthritis. b. ganglion cyst. c. carpal tunnel syndrome. d. nerve damage.

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's a. esotropia. b. strabismus. c. phoria. d. exotropia.

While assessing the feet of an adult client, the nurse notes that the client's great toes are deviated, with overlapping of the second toes. The client states that there is pain on the medial side. The nurse should refer the client to a physician for possible a. hallux valgus. b. pes planus. c. pes cavus. d. verruca vulgaris.

While assessing the feet of an adult client, the nurse observes hyperextension of the metatarsophalangeal joint with flexion at the proximal interphalangeal joint on the client's second toes. The nurse should refer the client to a physician for possible a. hammer toes. b. gouty arthritis. c. calluses. d. hallux valgus.

While assessing the musculoskeletal system of an adult client, the nurse observes hard painless nodules over the distal interphalangeal joints. The nurse should document the presence of a. osteoarthritis. b. bursitis. c. tendonitis. d. rheumatoid arthritis.

While assessing the pupils of a hospitalized adult client, the nurse observes that the client's pupils are dilated to 6 cm. The nurse suspects that the client is exhibiting signs of a. oculomotor nerve paralysis. b. damage to the pons. c. alcohol abuse. d. cocaine abuse.

While assessing the range of motion in an adult client's shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. The nurse plans to refer the client to a physician for possible a. rotator cuff tear. b. nerve damage. c. cervical disc degeneration. d. tendonitis.

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to a. repeat the phrase "ninety-nine." b. repeat the letter "E." c. whisper the phrase "one-two-three." d. repeat the letter "A."

While examining the prostate gland of an older adult, the nurse detects hard fixed nodules. The nurse should refer the client to a physician for possible a. prostate cancer. b. benign prostatic hypertrophy. c. acute prostatitis. d. prostatocystitis.

While examining the spine of an adult client, the nurse notes that the client has a flattened lumbar curvature. The nurse should refer the client to a physician for possible a. herniated disc. b. scoliosis. c. kyphosis. d. cervical disc degeneration.

While palpating the apex, left sternal border, and base in an adult client, the nurse detects a thrill. The nurse should further assess the client for a. cardiac murmur. b. left-sided heart failure. c. constrictive pericarditis. d. congestive heart failure.

While performing a gynecologic examination, the nurse observes small, painful, ulcer-like lesions with red bases on the client's labia. The nurse should refer the client to a physician for possible a. herpes simplex virus infection. b. syphilis. c. lice. d. herpes zoster virus infection.

A client visits the outpatient center with a complaint of sudden head and neck pain and stiffness. The client's oral temperature is 100°F. The nurse suspects the client is experiencing symptoms of a. migraine headache. b. meningeal irritation. c. trigeminal neuralgia. d. otitis media.

A female client tells the nurse that she has pain while urinating. Besides obtaining a urinalysis, the nurse should assess the client for a. kidney trauma. b. sexually transmitted disease. c. tumors. d. infestation.

A female client tells the nurse that she may be experiencing premenstrual syndrome. An appropriate question for the nurse to ask the client is a. "How often are your menstrual periods?" b. "Do you experience mood swings or bloating?" c. "Are you experiencing regular menstrual cycles?" d. "How old were you when you began to menstruate?"

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is a. lack of vitamin C in the diet. b. ultraviolet light exposure. c. obesity. d. use of antibiotics.

An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible a. glaucoma. b. increased intracranial pressure. c. hypertension. d. ophthalmic migraine.

An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible a. congestive heart failure. b. angina. c. palpitations. d. acute anxiety reaction.

Bones in synovial joints are joined together by a. cartilage. b. ligaments. c. tendons. d. periosteal tissue.

The apex of each lung is located at the a. level of the diaphragm. b. area slightly above the clavicle. c. level of the sixth rib. d. left oblique fissure.

The best approach to use when performing a total physical examination on a client is a. a toe-to-head integrated assessment of body systems. b. a head-to-toe integrated assessment of body systems. c. a total body system approach examining each body system individually. d. any approach that is convenient for you and the client.

The functional part of the breast that allows for milk production consists of tissue termed a. fibrous. b. glandular. c. adipose. d. lactiferous.

The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's a. pectus thorax. b. pectus excavatum. c. pectus carinatum. d. pectus diaphragm.

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as a. stage I. b. stage II. c. stage III. d. stage IV.

The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to a. congenital cataracts. b. decreased accommodation. c. muscle weakness. d. constant misalignment of the eyes.

The nurse is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the a. area on top of the tongue. b. area underneath the tongue. c. inside of the cheeks. d. area near the salivary glands.

The nurse is assessing an adult male client when the nurse observes gynecomastia in the client. The nurse should ask the client if he is taking any medications for a. inflammation. b. depression. c. infection. d. ulcers.

The nurse is assessing an older adult client when the client tells the nurse that she has experienced transient blind spots for the last few days. The nurse should refer the client to a physician for possible a. vagus nerve damage. b. cerebral vascular accident. c. spinal cord compression. d. Parkinson's disease.

The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible a. aortic aneurysm. b. paralytic ileus. c. gastroenteritis. d. fluid and electrolyte imbalances.

The nurse is assessing the peripheral vascular system of an older adult client. The client tells the nurse that her legs "seem cold all the time and sometimes feel tingly." The nurse suspects that the client may be experiencing a. varicose veins. b. intermittent claudication. c. edema. d. thrombophlebitis.

The nurse is auscultating the heart sounds of an adult client. To auscultate Erb's point, the nurse should place the stethoscope at the a. second intercostal space at the right sternal border. b. third to fifth intercostal space at the left sternal border. c. apex of the heart near the midclavicular line (MCL). d. fourth or fifth intercostal space at the left lower sternal border.

The nurse is caring for a healthy adult client with no history of vision problems. The nurse should tell the client that a thorough eye examination is recommended every a. year. b. 2 years. c. 3 years. d. 4 years.

The nurse is planning a presentation to a group of adults on the topic of cardiovascular accidents. Which of the following should the nurse plan to include in the teaching plan? a. Strokes are the number one cause of death in the United States. b. Smoking and high cholesterol levels are risk factors for CVA. c. Clients who smoke while taking oral contraceptives are not at higher risk. d. Postmenopausal women taking estrogen are at greater risk for CVA.

The nurse is planning to assess the anus and rectum of an adult male client. The nurse should position the client in a a. right lateral position. b. left lateral position. c. prone position. d. knee-chest position

The nurse is planning to test position sensation in an adult female client. To perform this procedure, the nurse should ask the client to close her eyes while the nurse moves the a. arm away from the body. b. toes up or down. c. hand forward and then backward. d. leg away from the body.

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first a. explain to the client why the assessment is necessary. b. ask the client if touching the head is permissible. c. determine whether the client desires a family member present. d. examine the lymph nodes of the neck before examining the head.

The nurse observes dimpling in an adult female client's breasts. The nurse should explain to the client that dimpling of the breast may indicate a a. fibroadenoma. b. tumor. c. genetic deviation. d. fibrocystic breast.

The prostate functions to a. store sperm until ejaculation occurs. b. secrete a milky substance that neutralizes female acidic secretions. c. produce the ejaculate that nourishes and protects sperm. d. produce mucus-like fluid to assist in lubrication.

The sigmoid colon is located in this area of the abdomen: the a. left upper quadrant. b. left lower quadrant. c. right upper quadrant. d. right lower quadrant.

The subacromial bursae are contained in the a. temporomandibular joint. b. shoulder joint. c. elbow joint. d. wrist joint.

The testes in the male scrotum are a. joined with the ejaculatory duct. b. suspended by the spermatic cord. c. able to produce progesterone. d. the location of the vas deferens.

To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's a. left upper quadrant. b. left lower quadrant. c. right upper quadrant. d. right lower quadrant.

To palpate the spleen of an adult client, the nurse should a. ask the client to exhale deeply. b. place the right hand below the left costal margin. c. point the fingers of the left hand downward. d. ask the client to remain in a supine position.

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the a. left lower quadrant. b. left upper quadrant. c. right upper quadrant. d. right lower quadrant.

Two body systems that may be logically integrated and assessed at the same time are the a. eye and ear exams. b. eye exam and cranial nerves II, III, IV, and VI. c. ear exam and cranial nerves IV, VI, and VIII. d. ear and nose exams.

While assessing an adult client's jaw, the nurse hears a clicking popping sound, and the client expresses pain in the joint. The nurse should further assess the client expresses pain in the joint. The nurse should further assess the client for a. arthritis. b. TMJ dysfunction. c. bruxism. d. previous fracture.

While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for a. parotid gland enlargement. b. acromegaly. c. Paget's disease. d. Cushing's syndrome.

While assessing an adult client, the nurse tests the client for Tinel's sign. The nurse should instruct the client that numbness or tingling may indicate a. arthritis. b. carpal tunnel syndrome. c. tenosynovitis. d. crepitus.

While assessing an adult male client, the nurse detects pimple-like lesions on the client's glans. The nurse explains the need for a referral to the client. The nurse determines that the client has understood the instructions when the client says he may have a. venereal warts. b. herpes infection. c. syphilis. d. gonorrhea.

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are a. signs of an infectious process. b. caused by aging of the skin in older adults. c. precancerous lesions. d. signs of dermatitis.

While inspecting the genitalia of a male client, the nurse observes a chancre lesion under the foreskin. The nurse has explained this observation to the client. The nurse determines that the client understands the need for a referral when the client says that chancre lesions are associated with a. herpes virus. b. syphilis. c. papilloma virus. d. gonorrhea.

. While assessing the nails of an adult client, the nurse observes Beau's lines. The nurse should ask the client if he has had a. chemotherapy. b. radiation. c. a recent illness. d. steroid therapy.

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of a. hypothyroidism. b. hyperthyroidism. c. infectious conditions. d. hypoparathyroidism.

A 25-year-old client asks the nurse how often he should have a testicular examination. After instructing the client about the American Cancer Society's guidelines, the nurse determines that the client has understood the instructions when he says he should have a testicular examination every a. year. b. 2 years. c. 3 years. d. 4 years.

A client with insulin-dependent diabetes visits the clinic and complains of painful hip joints. The nurse should assess the client carefully for signs and symptoms of a. arthritis. b. gait difficulties. c. osteomyelitis. d. scoliosis.

A female client tells the nurse that her breasts become lumpy and sore before menstruation but get better at the end of the menstrual cycle. The nurse should explain to the client that these symptoms are often associated with a. malignant tumors. b. fibroadenoma. c. fibrocystic breast disease. d. increased estrogen production.

A female client visits the clinic and tells the nurse that she wants to "stay healthy." The nurse observes that the client has diffuse neck enlargement, is perspiring, and is quite fidgety. The client tells the nurse that she is "hungry all the time, but I have lost weight." A priority nursing diagnosis for the client is a. imbalanced nutrition: less than body requirements related to energy level. b. ineffective health maintenance related to increased metabolism and hunger. c. health-seeking behaviors related to verbalization of wanting to stay healthy. d. thyroid dysfunction related to neck swelling, perspiration, and fidgeting.

A male client tells the nurse that his occupation requires heavy lifting and a great deal of strenuous activity. The nurse should assess the client for a. signs and symptoms of prostate enlargement. b. erectile dysfunction. c. inguinal hernia. d. urinary tract infection.

After assessing the breasts of a female client, the nurse should explain to the client that most breast tumors occur in the a. upper inner quadrant. b. lower inner quadrant. c. upper outer quadrant. d. lower outer quadrant.

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's a. femoral pulse. b. popliteal pulse. c. brachial pulse. d. tibial pulse.

An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should a. ask about the client's diet. b. determine whether there is a history of glaucoma. c. check the client's blood pressure. d. ask the client if he has any known allergies.

An adult client tells the nurse that his 80-year-old father is almost completely deaf. After an explanation to the client about risk factors for hearing loss, the nurse determines that the client needs further instruction when the client says a. "There is a genetic predisposition to hearing loss." b. "Certain cultural groups have a higher rate of hearing loss." c. "It is difficult to prevent hearing loss or worsening of hearing." d. "Chronic otitis media has been associated with hearing loss."

An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been a. dizzy. b. hypotensive. c. taking antibiotics. d. experiencing ear drainage.

An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are a. touching the uvula. b. visible upon inspection. c. touching each other. d. midway between the tonsillar pillars and uvula.

Before beginning a physical assessment it is important for the nurse to a. explain to the client in detail how each body system will be assessed. b. explain to the client the purpose of every physical assessment technique you will be using. c. acquire your client's verbal permission to perform the physical examination. d. acquire your client's written permission to perform the physical examination.

Blood from the lower trunk and legs drains upward into the inferior vena cava. The percentage of the body's blood volume that is contained in the veins is nearly a. 50%. b. 60%. c. 70%. d. 80%.

Cultural beliefs about the causes of breast cancer do not always agree with medical findings. Hispanic Americans often associate breast cancer with a. improper diet. b. punishment from God. c. physical stress. d. evil thoughts.

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's a. base of the heart. b. pulmonic valve area. c. apex of the heart. d. second left interspace.

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should a. palpate the abdomen before auscultation. b. listen in each quadrant for 15 seconds. c. use the diaphragm of the stethoscope. d. begin auscultation in the left upper quadrant.

One of the functions of a bone is to a. store fat. b. produce secretions. c. produce blood cells. d. store protein.

Sensations of temperature, pain, and crude and light touch are carried by way of the a. extrapyramidal tract. b. corticospinal tract. c. spinothalamic tract. d. posterior tract.

The Cowper's glands a. are located inside the rectum. b. produce a substance to aid in sperm motility. c. empty into the urethra. d. can be palpated through the rectum.

The abdominal contents are enclosed externally by the abdominal wall musculature—three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external a. rectal abdominis. b. transverse abdominis. c. abdominal oblique. d. umbilical oblique.

The nurse has assessed a male client and determines that one of the testes is absent. The nurse should explain to the client that this condition is termed a. hypospadias. b. hematocele. c. cryptorchidism. d. orchitis.

The nurse has performed the Rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing a. normal hearing. b. sensorineural hearing loss. c. conductive hearing loss. d. central hearing loss.

The nurse is assessing a 50-year-old client's breasts and observes a spontaneous discharge of fluid from the left nipple. The nurse should a. document this as a normal finding. b. ask the client if she has had retracted nipples. c. refer the client for a cytology examination. d. determine whether the client wears a supportive bra.

The nurse is assessing an African-American client's skin. After the assessment, the nurse should instruct the client that African-American persons are more susceptible to a. skin cancers than persons of European origin. b. melanomas if they reside in areas without ozone depletion. c. chronic discoid lupus erythematosus. d. genetic predisposition to melanomas.

The nurse is assessing an older adult client who has lost 5 pounds since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. The nurse should further assess the client for a. peptic ulcer. b. bulimia. c. appetite changes. d. pancreatic disorders.

The nurse is assessing the genitalia of an adult male client when he tells the nurse that his testes are swollen and painful. The nurse should refer the client to a physician for possible a. cancer. b. hydrocele. c. epididymitis. d. hematocele.

The nurse is caring for a female client during her first postoperative day after a temporary colostomy. The client refuses to look at the colostomy bag or the area. A priority nursing diagnosis for this client is a. denial related to temporary colostomy. b. fear related to potential outcome of surgery. c. disturbed body image related to temporary colostomy. d. altered role functioning related to frequent colostomy bag changes.

The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test a. assesses the muscle strength of the eye. b. assesses the functioning of the cranial nerves innervating the eye muscles. c. requires the covering of each eye separately. d. requires the client to focus on an object.

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that a. melanoma skin cancers are the most common type of cancers. b. African-Americans are the least susceptible to skin cancers. c. usually there are precursor lesions for basal cell carcinomas. d. squamous cell carcinomas are most common on body sites with heavy sun exposure.

The nurse is planning a presentation on osteoporosis to a group of high school students. Which of the following should the nurse plan to include in the presentation? a. Bone density rises to a peak at age 50 for both sexes. b. Bone density in the Asian population is higher than in the white population. c. Moderate strenuous exercise tends to increase bone density. d. Approximately 5 million fractures in the United States are due to osteoporosis.

The nurse is planning a presentation on the topic of colorectal cancer to a group of older adults. Which of the following should the nurse plan to include in the presentation? a. Colorectal cancer rates have steadily fallen over the past 30 years. b. Eighty percent of those diagnosed with colorectal cancer are younger than 50 years of age. c. Diets high in fat and low in fiber are associated with colorectal cancer. d. Colorectal cancer rates are decreasing outside the United States.

The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the a. degree of arterial occlusion that exists. b. pulse of a client with poor elasticity. c. competence of the saphenous vein valves. d. severity of thrombophlebitis.

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should a. place the bell of the stethoscope firmly on the posterior chest wall. b. auscultate from the base of the lungs to the apices. c. ask the client to breathe deeply through her mouth. d. ask the client to breathe normally through her nose.

The nurse is preparing to examine the breasts of a female client who had a left radical mastectomy 3 years ago. When examining the client, the nurse observes redness at the scar area. The nurse should explain to the client that this may be indicative of a. additional tumors. b. poor lymphatic drainage. c. an infectious process. d. metastasis to the right breast.

The nurse is preparing to palpate the epitrochlear lymph nodes of an adult male client. The nurse should instruct the client to a. assume a supine position. b. rest his arm on the examination table. c. flex his elbow about 90 degrees. d. make a fist with his left hand.

The nurse is preparing to perform a speculum examination on an adult woman. To lubricate the speculum before insertion, the nurse should use a. sterile water. b. K-Y jelly. c. warm tap water. d. petroleum jelly.

The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to a. squat down as far as he is able to do so. b. keep his eyes open while he bends at the knees. c. stand erect with arms at the sides and feet together. d. touch the tip of his nose with his finger.

The skin folds of the labia majora are composed of adipose tissue, sebaceous glands, and a. Skene's ducts. b. vestibular glands. c. sweat glands. d. Bartholin's glands.

The spinous process termed the vertebra prominens is in which cervical vertebra? a. fifth. b. sixth. c. seventh. d. eighth.

To assess an adult client for possible appendicitis and a positive psoas sign, the nurse should a. rotate the client's knee internally. b. palpate at the lower right quadrant. c. raise the client's right leg from the hip. d. support the client's right knee and ankle.

While assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. The nurse should refer the client to a physician because this is usually indicative of a. pulmonary hypertension. b. aortic stenosis. c. mitral valve stenosis. d. pulmonary hypotension.

While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should a. ask the client to flex his neck to the left side. b. observe whether the client has difficulty swallowing water. c. refer the client to a physician for further evaluation. d. palpate the cricoid cartilage for smoothness.

While assessing an older adult client, the client complains of chronic pain and severe limitation of all shoulder movements. The nurse should refer the client to a physician for possible a. rotator cuff tendonitis. b. rheumatoid arthritis. c. calcified tendinitis. d. chronic bursitis.

While assessing an older adult client, the nurse detects a bruit over the carotid artery. The nurse should explain to the client that a bruit is a. a normal sound heard in adult clients. b. a wheezing sound. c. associated with occlusive arterial disease. d. heard when the artery is almost totally occluded.

While assessing an older adult client, the nurse notes decreased range of motion and crepitation as the client tries to bend his knees to his chest. The nurse determines that the client is most likely experiencing a. flexion contractures. b. signs of aging. c. osteoarthritis. d. genu valgum.

While assessing muscle strength in an older adult client, the nurse determines that the client's knee joint has a rating of 3 and exhibits active motion against gravity. The nurse should document the client's muscle strength as being/having a. normal. b. slight weakness. c. average weakness. d. poor range of motion.

While assessing the anal area of an adult client, the nurse detects redness and excoriation. The nurse determines that this sign is most likely due to a. internal hemorrhoids. b. an anorectal fistula. c. a fungal infection. d. previous surgery.

While assessing the anal area of an adult client, the nurse observes a reddened swollen area covered by a small tuft of hair located midline on the lower sacrum. The nurse should refer the client to a physician for possible a. perianal abscess. b. neurologic disorder. c. pilonidal cyst. d. anorectal fistula.

While assessing the feet of an adult client, the nurse observes tiny dark spots under a painful callus on the client's foot. The nurse should document the presence of a. corns. b. bunions. c. plantar warts. d. gouty arthritis.

While assessing the plantar reflex of an adult client, the nurse observes a positive Babinski reflex. The nurse suspects that the client may be exhibiting signs of a. meningeal irritation. b. diabetes mellitus. c. drug intoxication. d. lower motor neuron lesions.

. An African-American female client visits the clinic. She tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the earlobe. The nurse should document a a. cyst. b. lichenification. c. bulla. d. keloid.

. An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of a. ulcers. b. erosion. c. scales. d. fissures.

A 60-year-old male client asks the nurse about risk factors for prostate cancer. The nurse should explain to the client that one possible risk factor is a. a high-carbohydrate diet. b. exposure to sulfur. c. genetic inheritance. d. advanced age.

A client has had a recent mastectomy and visits the clinic for postoperative evaluation. The client tells the nurse that she has been depressed and feels as if she is no longer a woman. The most appropriate nursing diagnosis for this client is a. ineffective individual coping related to mastectomy. b. fear of additional breast cancer related to presence of risk factors. c. PC: hematoma after mastectomy. d. disturbed body image related to mastectomy.

A client tells the nurse that his grandmother had a diagnosis of osteomalacia. The nurse should instruct the client that to decrease the risk factors for osteomalacia, the clients should have adequate amounts of a. vitamin E. b. riboflavin. c. β-carotene. d. vitamin D.

A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with a. retinal deterioration. b. head trauma. c. migraine headaches. d. vitamin A deficiency.

A client visits the clinic and complains of wrist pain. To perform Phalen's test, the nurse should ask the client to a. move the hand inward with the wrists straight. b. place both palms on the examination table. c. flex both wrists against resistance. d. place the backs of both hands against each other.

A client visits the clinic and tells the nurse that after playing softball yesterday, he thinks his knee is "locking up." The nurse should perform the McMurray's test by asking the client to a. move from a standing to a squatting position. b. raise his leg while in a supine position. c. bend forward while trying to touch the toes. d. flex the knee and hip while in a supine position.

A client visits the clinic and tells the nurse that he has had lower back pain for the past several days. To perform Lasègue's test, the nurse should ask the client to a. bend backward toward the nurse. b. lean forward and touch his toes. c. twist the shoulders in both directions. d. lie flat and raise his leg to the point of pain.

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should document the client's a. cluster headaches. b. tumor-related headaches. c. migraine headaches. d. tension headaches.

A client visits the clinic and tells the nurse that his stools have been black for the past 3 days. The nurse should assess the client for a. gallbladder disease. b. colitis. c. polyps. d. gastrointestinal bleeding.

A client visits the clinic and tells the nurse that she has painful cracking in the corners of her lips. The nurse should assess the client's diet for a deficiency of a. vitamin C. b. fluoride. c. vitamin A. d. riboflavin.

A client visits the clinic because she has missed one period and suspects she is pregnant. While assessing the client, the nurse detects a solid, mobile, tender, unilateral adnexal mass. The client's cervix is soft. The nurse suspects that the client may be experiencing a. normal pregnancy. b. endometriosis. c. pelvic inflammatory disease. d. ectopic pregnancy.

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially a. basal cell carcinoma. b. actinic keratoses. c. squamous cell carcinoma. d. malignant melanoma.

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is a. ineffective individual coping related to changes in appearance. b. anxiety related to loss of outdoor activities and altered skin appearance. c. dry flaking skin and dull dry hair as a result of disease. d. risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's a. abdomen. b. arms. c. legs. d. sclera.

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate a. calcium. b. vitamin D. c. carbohydrates. d. fluid intake.

An adolescent client tells the nurse that her mother says she grinds her teeth when she sleeps. The nurse should explain to the client that grinding the teeth may be a sign of a. precancerous lesions. b. poor oral hygiene. c. malabsorption. d. stress and anxiety.

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to a. retinal damage. b. cataracts. c. myopia. d. corneal damage.

An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for a. a foreign body. b. recent trauma. c. blind spots. d. allergies.

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible a. pulmonary edema. b. bronchitis. c. asthma. d. tuberculosis.

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for a. viral infection. b. double vision. c. allergic reactions. d. lacrimal obstruction.

An adult client visits the clinic and tells the nurse that she has been experiencing frequent nosebleeds for the past month. The nurse should a. ask the client if she has had recent oral surgery. b. assess the client's nasal passages for blockage. c. ask the client if she is a smoker. d. refer the client for further evaluation.

An adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in vision are often associated with a. diabetes. b. the aging process. c. hypertension. d. head trauma.

An adult client visits the clinic complaining of recurrent ulcers in the mouth. The nurse assesses the client's mouth and observes a painful ulcer. The nurse should document the presence of a. a cancerous lesion. b. Candida albicans infection. c. an oral ulceration. d. aphthous stomatitis.

An adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. The nurse should assess the client for a. recent exposure to irritants. b. increased intracranial pressure. c. excessive tearing. d. a foreign body in the eye.

An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "result of an accident." The nurse suspects that the client may be experiencing a. leukemia. b. diabetes mellitus. c. melanoma. d. domestic abuse.

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a a. migraine headache. b. cluster headache. c. tension headache. d. tumor-related headache.

Articulation between the head of the femur and the acetabulum is in the a. knee joint. b. tibial joint. c. ankle joint. d. hip joint.

Before examining the mouth of an adult client, the nurse should first a. ask the client to leave dentures in place. b. don sterile gloves for the procedure. c. offer the client mouthwash. d. don clean gloves for the procedure.

During assessment of an adult client, which of the following lifestyle practices would indicate to the nurse that the client may be at high risk for HIV/AIDS? A client who a. uses a condom on a regular basis. b. has multiple female partners. c. smokes marijuana occasionally. d. has anal intercourse with other males.

During assessment of an elderly male client, the client tells the nurse that he has had difficulty urinating for the past few weeks. The nurse should refer the client to the physician for possible a. inguinal hernia. b. sexually transmitted disease. c. impotence. d. prostate enlargement.

During assessment of the genitalia of an adult male, the client has an erection. The nurse should a. explain to the client that this often happens during an examination. b. cover the client's genitals and discontinue the examination. c. allow the client time to rest before proceeding with the examination. d. continue the examination in an unhurried manner.

During assessment of the vaginal area of an adult client, the client tells the nurse that she has had pain in her vaginal area. The nurse should further assess the client for a. trauma. b. cancer. c. pregnancy. d. infection.

Elevated sebaceous glands, known as Montgomery's glands, are located in the breast's a. nipples. b. hair follicles. c. lactiferous ducts. d. areolas.

Fibrous tissue that provides support for the glandular tissue of the breasts is termed a. lateral ligaments. b. Wharton's ligaments. c. pectoral ligaments. d. Cooper's ligaments.

If a male client is uncircumcised, the glans of the penis is covered by the a. epididymis. b. frenulum. c. corona. d. foreskin.

Joints may be classified as cartilaginous, synovial, or a. articulate. b. flexible. c. immobile. d. fibrous.

The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates a. deep coma. b. severe impairment. c. no verbal response. d. some impairment.

The S4 heart sound a. can be heard during systole. b. is often termed ventricular gallop. c. is usually due to a heart murmur. d. can be heard during diastole.

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the a. vagus. b. hypoglossal. c. trigeminal. d. glossopharyngeal.

The external covering of the bone that contains osteoblasts and blood vessels is termed the a. cartilage. b. synovial membrane. c. connective tissue. d. periosteum.

The external sphincter and internal sphincter of the rectum are divided by the a. anorectal junction. b. rectovesical pouch. c. median sulcus. d. intersphincteric groove.

The lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the a. bronchioles. b. alveolar sacs. c. alveolar ducts. d. cilia.

The major artery that supplies blood to the arm is the a. radial artery. b. ulnar artery. c. posterior artery. d. brachial artery.

The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of a. pulmonary emphysema. b. diastolic murmurs. c. patent ductus arteriosus. d. increased central venous pressure.

The nurse assesses an adult client's breath sounds and hears sonorous wheezes, primarily during the client's expiration. The nurse should refer the client to a physician for possible a. asthma. b. chronic emphysema. c. pleuritis. d. bronchitis.

The nurse assesses an adult male client's abdomen and observes diminished abdominal respiration. The nurse determines that the client should be further assessed for a. liver disease. b. umbilical hernia. c. intestinal obstruction. d. peritoneal irritation.

The nurse has assessed the heart sounds of an adolescent client and detects the presence of an S3 heart sound at the beginning of the diastolic pause. The nurse should instruct the client that she should a. be referred to a cardiologist for further evaluation. b. be examined again in 6 months. c. restrict exercise and strenuous activities. d. recognize that this finding is normal in adolescents.

The nurse has assessed the nose of an adult client and has explained to the client about her thick yellowish nasal discharge. The nurse determines that the client understands the instructions when the client says that the yellowish discharge is most likely due to a. too much smoking. b. chronic allergies. c. trauma to the nasal passages. d. an upper respiratory infection.

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should a. refer the client for further evaluation. b. examine the client for other signs of glaucoma. c. ask the client if there is a genetic history of blindness. d. document the findings in the client's records.

The nurse is assessing an adult client with a diagnosis of sinus arrhythmia. The nurse should explain to the client that this indicates that the a. heartbeats are followed by a pause. b. ventricular contraction occurs irregularly. c. S1 and S2 sounds are both split. d. heart rate speeds up and slows down during a cycle.

The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible a. liver disease. b. abdominal distention. c. Cushing's syndrome. d. internal bleeding.

The nurse is assessing the genitalia of a female client and detects a bulging anterior wall in the vagina. The nurse should plan to refer the client to a physician for a. stress incontinence. b. rectocele. c. tumor of the vagina. d. cystocele.

The nurse is assessing the neurologic system of a client who has spastic muscle tone. The nurse should explain to the client that spastic muscle tone is associated with impairment to the a. extrapyramidal tract. b. spinothalamic tract. c. posterior columns. d. corticospinal tract.

The nurse is assessing the neurologic system of an adult client. To test the client's use of memory to learn new information, the nurse should ask the client a. "What did you have for breakfast?" b. "How old were you when you began working?" c. "Can you repeat rose, hose, nose, clothes?" d. "Can you repeat brown, chair, textbook, tomato?"

The nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved side. The nurse suspects that the client is experiencing a. lordosis. b. arthritis. c. kyphosis. d. scoliosis.

The nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. The nurse should instruct the client to reduce her risk factors by a. eating a high-protein diet. b. resting frequently. c. drinking large quantities of milk. d. getting regular exercise.

The nurse is caring for a female client who has received a diagnosis of fibrocystic breast disease. The nurse has instructed the client about the disease. The nurse determines that the client needs further instructions when the client says she should avoid drinking a. regular coffee. b. regular tea. c. diet colas. d. grapefruit juice.

The nurse is caring for an adult client who is in a cast because of a fractured arm. To promote healing of the bone and tissue, the nurse should instruct the client to eat a diet that is high in a. whole grains. b. vitamin B. c. vitamin E. d. vitamin C.

The nurse is caring for an adult female client when the client tells the nurse that she has had a clear discharge from her nipples for the past month. The nurse should ask the client if she has been taking a. antidepressants. b. antibiotics. c. insulin. d. contraceptives.

The nurse is examining an adult client's range of motion in the shoulders. The client is unable to shrug her shoulders against resistance. The nurse suspects that the client has a lesion of cranial nerve a. VIII. b. IX. c. X. d. XI.

The nurse is planning a presentation about coronary heart disease for a group of middle-aged adults. Which of the following should be included in the nurse's teaching plan? a. Hispanic clients have a higher incidence of CHD than black or white Americans. b. The incidence of hypertension in the white population of the United States is greater than in the black population. c. Women are more likely to have serious stenosis after a heart attack. d. Estrogen replacement therapy in postmenopausal women decreases the risk of heart attack.

The nurse is planning a presentation to a group of high school students on the topic of lung cancer. Which of the following should the nurse plan to include in the presentation? a. Compared with whites in the United States, African-Americans have a lower incidence of lung cancer. b. Lung cancer is the third leading cause of death in the United States. c. There is a higher incidence of lung cancer in women than men in the United States. d. Studies have indicated that there is a genetic component in the development of lung cancer.

The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should a. perform this abdominal assessment first. b. ask the client to assume a side-lying position. c. palpate lightly while slowly releasing pressure. d. palpate deeply while quickly releasing pressure.

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to a. strike a tuning fork and place it at the base of the client's mastoid process. b. whisper a word with two distinct syllables to the client. c. ask the client to close his eyes while standing with feet together. d. strike a tuning fork and place it on the center of the client's head or forehead.

The nurse is planning to inspect the anal area of an adult male client. To assess for any bulges or lesions, the nurse should ask the client to a. hold his breath. b. breathe deeply through his mouth. c. breathe normally. d. bear down.

The nurse is planning to percuss the chest of an adult male client for diaphragmatic excursion. The nurse should begin the assessment by a. asking the client to take a deep breath and hold it. b. percussing upward from the base of the lungs. c. percussing downward until the tone changes to resonance. d. asking the client to exhale forcefully and hold his breath.

The nurse is planning to perform an eye and ear examination on an adult client. After explaining the procedures to the client, the nurse should a. ask the client to remain standing. b. show the client the otoscope. c. ask the client to remove his contact lenses. d. observe the client's response to the explanations.

The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first a. palpate the incision site. b. auscultate for bowel sounds. c. percuss for tympany. d. inspect the abdominal area.

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to a. lie in a supine position. b. lie in a side-lying position. c. stand upright in front of the nurse. d. sit in an upright position.

The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to a. ask the client to tilt the head slightly forward. b. release the auricle during the examination. c. use a speculum that measures 10 mm in diameter. d. firmly pull the auricle out, up, and back.

The nurse is preparing to perform a musculoskeletal examination on an adult client. The nurse has explained the examination procedure to the client. The nurse determines that the client needs further instructions when the client says a. "You will be asking me to change positions often." b. "You'll be comparing bilateral joints." c. "You'll be assessing the size and strength of my joints." d. "You'll continue with range of motion even if I have discomfort."

The nurse is working with a community group to set up teaching programs to increase awareness among African-American women about preventive screening techniques for breast cancer. In the teaching program, the nurse should plan to include a. local female physicians who work with cancer clients. b. hospital clinic workers from various racial backgrounds. c. nurses who work in outpatient centers. d. breast cancer patients of the same race.

The nurse plans to assess an adult client for Homans' sign. The nurse should a. ask the client to remain standing for the procedure. b. place the hands on the client's thigh muscle. c. place the hands near the client's ankle. d. flex the client's knee, then dorsiflex the foot.

The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the a. right upper quadrant. b. left upper quadrant. c. external oblique angle. d. costovertebral angle.

The nurse plans to instruct an adult female client with regular menstrual cycles, who is not taking oral contraceptives, about breast self-examination. The nurse should plan to instruct the client to perform breast self-examination a. during menstruation. b. on the same day every month. c. midway between the cycles. d. right after menstruation.

The nurse suspects that a male client may have a hernia. The nurse should further assess the client for a. bruising at the site. b. urinary tract infection. c. cysts at the spermatic cord. d. bowel sounds at the bulge.

The outer layer of the vaginal wall is under the direct influence of a. androgen. b. progesterone. c. aldosterone. d. estrogen.

The pancreas of an adult client is located a. below the diaphragm and extending below the right costal margin. b. posterior to the left midaxillary line and posterior to the stomach. c. high and deep under the diaphragm and can be palpated. d. deep in the upper abdomen and is not normally palpable.

The posterior tibial pulse can be palpated at the a. great toe. b. knee. c. top of the foot. d. ankle.

The rectum is lined with folds of mucosa, and each fold contains a network of arteries, veins, and visceral nerves. When these veins undergo chronic pressure, the result may be a. polyps. b. tumors. c. fissures. d. hemorrhoids.

The size and shape of the breasts in females is related to the amount of a. glandular tissue. b. fibrous tissue. c. lactiferous ducts. d. fatty tissue.

The visible portion of the clitoris is termed the a. corpus. b. crura. c. vestibule. d. glans.

Under normal circumstances, the strongest stimulus in a human being to breathe is a. hypoxemia. b. hypocapnia. c. pH changes. d. hypercapnia.

When the nurse moves the client's arm away from the midline of the body, the nurse is performing a. adduction. b. external rotation. c. retraction. d. abduction.

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible a. gallbladder disease. b. cachexia. c. kidney trauma. d. masses.

While assessing an adult client, the client tells the nurse that she "has had difficulty catching her breath since yesterday." The nurse should assess the client further for signs and symptoms of a. emphysema. b. cardiac disease. c. trauma to the chest. d. infection.

While assessing an adult client, the nurse observes decreased chest expansion at the bases of the client's lungs. The nurse should refer the client to a physician for possible a. atelectasis. b. pneumonia. c. chest trauma. d. chronic obstructive pulmonary disease.

While assessing the Achilles reflex in an 84-year-old client, the nurse observes that the Achilles reflex is difficult to elicit. The nurse should a. refer the client to a physician for further evaluation. b. ask the client about injuries to the feet. c. determine whether the client is having any pain in the feet. d. document the finding in the client's record.

While assessing the anus of an adult client, the nurse detects a peritoneal protrusion. The nurse should refer the client to a physician for possible a. anorectal fistula. b. polyps. c. prostate enlargement. d. peritoneal metastasis.

While assessing the feet of an older adult client, the nurse observes that the metatarsophalangeal joint to the client's great toe is tender, reddened, and painful. The nurse should refer the client to a physician for possible a. bunions. b. corns. c. hammer toe. d. gouty arthritis.

While assessing the genitalia of a female client, the nurse observes moist fleshy lesions on the client's labia. The nurse should refer the client to a physician for possible a. gonorrhea. b. herpes simplex virus infection. c. nabothian cysts. d. genital warts.

While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with a. localized infection. b. systemic infection. c. arterial insufficiency. d. malignancy.

While assessing the musculoskeletal system of an adult client, the nurse detects tenderness, warmth, and a boggy consistency of the client's knee. The nurse should refer the client to a physician for possible a. torn meniscus. b. malignancy. c. fracture. d. synovitis.

While assessing the neurologic system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that the client may be exhibiting signs of a. depression. b. anxiety. c. attention deficit disorder. d. cerebral cortex disorder.

While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing a. venous stasis. b. varicose veins. c. thrombophlebitis. d. arterial insufficiency.

While auscultating an adult client's heart rate and rhythm, the nurse detects an irregular pattern. The nurse should a. assess the client for signs and symptoms of pulmonary disease. b. document this as a normal finding. c. schedule the client for an ECG. d. refer the client to a physician.

While inspecting the skin color of a male client's legs, the nurse observes that the client's legs are slightly cyanotic while he is sitting on the edge of the examination table. The nurse should refer the client to a physician for possible a. arterial insufficiency. b. congestive heart failure. c. Raynaud's disease. d. venous insufficiency.

While reviewing a client's chart before seeing the client for the first time, the nurse notes that the client has a diagnosis of Dupuytren's contracture. The nurse anticipates that the client will exhibit a. inability to turn the wrists. b. ulnar deviation of the hands. c. flexion of the distal interphalangeal joints. d. inability to extend the ring and little finger.

While reviewing a client's chart before seeing the client for the first time, the nurse notes that the client has a diagnosis of pes planus. The nurse anticipates that the client has a. high arches. b. bunions. c. calluses. d. flat feet.

While transilluminating the scrotal contents in a male adult client, the nurse does not detect a red glow. The nurse should refer the client to a physician for possible a. spermatocele. b. orchitis. c. hydrocele. d. varicocele.

health assessment III (nursing assessment of physical systems)

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