Health Promotion and Disease Prevention Exam

A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells the client that this test measures:

Peripheral vision.

A nurse is preparing to check the breath sounds of a client. Over which anatomic area does the nurse place the stethoscope when auscultating for bronchial breath sounds?

2.

A nurse sees documentation in the client's record indicating that the physician has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds are:

Abnormal sounds that should not be heard in the lungs.

A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding?

Accommodation.

A nurse performing a neurological examination is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which of the following actions does the nurse take to test this nerve?

Asking the client to close his or her eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear.

A 16-year-old girl visits the women's health clinic to obtain information about birth control because she is sexually active and wants to avoid pregnancy. The nurse who is interviewing the client should first:

Assess the client's knowledge of available birth control methods

A nurse is reviewing the healthcare record of a client who has just undergone an examination of the internal genitalia. Which of the following documented findings indicates an abnormality?

Clear secretions with a foul odor are noted on the cervix.

A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which of the following actions does the nurse take to help ensure the success of the interview?

Ensuring that the room is private.

A client complains that her skin is redder than normal. The nurse assesses the client's skin, documents hypermedia, and explains to the client that this condition is caused by:

Excess blood in the dilated superficial capillaries.

An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?

Exposure to cigarette smoke.

A nurse performing a cranial nerve assessment is testing the function of the oculomotor, trochlear, and abducens nerves. Which of the following parameters does the nurse check to determine the function of these nerves?

Eye movements.

A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope at the:

Fifth left inerspace at the midclavicular line.

A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment?

Follow-up.

A nurse reviewing the healthcare record of a client notes documentation of grade 4 muscle strength. The nurse understands that this indicates:

Full ROM against gravity with some resistance.

A nurse performing a physical examination is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note?

Gurgling sounds.

While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which of the following findings does the nurse expect to note when auscultating the client's bowel sounds?

Hyperactive bowel sounds.

A nurse performing a physical examination is assessing the client for costovertebral angle tenderness. When the nurse percusses the area, the client complains of sharp pain. The nurse interprets this finding as most indicative of:

Kidney inflammation.

A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips:

Lateral to the extensor tendon of the big toe.

A nurse is preparing to listen to the breath sounds of a client. The nurse should:

Listen for at least one full respiration in each location on the chest.

A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment by:

Listening to the carotid artery, using the bell of the stethoscope to assess for bruits.

A nurse is preparing to assist the physician in performing an internal gynecological examination of a client. In which of the following positions does the nurse place the client for this examination?

Lithotomy.

A nurse is assisting the physician in performing transillumination of a client's scrotum. The nurse prepares for this procedure by:

Obtaining a flashlight and darkening the room.

Performing an abdominal assessment, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner because:

Palpation and percussion can increase peristalsis.

A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign?

Percussing at the location of the median nerve.

A nurse is preparing to measure a client s calf circumference. The nurse performs this procedure by:

Placing a tape measure around the widest point of the lower leg.

A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse take before inserting the otoscope?

Pulling the pinna up and back.

During a neurological assessment, the nurse asks the client to close the jaws tightly, after which the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of the:

Trigeminal nerve.

A nurse preparing to perform an abdominal assessment asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity?

Tympany.

A nurse is preparing to listen to a client's breath sounds. The nurse should:

Use the diaphragm of the stethoscope, holding it firmly against the client's chest.

A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat words that are:

Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested.

A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands that the primary purpose of including cultural information in the health assessment is to:

Determine what the client believes has caused the epilepsy.

During a neurological assessment, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing?

Facial.

A nurse is palpating a client's sinus areas. Which of the following sensations does the nurse expect the client to indicate that he/she is feelings during palpation is the sinuses are normal?

Firm pressure.

A female client is seen in the clinic for a gynecological examination. The nurse begins collecting subjective data. Which of the following topics does the nurse ask the client about first?

Her menstrual history.

A nurse performing a musculoskeletal assessment of a client with suspected carpal tunnel syndrome plans to perform the Phalen test. The nurse should ask the client to:

Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds.

A nurse is assessing a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the nurse obtain data on from the client?

Hypertension.

At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she states that:

Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.

A nurse is performing an abdominal assessment on a client. On auscultation of the abdomen the nurse hears a bruit over the abdominal aorta. Which action should the nurse take as a priority on the basis of this finding?

Notify the healthcare provider.

A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as:

Nystagmus.

A nurse performing a neurological assessment of an adult client asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?

Olfactory.

A nurse reviewing a client's healthcare record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the nurse determine that the client has?

Osteoarthritis.

A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be?

Rustling.

A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the nurse places the stethoscope over:

The peripheral lung fields.

A nurse performing a skin assessment uses the back of the hand of feel the client's skin on both arms and notes that the skin is warm. The nurse determines that:

The skin temperature is normal.

A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing?

Cranial nerve XII.

A nurse inspecting a client s throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of:

Cranial nerves IX and X.

A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which of the following findings does the nurse expect to note if cholecystitis is present?

Murphy sign.

A nurse is providing instructions to a client who is scheduled to undergo a Papanicolaou (Pap) test in one week. Which statement does the nurse make to the client?

"Avoid intercourse for 24 hours before the scheduled examination."

A nurse is describing the procedure for testicular self-examination (TSE) to a male client. Which statement should the nurse make to the client?

"If you notice an enlarged testicle or a lump, you need to notify the physician."

A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. The nurse, inspecting the ears for cerumen impaction checks for:

A yellowish or brownish waxy material in the external auditory canal.

The nurse, performing an abdominal examination, inspects the client's abdomen. Which assessment technique does the nurse perform next?

Auscultation.

A nurse performing an abdominal assessment is preparing to auscultate for bowel sounds. The nurse:

Begins in the right lower quadrant.

A nurse reviewing a client's record notes documentation that the client has melena. How does the nurse detect the presence of melena?

By checking the client's stool for blood.

A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork?

On the client's mastoid bone.

A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination:

One week after menstruation begins.

A nurse teaches a client about healthy dietary measures and explains the MyPlate food plan. The nurse determines that the client understands the information if the client says how many of his grains should be whole grains?

One-half.

A nurse performing an eye examination uses an opthalmoscope to best visualize which of the following areas?

Optic disc.

A nurse performing a respiratory assessment of a client plans to assess tactile (vocal) fremitus. The nurse performs this assessment by:

Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine."

A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct?

Setting the room temperature at a comfortable level.

A nurse is preparing to assess the function of a client's spinal accessory nerve. Which of the following actions does the nurse ask the client to take to aid assessment of this nerve?

Shrugging the shoulders against the nurse's resistance.

A nurse is examining the peripheral vision of a client using the confrontation test. To carry out this procedure, the nurse:

Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field.

A nurse conducting an interview with a client collects subjective data. During the interview, the nurse:

Take minimal notes to avoid observation of the client's nonverbal behaviors.

A nurse is preparing to screen a client's vision with the use of a Snellen chart. The nurse:

Tests the right eye, then tests the left eye, and finally tests both eyes together.

A nurse performing a physical assessment of a client gathers both subjective and objective data. Which of the following findings would the nurse document as subjective data?

The client states that he has a rash.

A 35-year-old female client asks the clinic nurse when she should begin to have yearly mammograms. What does the nurse tell the client?

Yearly mammograms are recommended starting at age 40

A nurse reviewing the medical record of a client with the diagnosis of heart failure notes documentation indicating that the client has deep pitting edema, that the indentation remains for a short time, and that the leg looks swollen. How does the nurse document this finding?

3+ edema.

An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse concludes that:

The client has a normal cardiac output.

A nurse reviewing the physical assessment findings in a client's healthcare record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has?

Carpal tunnel syndrome.

A nurse is preparing the perform a skin examination with the use of a Wood light. In preparing for this diagnostic test, the nurse should:

Darken the room.

A nurse in the emergency department is performing a musculoskeletal assessment of a client. The presence of which of the following conditions would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

Neck trauma.

A nurse performing a neurological assessment is preparing to assess the optic nerve. The nurse performs this examination by:

Assessing visual activity.

A nurse is making an initial home visit to a client with chronic obstructive disease who was recently discharged from the hospital. Which type of database dose the nurse use to obtain information from the client?

Complete

A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?

Coffee.

A nurse is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the nurse:

Uses a tuning fork.

A nurse is gathering supplies to perform a physical assessment of a client. Which necessary item does the nurse select to perform the Weber test?

4.

A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data?

A 1 x 2-inch scar is present on the lower right portion of the abdomen.

A nurse performing a genital examination of a male client notes that the skin of the penis and scrotum is wrinkled. On the basis of this finding, the nurse:

Documents the normal finding.

A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as:

Abnormal bronchophony.

Performing an abdominal assessment, a nurse notes tenderness while lightly palpating a client's right lower quadrant. The nurse determines that this finding is most likely associated with which of the following anatomic structures?

Appendix.

A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection?

Ask health history questions while performing the examination and initiating emergency measures.

During a physical assessment, the client tells the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing:

Dysphagia.

On assessing a client's skin, the nurse notes the presence of several large red-blue and purple areas on the client's body that do not blanch when pressure is applied. The nurse documents this finding as:

Ecchymosis.

A mother brings her 18-month-old child to the clinic to receive the next scheduled vaccine. The child has previously received the following vaccines: three doses of the hepatitis B vaccine (at birth and 1 and 6 months of age); three doses of the diphtheria/tetanus/acellular pertussis (DTaP) vaccine (at 2, 4, and 6 months of age); four doses of Haemophilus influenzae type b (Hib) conjugate vaccine (at 2, 4, 6, and 12 months of age); three doses of inactivated poliovirus vaccine (IPV) (at 2, 4, and 6 months of age); one dose of measles/mumps/rubella vaccine (MMR) (at 12 months of age); varicella zoster vaccine at 12 months of age; and four doses of pneumococcal vaccine (at 2, 4, 6, and 12 months of age). After reviewing the child's immunization record, which scheduled vaccine does the nurse prepare to administer?

DTaP

A nurse is examining a 25 year old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting:

Data related to the respiratory system.

During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client?

"I need some more information about the discharge. What color is it?"

A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the client's pulse is normal. Which of the following notations would the nurse make in the client's record to document the force of the client's pulse?

2+.

A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding as:

Anasarca.

A nurse performing a neurological assessment is inspecting the client's eyelids for ptosis. The nurse checks the client for:

Drooping.

A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing:

Intermittent claudication.

A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client?

Left lateral.

A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that the client has normal:

Ocular movements.

A nurse is preparing to test the function of cranial nerve XI. Which of the following actions does the nurse take to test this nerve?

Placing his/her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands.

A nurse conducting a peripheral vascular assessment performs the Allen test. The nurse understands that this test is used to determine the patency of the:

Radial and ulnar arteries.

A nurse performing a skin assessment notes that the client's skin is very dry. The nurse documents this finding as:

Xerosis.

A nurse conducting a physical assessment of a client plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal:

A problem with balance.

A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. The nurse interprets this to mean that the client:

Can read at a distance of 20 feet with a client with normal vision can read at 80 feet.

A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expects to note if the bladder is full?

Dull sounds.

A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?

Right lower quadrant.