Holistic Assessment Exam Questions

Which patient situation would the nurse interpret as requiring an emergency assessment? -A patient who overdosed on acetaminophen. -A patient needing an employment physical. -A distraught patient who wants a pregnancy test. -A pediatric patient with severe sunburn.

-A patient who overdosed on acetaminophen.

Higher prevalence of asthma is which group -African Americans -Non-hispanic Blacks -Caucasians -SE Asians

-African Americans

During chest auscultation the nurse hears a quiet murmur immediately upon placing the stethoscope on patients chest, this is grade -3 -1 -2 -4

-4

When auscultating the lungs, adventitious sounds are noticed, what should the nurse do first: -Ask the pt to cough then listen again -Perform bronchophony -Refer the pt for further medical evaluation -auscultate for egophony

-Ask the pt to cough then listen again

A patient has a sensorineural hearing loss. Which condition would the nurse most likely identify as a cause? -Inner ear problem -Otosclerosis -Perforated eardrum -Otitis Media

-Inner ear problem

Select assessment findings associated with breast cancer -irregular, firm lumps -elastic, tender, mobile lump -dimpling and nipple retraction -orange peel-like appearance -redness & warmth w/ smooth texture -breast fullness & pain

-irregular, firm lumps -dimpling and nipple retraction -orange peel-like appearance

The nurse has been applying the nursing process in the care of an adult patient who is being treated for acute pancreatitis. Place the nurse's actions in their proper sequence from first to last. Determining outcome achievement. Identifying outcomes. Determining the patient's nursing problem. Carrying out interventions. Collecting information about the patient.

Collecting information about the patient. Determining the patient's nursing problem. Identifying outcomes. Carrying out interventions. Determining outcome achievement

A nurse is assessing a patient for possible fluid overload. Which assessment finding is most consistent with this diagnosis -Boggy eyeball -Moist, plump tongue -Distended neck veins w/ head elevated at 45 degrees -venous filling of 3 second

Distended neck veins w/ head elevated at 45 degrees

When assessing the ear, which finding would be cause for concern? -Red, flaky cerumen -Darwin tubercle -Tender tragus -Pearly gray tympanic membrane

-Tender tragus

The nurse observes a line across the tip of an 8 yr old's nose, the nurse consider what: -chronic allergies -chronic nose picking -nasal mucosal polyps -history of abuse

-chronic allergies

A nurse examines an older adult patient. Which of the following would the nurse document as a normal finding? -Episcleritis -Ectropion -Exophthalmos -Chalazion

-Ectropion

During the palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6 cm mass above the umbilicus, what action should the nurse take -refer the client to an oncologist -stop palpating & get medical assistance -counsel the client regarding hernia repair -provide a dietician consult for the client

-stop palpating & get medical assistance

The nurse is performing blunt percussion of a client's kidneys, for what abnormal finding is the nurse primarily assessing -tympany -hyperresonance -tenderness -dullnessr

-tenderness

A nurse is reviewing electrical conduction system of the heart in preparation for assessing a pt w/ a conduction problem. The nurse should be aware that the electrical signal originates in which location -SA node -bundle of His -Purkinje fibers -AV node

SA node

A 60-year-old patient has difficulty hearing high-pitched sounds. The nurse would document this finding as which of the following? -Otalgia -Tinnitus -Vertigo -Presbycusis

-Presbycusis

The nurse is percussing the area over the patient's lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following? -Tympany -Dullness -Flatness -Resonance

-Resonance

An older adult pt presents w/ cramping type leg pain when walking which is relieved by rest. The pt has cool, pale feet & capillary refill in the toes of 4-6 sec.s, what would the nurse suspect -Arterial insufficiency -diabetic neuropathy -venous insufficiency -musculoskeletal weakness

-Arterial insufficiency

When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free flow of thought and the woman's ability to follow directions. What would the nurse do first? -Assess the client's vision and hearing. -Refer the client to social services for home assistance. -Refer for further medical evaluation. -Use a Geriatric Depression Scale.

-Assess the client's vision and hearing.

While assessing the scrotom of an adult client the nurse notes thin and rugated scrotal skin w/ little hair dispersion, how would this be documented -Normal -geiter syndrome -gonorrhea -effects of chemotherapy

-Normal

What instruction should the nurse give to palpate for fremitus in respiratory system -Say letter "e" -Breath in as deeply as you can and hold your breath -Please say the number "99" -When I say so, please exhale forcefully & hold breath

-Please say the number "99"

A nurse has completed the general survey of a patient who has been transferred to the unit. The information gathered during the general survey primarily provides the nurse with which of the following? SELECT ALL THAT APPLY. -An indication of the level of physical distress experienced by the patient. -Clues about the overall health of the patient. -A direct link to the patient's medical diagnosis. -Indications about normal variations in the status of body systems. -Data relating to the patient's level of social support.

-An indication of the level of physical distress experienced by the patient. -Clues about the overall health of the patient. -Indications about normal variations in the status of body systems.

The nurse is collecting data from a patient who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. What would the nurse categorize as objective data? -Family history -Appearance -History of present health concern -Occupation

-Appearance

The nurse tests the distant visual acuity of several patients and records the findings. Which finding indicates that the patient with the poorest vision? -20/30 -20/50 -20/60 -20/40

-20/60

The nurse assesses brisk reflexes in a client during a neurologic assessment, how would the nurse document this -3+ -2+ -4+ -1+

-3+

The nurse is inspecting a pt's tonsils & notes that they make contact w/ the uvula, how would the nurse document this? -3+ -2+ -4+ -1+

-3+

When evaluating a pt risk for cerebrovascular accident, which pt would the nurse identify at highest risk -35 yr old African American male w/ sleep apnea -70 yr old caucasian male who has 2 beers/day -an obese 42 yr old caucasian female -68 yr old African American male w/ HTN

-68 yr old African American male w/ HTN

Which client would the nurse consider a bluish tint to the cervix an expected assessment finding -71 yr old multiparous pt -a pt who is 17 yrs old & sexually active -a pt who has a 24 pack-yr smoking hx -a pt who is 10 wks pregnant

-a pt who is 10 wks pregnant

The nurse is assessing the genitalia & rectum of a 71 yr old client. When assessing the pt's vagina, the nurse should know that age-related changes increases the client risk of what abnormal finding -trichomonas vaginitis -atrophic vaginitis -candidal vaginitis -bacterial vaginosis

-atrophic vaginitis

While inspecting the vagina, the nurse observes a thin, grayish-white vaginal discharge w/ a fishy odor, what would the nurse suspect -bacterial vaginosis -atrophic vaginitis -trichomoniasis -HIV/AIDS

-bacterial vaginosis

While inspecting the penis of a client, the nurse suspects herpes progenitalis based on which assessment finding -hardened nodules on the glans -clear vesicles that erupt -red oval ulcerations -painless fleshy papules

-clear vesicles that erupt

When examining a newborn male infant, the nurse notes that neither testicle is descended, how would this be documented -cryptorchidism -epididymitis -varicocele -orchitis

-cryptorchidism

A client complains of scrotal pain & the nurse elicits a positive prehn sign, the nurse would refer the client for treatment of what condition -tortuous varicocele -scrotal mass -strangulated hernia -epididymitis

-epididymitis

During the health history of a post menopausal pt she mentions she is experiencing vaginal dryness. When explaining the most likely reason to the client, the nurse should expect the role of which hormone -oxytocin -estrogen -follicle-stimulating hormone -progesterone

-estrogen

A nurse is planning to assess a male client for urethral discharge, which technique would be best for the nurse to use -gently squeeze the glans between the thumb -observe the glans of the penis for signs of abnormal discharge -have the client hold the penis while the examiner looks for discharge -inspect the scrotal skin while holding the penis aside

-gently squeeze the glans between the thumb

A client's electronic health record reveals he had sx as an infant to correct his urethra location on the ventral side of his penis, what condition is this called -paraphimosis -hypospadias -epispadias -phimosis

-hypospadias (ventral side) -epispadias (dorsal side)

A client has presented w/ s/s that are suggestion of bell palsy, what assessment finding is most consistent w/ this diagnosis -closure of the affected eye from swelling -muscle spasm of the lower face on the affected side -inability to wrinkle the forehead -inability to detect sharp & dull sensation

-inability to wrinkle the forehead

The nurse placed her hands behind the pt's head & flexed the pt's neck forward as far as the client can tolerate. During the test, the pt experiences leg pain & bends his knees. This assessment finding is suggestive of what health problem -meningitis -brain stem lesion -ischemic stroke -bell plasy

-meningitis

A male client has presented for follow-up to a diagnosis of genital warts, the nurse should expect to assess for what type of lesions -firm, shiny nodules -moist, fleshy papules -reddened ulcers that occasionally bleed -pimple-like vesicles

-moist, fleshy papules

The nurse should instruct the client to perform the testicular self examination at which frequency -bimonthly -quarterly -weekly -monthly

-monthly

The nurse notes a malodorus, yellow discharge upon inserting the speculum into the client's vagina, what would the nurse do next -obtain a sample for testing -procure a pap smear -perform a bimanual exam -obtain a urine specimen

-obtain a sample for testing

Nurse is assessing a 39 ur old woman w/ a 20 yr smoking history. When reviewing current meds, which drug would the nurse identify as increasing the pt's risk of stroke -Acetaminophen -ASA -oral contraceptive -beta blocker

-oral contraceptive

What would be the most appropriate for the nurse to do when assessing motor function of a client's trigeminal nerve -have the client smile, frown, and wrinkle the forehead -palpate temporal & masseter muscles while client clenches the teeth -assess dilation of the client's pupils w/ direct light -ask client to differentiate sharp & dull sensations on the face

-palpate temporal & masseter muscles while client clenches the teeth

An adult male client reports hesitancy when urinating, the nurse would further assess this client for what complication -STI -testicular tumor -prostate enlargement -scrotal hernia

-prostate enlargement

The nurse is planning to assess a client for graphesthesia, how will the nurse perform the phase of assessment -have the client close the eyes, the nurse will check sensations -the pt is asked to identify number of points nurse touches at same time -pt will close eyes and identify what number the nurse writes in the pt's palm

-pt will close eyes and identify what number the nurse writes in the pt's palm

When the nurse is examining a male client's genitalia, the client experiences an erection, what should the nurse do -stop the exam and leave the room for a few minutes -remain silent but continue the exam -reassure the pt that this is not unusual -ask pt whether continuing the exam will embarrass him

-reassure the pt that this is not unusual

An older client states that they urinate when they sneeze, how would the nurse interpret this -stress incontinence -total incontinence -urge incontinence -reflex incontinence

-stress incontinence

The nurse is completing a pt's genitourinary assessment & is preparing to assess the client's cervix, what finding would most clearly warrant referral -the cervix is pink & smooth on inspection -the cervix is firm on palpation -the cervix is immobile on palpation -the cervix projects 2 cm into the client's vagina

-the cervix is immobile on palpation

The nurse is conducting a focused neurologic assessment of an 81 yr old client, when analyzing the assessment data the nurse should be aware of what age-related neurologic change -loss of sensations in distal extremities -loss of remote memory -impaired judgement -tremors accompanying intentional movements

-tremors accompanying intentional movements

The nurse would pursue additional assessment and evaluation of an older adult patient with diabetes upon assessing which of the following? -Cutaneous horn -Pressure ulcer -Seborrheic keratosis -Cherry angioma

-Pressure ulcer

Correct area to palpate for rebound tenderness test -RUQ -LLQ -LUQ -RLQ

-RLQ

A nurse is reviewing the various causes associated w/ abdominal distention. What should the nurse identify -fat -stool -gas -hernia -fibroid tumor

-fat -stool -gas -fibroid tumor

An adult pt has been diagnosed w/ bronchitis, what would the nurse most likely hear on auscultation -fine crackles -sonorous wheezes -sibilant wheezes -coarse crackles

-fine crackles -sonorous wheezes

A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new patient from post-anesthetic recovery. The nurse should plan to perform which technique first? -Inspection -Palpation -Percussion -Auscultation

-Inspection

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a patient with a severe asthma attack? -Nail beds. -Sclera. -Palms. -Lips/oral mucosa.

-Lips/oral mucosa.

When assessing pain in an older adult patient who is alert and oriented, which assessment tool would be most appropriate to use? -Faces Pain Scale-Revised -FLACC Scale -Graphic Rating Scale -Numeric Rating Scale

-Numeric Rating Scale

During a health history, a patient reports complaints of headaches. What would lead the nurse to suspect that the patient is experiencing cluster headaches? -Additional complaint of sensitivity to light. -Throbbing and severe pain. -Pain radiating from eye to temporal region. -Report of ringing in the ears prior to headache.

-Pain radiating from eye to temporal region.

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which patient would the nurse determine to be in most need of an emergency assessment? -A 14-year-old girl who is crying because she thinks she is pregnant. -A 3-year-old child with fever, rash, and sore throat. -A 20-year-old man with a 3-in shallow laceration on his leg. -A 45-year-old man with chest pain and diaphoresis for 1 hour.

-A 45-year-old man with chest pain and diaphoresis for 1 hour.

A nurse is preparing to address family violence prevention. What would be MOST important for the nurse to incorporate into the program -1 out of 10 women who are pregnant often fall victim to intimate partner violence -abuse is most commonly perpetrated by people w/ low levels of education -Children raised w/ intimate partner violence are more likely to use violence as adults -Victims of abuse account for approximately 2500 visits to their health care providers yearly

-Children raised w/ intimate partner violence are more likely to use violence as adults

A nurse has received a report on a patient who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, what should the nurse do first? -Validate important data. -Collect subjective data. -Document the data. -Collect objective data.

-Collect subjective data.

Assessment of a patient who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following? -Obtunded -Coma -Stupor -Lethargy

-Coma

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

-Discrete

The nurse in a prenatal clinic is performing an assessment on a pregnant patient. When it is noted that clumps of hair are missing from the patient's scalp, the nurse should ask what assessment question? -Do you feel safe in your home setting? -Can you tell me if anyone recently attacked you -Have you ever been the victim of a crime -What do you know about the problem of domestic violence?

-Do you feel safe in your home setting?

During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following would be most appropriate? -Refer the client for medical follow-up. -Evaluate further for a problem with the spleen. -Assess urinary output. -Document the position of the liver.

-Document the position of the liver.

A school nurse who provides care in a middle school works exclusively with adolescents. According to Erikson's theory of psychosocial development, what task will underlie much of the students' behavior? -Appraising religious dogma. -Establishing a personal identity. -Evaluating the merits of their parents' beliefs. -Exerting influence over others.

-Establishing a personal identity.

A nurse is preparing to assess a patient who is new to the clinic. When beginning the collection of the patient database, which of the following actions should the nurse prioritize? -Identifying potential health problems. -Determining the patient's strengths. -Establishing a trusting relationship. -Making clinical inferences.

-Establishing a trusting relationship.

Which test would be most appropriate for the nurse to perform when assessing eye muscle strength and cranial nerve function? -Eye positions test -Vision fields test -Corneal light reflex test -Cover test

-Eye positions test

The nurse is preparing to test a patient's eyes for accommodation. The nurse would have the patient focus on an object in which sequence for this test? -Near, then far -Lateral, then near -Lateral, then far -Far, then near

-Far, then near

A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which action? -Placing the non-dominant hand on top of the dominant hand for improved sensation. -Feeling the surface structures using a circular motion. -Depressing the skin 1 to 2 inches with the dominant hand. -Using one hand to apply pressure and the other hand to feel the structure

-Feeling the surface structures using a circular motio

A pt states he cannot breath well at night when lying down, the nurse should further assess for what: -Pneumonia -bronchitis -TB -HF

-HF

A nurse utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted patient, the nurse should recognize the possibility of which of the following? -Imminent liver disease. -Alcoholism. -Acute pancreatitis. -Hazardous and harmful alcohol use.

-Hazardous and harmful alcohol use.

When talking to a patient before starting the physical exam, the nurse notes that the patient repeatedly tilts her head to one side with the left ear facing the RN. Which of the following would the nurse examine first? -Mental Status -Thyroid Gland -Lymph Nodes -Hearing Acuity

-Hearing Acuity

The nurse is completing the general survey of a patient and determines that his temperature is 102°F. What would the nurse also expect to find? -Weak, thready pulse. -Heart rate greater than 100 beats/min. -Diastolic blood pressure 10 mm Hg greater than normal. -Respiratory rate between 12 and 20 breaths/min.

-Heart rate greater than 100 beats/min.

The nurse collects vital signs on a hospital patient who has recently been experiencing pain. Which finding would indicate the patient is currently experiencing pain? -Respiratory rate of 18 breaths/min. -Temperature of 37.3°C (99.1°F). -Heart rate of 110 beats/min. -Blood pressure of 115/65 mm Hg

-Heart rate of 110 beats/min.

Pt reports a "wicked cough" leading to dyspnea. When trying to differentiate between pathologic lung changes & an infection as the etiology of the patient's cough, which interview ? should the nurse ask: -How long have you been experiencing your cough -do you experience chest pain when you cough -does your cough often cause you to be short of breath -are you now or have you ever been a smoker

-How long have you been experiencing your cough

An adolescent shows the nurse a "bump" on his neck. The nurse observes a raised, erythematous, solid 0.3-cm by 0.2-cm mass. How would the nurse document this finding? -Macule -Nodule -Papule -Pustule

-Papule

Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. What nursing diagnosis would be priority? -Potential complication: hypertension. -Powerlessness related to diabetes self-care and management. -Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination. -Imbalanced nutrition: more than body requirements related to diabetes

-Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination.

The nurse is assessing an older adult patient's mental status. Consistently, the patient pauses after the nurse poses a question, but then provides a response that is correct or appropriate. How should the nurse best interpret this characteristic of the patient? -The patient is displaying a sign of early Alzheimer disease. -Slight delays in mental processing are normal in older adults. -The patient may be trying to anticipate the nurse's desired response. -The patient may be experiencing an early sign of delirium.

-Slight delays in mental processing are normal in older adults.

The nurse is assessing the apices of the pt's lungs, the nurse should locate them at which position -Level of the diaphragm -At about the tenth rib -Slightly above the clavicle -Near the level of 8th rib

-Slightly above the clavicle

What would a nurse suspect if dullness is percussed at the last L interspace at the anterior axillary line on deep inspiration -Splenomegaly -abdominal mass -hepatomegaly -intestinal air

-Splenomegaly

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

-Sternomastoid

An infant was removed from her home by social services because of the dangerous and neglectful conditions that existed. According to Erikson, failure of the infant to resolve the central crisis of infancy may lead to what personality characteristics later in life? -Suspicion and fear. -Dependency and relational entanglement. -Aggression and antagonism. -Depression and introversion.

-Suspicion and fear.

The nurse is preparing to perform a nutritional assessment of a newly admitted patient. What question would be most appropriate for the nurse to ask when initiating the assessment? -Did you eat breakfast today? -How many meals do you eat each day? -How often do you eat out? -Tell me what have you eaten in the last 24 hours?

-Tell me what have you eaten in the last 24 hours?

The nurse has begun a client's assessment and is applying the blood pressure cuff on a patient's arm. Which action would be most appropriate? -The nurse can fit three to four fingers under the inflated cuff. -The cuff is wrapped loosely around the arm. -The cuff is placed about 1 in above the antecubital area. -The bladder inside the cuff encircles 50% of the arm circumference.

-The cuff is placed about 1 in above the antecubital area.

A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which principle would guide the nurse's assessment of the patient's mental status? -The nurse must explain that the results of the assessment will be used to determine if admission to long-term care is necessary. -The nurse must modify the cognitive assessment to exclude assessments requiring reading or writing. -The nurse should first explain to the couple that senility is expected among adults over age 80. -The nurse must differentiate between age-related changes and the signs and symptoms of dementia.

-The nurse must differentiate between age-related changes and the signs and symptoms of dementia.

The nurse has identified abnormal findings when reviewing a young adult patient's health history. Within Kohlberg theory of moral development, what behavioral characteristic is the nurse most likely to observe? -The patient is easily manipulated by others. -The patient is unable to weigh options when presented with a dilemma. -The patient has difficulty trusting others. -The patient makes decisions without considering the impact on others.

-The patient makes decisions without considering the impact on others.

A nurse is reviewing a colleague's documentation of a patient assessment. The nurse reads that the patient's radial pulse was 2+. How should the nurse interpret this assessment finding? -The patient's radial pulse occluded with moderate pressure. -The patient's radial pulse could not be manually occluded. -The patient's radial pulse occluded with very firm pressure. -The patient's radial pulse occluded easily.

-The patient's radial pulse occluded with moderate pressure.

The nurse is conducting a health interview and has asked the patient, How would you describe yourself to others? The patient's response informs the nurse's assessment of which of the following? -The patient's self-concept. -The patient's aspirations. -The patient's superego. -The patient's morality and honesty.

-The patient's self-concept.

A pt has sustained a brain stem injury & is being treated in the ICU, what would the nurse need to consider when assessing the pt's respiratory status? -The pt will have greatly increased respiratory effort -The pt will exhibit Cheyne-Stokes Respirations -The pt will have a loss of involuntary respiratory control -the pt will respond negatively to increased stimuli

-The pt will have greatly increased respiratory effort

During a Weber test, the patient reports lateralization of sound to the good ear. The nurse interprets this as which the following? -The poor ear is receiving sound vibrations by air. -The good ear cannot receive sound vibrations. -There is a sensorineural hearing impairment. -There is a dysfunction of the middle ear.

-There is a sensorineural hearing impairment.

The nurse has completed the comprehensive health assessment of a patient who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason? -Provide information for the client's record. -Address areas previously omitted. -To determine the need for crisis intervention. -To reassess previously detected problems.

-To reassess previously detected problems.

The nurse is preparing to perform a physical examination on a female patient who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which examination? -Head and neck examination. -Palpation of lymph nodes. -Vital signs. -Breast examination

-Vital signs.

A nurse is admitting a new patient to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which action? -Discarding in the trash can the safety pin that was used to assess sensory perception. -Wearing a gown, gloves, and mask during the physical exam. -Wearing gloves to palpate the tongue and buccal membranes. -Performing hand hygiene between examinations of each body part

-Wearing gloves to palpate the tongue and buccal membranes.

When obtaining the nutritional health history from a patient, which of the nurse's questions would best elicit information about the patient's knowledge of her own health status? -Are you now or have you been on a diet recently? -How much fluid do you drink in a day? -What are your height and usual weight? -Can you tell me what you consider to be a healthy meal?

-What are your height and usual weight?

A patient has presented for care with complaints of persistent lower back pain. When assessing the patient's pain, which statement, made by the nurse, would be most appropriate? -Heating pads usually help relieve my pain. -What makes your pain better or worse? -Did either of your parents have back pain? -Does this pain really bother you every day?

-What makes your pain better or worse?

Nurse is assessing a pt w/ complaints of chest pain, what question would be MOST important for the nurse to ask -do you have a family history of cardiac chest pain -are you having any other symptoms w/ your chest pain -do you have a history of HTN or high cholesterol -have you ever experienced chest pain in the past

-are you having any other symptoms w/ your chest pain

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain, which statement by the nurse would be most appropriate -since you're having pain in a certain area, i wont do a very detailed exam there -before i get ready to examine the painful area, i will let you know in plenty of time -you don't need to worry about anything, I will make sure to be very gently during the exam -im going to examine the area where you're having pain first to get a better picture

-before i get ready to examine the painful area, i will let you know in plenty of time

While auscultating a patent's trachea, a high, harsh sound w/ short inspirations & long expirations is heard. How would this be documented. -Adventitious breath sounds -Bronchovesicular breath sounds -bronchial breath sounds -vesicular breath sounds

-bronchial breath sounds

Type of respiratory pattern often seen with severe, uncompensated HF: -kussmaul -bradypnea -biot -cheyne-stokes

-cheyne-stokes

Assessment of a pt's lower extremities reveals unilateral edema of the R foot and ankle, what would the nurse do next -check for bilateral varicosities -perform the allen test -compare measurements of bilateral extremities -palpate femoral pulses

-compare measurements of bilateral extremities

After teaching a group of students about the external and internal structures of the eye, the instructor determines that the teaching was successful when the students identify which of the following as external structures? SELECT ALL THAT APPLY -Lacrimal apparatus -Conjunctiva -Lens -Iris -Sclera -Caruncle

-conjunctiva -lens -iris

The nurse is assessing the eyes of a client who has a lesion of the SNS, what assessment finding should the nurse anticipate -constricted pupils, unresponsive to light -nystagmus -bilateral dilated pupils -argyll robertson pupils

-constricted pupils, unresponsive to light

A client has sustained an injury to the cerebellum, which area should be the nurses primary focus for assessment -respiratory status -vital signs -coordination -cardiac function

-coordination

What would the nurse do FIRST when collecting subjective data from a patient when domestic violence is suspected -have a witness to the conversation -create a safe environment -discuss legal reporting requirements -talk about limits of confidentiality

-create a safe environment

A pt has been diagnosed w/ a sinus infection accompanied by large amounts of exudate, what assessment finding should the nurse anticipate along with this condition? -Frontal sinuses non-tender to palpation -crepitus over maxillary sinuses -increased amounts of saliva production -red, tender tympanic membrane

-crepitus over maxillary sinuses

What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident -difficulty speaking -loss of tactile sensation -blurred vision -inability to hear high-pitched sounds

-difficulty speaking

Nurse is performing the allen test on a pt who has a diagnosis of pvd, what action should the nurse take after a positive allen test -document the absence of dorsalis pedis or posterior tibial pulses -document the lack of patency in the ulnar and/or radial arteries -corroborate the finding by assessing capillary refill in the pt great toes -attempt to palpate the popliteal pulse w/ the pt's leg in a dependent position

-document the lack of patency in the ulnar and/or radial arteries

The nurse asked a pt if she has noticed any lumps/swelling in her breasts. Pt responds "yes", what would the nurse ask next -has there been any corresponding changes in your breast size -have any of the other women in your family had this happen -what do you think is causing this change -does the lump change over the course of your menstrual cycle

-does the lump change over the course of your menstrual cycle

A nurse is assessing a pt of E. Asian descent, which biologic variation would the nurse expect -longer eustachian tubes -profuse perspiration in the pt's axillary area -strong body odor -dry cerumen in the pt's ear

-dry cerumen in the pt's ear

What assessment finding is most consistent with arterial insufficiency -numbness & tingling of the lower extremities -pitting edema to feet & ankles -dry, shiny, hairless shins and feet -reddish blue coloration of the shins and feet

-dry, shiny, hairless shins and feet

A nurse assesses a pt's epitrochlear nodes & finds them to be enlarged & tender, what would the nurse do next -examine the lower arm & hand for infection sites -careful assess the cervical lymph nodes for enlargement -ask the pt about any recent ear and throat infections -assess both legs for Homans sign

-examine the lower arm & hand for infection sites

Nurse demonstrates correct technique for assessing the psoas sign by which action -flexing the client's R hip, applying downward pressure at the R thigh -percussing over the client's symphysis pubis w/ the client supine & then sitting upright -tapping fingerpads over the client's abdominal wall, feeling for a floating mass -applying deep palpation pressure to the client's RLQ, then suddenly releasing

-flexing the client's R hip, applying downward pressure at the R thigh

What would the nurse include when describing the effects of religion & spirituality on patients -improved pt sense of well-being -enhanced coping w/ end of life issues -increased mortality levels -increased timely use of health care -increased adherence to medical regiments

-improved pt sense of well-being -enhanced coping w/ end of life issues

Nurse is assessing a pt who is uncompensated R-sided HF. What assessment should the nurse anticipate -Dysrhythmias -bradycardia -decreased BP -increased jugular venous pressure

-increased jugular venous pressure

What would best describe an aspect of the term "culture" -It is adapted to a specific environment -it is shared through norms for behaviors, values & beliefs -it is experienced by all people even w/out human contact -transmission occurs to another generation through genetics

-it is shared through norms for behaviors, values & beliefs

The nurse is assessing a patients heart and neck vessels, which technique would be MOST appropriate to use when examining the patients jugular vein pulse -have the client look straight ahead w/ chin slightly lifted -inspect the suprasternal notch or around the clavicles -perform the exam w/ the client in supine position -have the client sit at a 90 degree angle

-perform the exam w/ the client in supine position

An adult client states his mother has been living w/ PUD and he is motivated to avoid it, what advice should the nurse give -exercise for at least 30 min, 3x/wk -attend screening clinics at least 2x/year -eat several small meals a day rather than 3 larger meals -quit smoking as soon as possible

-quit smoking as soon as possible

The nurse is preparing to inspect a woman's breasts for retraction & dimpling, which position is most appropriate -supine -semi-fowler -standing -sitting

-sitting

Nurse has begun the objective assessment of a pt's heart & neck vessels and is assessing the pt's jugular veins. What finding would the nurse consider to be normal in a healthy pt -the jugular veins are fully distended when the client is in a high fowler position -the jugular venous pulse is not visible when the client is sitting upright -the jugular venous pulse is visible when the client lies supine -the jugular veins are distended when the client sits at a 45 degree angle

-the jugular venous pulse is not visible when the client is sitting upright

The nurse is screening a 4 yr old who is being treated for a burn. When determining whether the burn may be the result of abuse, what assessment parameters should the nurse consider, select all that apply: -the presence of other scars on the child's skin -the pattern or shape of the burn -the location of the burn -the child's explanation of how she got the burn -the child's prognosis for recovering from the burn

-the presence of other scars on the child's skin -the pattern or shape of the burn -the location of the burn -the child's explanation of how she got the burn

An 18 yr old pt complains because one breast is larger than the other, what additional data would suggest a need for referral -the pt states that this represents a sudden change in her breast size -the pt states that she is sexually active -the pt states that she does not perform breast self-examination -the pt states that her problem affects her body image

-the pt states that this represents a sudden change in her breast size

What is MOST important to include in educating an elderly pt w/ dysphagia following a recent ischemic stroke? -Be aware of the possibility of temporomandibular joint pain -Drink fluids before & after but not during meals -Sit with the head of the bed at a 45 degree angle during meals -thoroughly chew small amounts of food w/ each mouthful

-thoroughly chew small amounts of food w/ each mouthful

Which technique should be used to palpate the breasts -use the flat pads of 3 fingers -use the palm of one hand -use the fingertips of both hands -gently pinch the skin between 2 fingers

-use the flat pads of 3 fingers

The nurse refers an older adult pt for further evaluation after the nurse assesses warm skin & brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral -arterial occlusion -stasis ulceration -venous insufficiency -dependent edema

-venous insufficiency

An ED nurse asks a pt to complete an intimate partner violence assessment screening. How should the nurse best explain the rationale for this assessment -we are required by law to ask you these questions -this is just something we need to do for reimbursement -we routinely screen everyone because violence affects so many people -We don't think you're abused but we have to ask

-we routinely screen everyone because violence affects so many people