Module 2

A nurse is providing instructions to a client who is scheduled to undergo a Papanicolaou (Pap) test in 1 week. Which statement does the nurse make to the client?

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

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

2+

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

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 assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

A problem with balance

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 which finding?

A yellowish or brownish waxy material in the external auditory canal

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 in which way?

Abnormal bronchophony

A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?

Abnormal sounds that should not be heard in the lungs

A nurse assisting with data collection regarding the 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

Assisting with data collection, a nurse notes tenderness while lightly palpating a client's right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?

Appendix

A nurse assisting with data collection is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which action 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 should first take which action when interviewing the client?

Assess the client's knowledge of available birth control methods.

A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?

Assessing visual acuity

The nurse, assisting with data collection of the abdomen, inspects the client's abdomen. Which assessment technique does the nurse perform next?

Auscultation

A nurse assisting with data collection is preparing to auscultate for bowel sounds. The nurse should use which technique?

Begin 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 reviewing the physical assessment findings in a client's health care 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 reviewing the health care record of a client who has just undergone an examination of the internal genitalia. Which documented finding indicates an abnormality?

Clear secretions with a foul odor are noted on the cervix

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

Coffee

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 cranial nerve 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 which cranial nerves?

Cranial nerves IX and X

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 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 takes which action?

Documents the normal finding

A nurse assisting with data collection is inspecting the client's eyelids for ptosis. The nurse checks the client for which abnormality?

Drooping

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

Dull sounds

While the nurse is assisting with data collection, 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 which disorder?

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 using which term?

Ecchymosis

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 assisting with data collection is testing the function of the oculomotor, trochlear, and abducens nerves. Which parameter does the nurse check to determine the function of these nerves?

Eye movements

While assisting with data collection regarding the neurological system, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing?

Facial

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 on which part of the client's chest?

Fifth left interspace at the midclavicular line

A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?

Firm pressure

A nurse reviewing the health care 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 assisting with data collection 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

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

Her menstrual history

A nurse assisting with data collection of a client with suspected carpal tunnel syndrome plans to perform the Phalen test. The nurse should ask the client to perform which activity?

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

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

Hyperactive bowel sounds

A nurse is assisting with data collection on 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

A nurse assisting with data collection is monitoring 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 which disorder?

Kidney inflammation

A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips in which location?

Lateral to the extensor tendon of the big toe

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

Left lateral

A nurse is preparing to listen to the breath sounds of a client. The nurse should listen to the breath sounds in which way?

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

A nurse assisting with data collection on the carotid artery of a client with cardiovascular disease. The nurse performs this in which way?

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

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 makes which statement?

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

A nurse is assisting with data collection of a client with suspected cholecystitis. Which finding does the nurse expect to note if cholecystitis is present?

Murphy sign

A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

Neck trauma

A nurse is assisting with data collection 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 health care provider

A nurse assisting with data collection and notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding using which term?

Nystagmus

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

Obtaining a flashlight and darkening the room

A nurse assisting with data collection of an adult client asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?

Olfactory

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 in which manner?

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 ophthalmoscope to best visualize which area?

Optic disc

A nurse reviewing a client's health care 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 assisting with data collection plans to assess tactile (vocal) fremitus. The nurse performs this by using which technique?

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

When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?

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 preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells the client that this test measures which aspect of vision?

Peripheral vision

A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by performing which action?

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

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

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

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

A nurse assisting with data collection of the peripheral vascular system performs the Allen test. The nurse understands that this test is used to determine the patency of which blood vessel(s)?

Radial and ulnar arteries

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

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 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 action does the nurse ask the client to take to aid assessment of this nerve?

Shrugging the shoulders against the nurse's resistance

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 makes which conclusion?

The client has a normal cardiac output.

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

The peripheral lung fields

While assisting with data collection, 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 which nerve?

Trigeminal nerve

A nurse preparing to assisting with data collection of the abdomen 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 which technique?

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

A nurse is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the nurse uses which technique?

Uses a tuning fork

A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat words that are provided in which manner?

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

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 is reviewing the medical record of a client whose health care provider used an otoscope to examine the client's ears. Which finding indicates to the nurse that the tympanic membrane is normal?

a

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

A nurse assisting with data collection for a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding using which terminology?

anasarca

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 exam and initating emergency measures

A nurse is reading the report from the registered nurse for an initial home visit to a client with chronic obstructive pulmonary disease. The client was recently discharged from the hospital. Which type of database does the nurse read that contains this information from the client?

complete

A nurse is preparing to assist the health care provider examine a client's skin with the use of a Wood light. In preparing for this diagnostic test, the nurse should perform which action?

darken the room

A 25-year-old client 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 assist with the data collection by collecting which information?

data related to the respiratory system

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

determine what the client believes has caused epilepsy

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

ensuring that the room is private seeing that distracting objects are removed from the room

A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?

excess blood in the dilated superficial capillaries

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 is preparing to assist the health care provider in performing an internal gynecological examination of a client. In which position does the nurse place the client for this examination?

lithotomy

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 which disorder?

ntermittent claudication

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 which aspect of the eye function is normal?

ocular movements

A nurse is assisting with data collection of the peripheral vision of a client using the confrontation test. To carry out this procedure, the nurse performs which action?

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 obect into the visual field

A nurse conducting an interview with a client collects subjective data. During the interview, the nurse takes which action?

takes minimal notes to avoid impeding 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 uses which technique?

test the right eye then tests the left eye and finally tests both eyes together

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 the client's results in which way?

the client can read at a distance of 20 feet what a client with normal vision can read at 80 feet

A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data?

the client states that he has a rash

A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?

the skin temp is normal

A nurse assisting with data collection notes that the client's skin is very dry. The nurse documents this finding using which term?

xerosis