my nclex review

The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)? 1.Elevate the shoulders. 2.Swallow a sip of water. 3.Open the mouth and say "aah." 4.Vocalize the sounds "la-la," "mi-mi," and "kuh-kuh."

1.Elevate the shoulders.

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test? 1."I will tell you when I see the colored dots." 2."I will tell you when I see the flash of bright light." 3."I will tell you when the small object is in my visual field." 4."I will tell you when the blocks and shapes are in my visual field."

3."I will tell you when the small object is in my visual field."

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the primary health care provider (PHCP)? 1.Absence of a bruit 2.Concave, midline umbilicus 3.Pulsation between the umbilicus and the pubis 4.Bowel sound frequency of 15 sounds per minute

3.Pulsation between the umbilicus and the pubis

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1.Stridor 2.Crackles 3.Wheezes 4.Diminished

3.Wheezes

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area? 1.Sclerae 2.Oral mucosa 3.Sole of the foot 4.Palm of the hand

2.Oral mucosa

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? 1.Ask the client to puff out the cheeks. 2.Separate the client's jaw by pushing down on the chin. 3.Place a small amount of sugar on the client's tongue and ask him or her to identify the taste. 4.Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

2.Separate the client's jaw by pushing down on the chin.

The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what should the nurse test? 1.The corneal reflex 2.The 6 cardinal fields of gaze 3.The pupillary response to light 4.Pupillary response to light and accommodation

2.The 6 cardinal fields of gaze

The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions on breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which information should the nurse give to the client? 1. "You need to perform BSE on the same day every month." 2."It is not necessary to do BSE because you are postmenopausal." 3."You are not at risk for breast cancer because you are in the postmenopausal phase." 4."Mammograms performed every 20 years are sufficient in the postmenopausal phase."

1."You need to perform BSE on the same day every month."

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective? 1."This is mostly used in a walk-in clinic or emergency department." 2."This is focused on disease detection and conducted in a health care provider's office." 3."This is conducted on admission in a primary care or long-term care setting." 4."This is conducted as a follow-up examination by a health care provider."

1."This is mostly used in a walk-in clinic or emergency department."

The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area? 1.Left shoulder 2.Right scapula 3.Right shoulder 4.Small of the back

1.Left shoulder

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1.Rhythmic respirations with periods of apnea 2.Regular rapid and deep, sustained respirations 3.Totally irregular respiration in rhythm and depth 4.Irregular respirations with pauses at the end of inspiration and expiration

1.Rhythmic respirations with periods of apnea

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply. 1.Presence of fasciculations 2.Muscle strength graded 5/5 3.Symmetrical movements bilaterally 4.Increased muscle size on the dominant arm 5.A 1-cm hypertrophy of the right upper arm

2.Muscle strength graded 5/5 3.Symmetrical movements bilaterally 4.Increased muscle size on the dominant arm 5.A 1-cm hypertrophy of the right upper arm

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? 1.To examine the testicles while lying down 2.That the best time for the examination is after a shower 3.To gently feel the testicle with one finger to feel for a growth 4.That TSEs should be done at least every 6 months

2.That the best time for the examination is after a shower

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1."I swim 3 times a week." 2."I have stopped smoking cigars." 3."I drink hot chocolate before bedtime." 4."I read for 40 minutes before bedtime."

3."I drink hot chocolate before bedtime."

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1.A defect in the cochlea 2.A defect in cranial nerve VIII 3.A physical obstruction to the transmission of sound waves 4.A defect in the sensory fibers that lead to the cerebral cortex

3.A physical obstruction to the transmission of sound waves

After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds? 1.Waves of loud gurgles auscultated in all 4 quadrants 2.Low-pitched swishing auscultated in 1 or 2 quadrants 3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants 4.Very high-pitched loud rushes auscultated especially in 1 or 2 quadrants

3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees to identify which client as most typically a victim of abuse? 1.A man who has moderate hypertension 2.A man who has newly diagnosed cataracts 3.A woman who has advanced Parkinson's disease 4.A woman who has early diagnosed Lyme disease

3.A woman who has advanced Parkinson's disease

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1.Provide the client with materials on legal blindness. 2.Instruct the client that he or she may need glasses when driving. 3.Inform the client of where he or she can purchase a white cane with a red tip. 4.Inform the client that it is best to sit near the back of the room when attending lectures.

. 2.Instruct the client that he or she may need glasses when driving.

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. 1.Set the room temperature at a comfortable level. 2.Remove distracting objects from the interviewing area. 3.Place a chair for the client across from the nurse's desk. 4.Ensure comfortable seating at eye level for the client and nurse. 5.Provide seating for the client so that the client faces a strong light. 6.Ensure that the distance between the client and nurse is at least 7 ft (2.1 meters).

1.Set the room temperature at a comfortable level. 2.Remove distracting objects from the interviewing area. 4.Ensure comfortable seating at eye level for the client and nurse.

The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client? 1. "You have normal vision." 2."You have some degree of blindness." 3."You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)." 4."You can read at a distance of 30 ft (9 meters) what a person with normal vision can read at 20 ft (6 meters)."

D. "You can read at a distance of 30 ft (9 meters) what a person with normal vision can read at 20 ft (6 meters)."

The registered nurse (RN) is educating a new RN on the "law and order orientation" found in level 2 of Kohlberg's theory of moral development. Which statement by the new RN indicates that the teaching has been effective? 1."An example of this is: If I skip down the hall, will the teacher be mad at me?" 2."An example of this is: We will spend time talking about the activities for the week." 3."An example of this is: I don't like it when you yell while I am talking to my friend. Here are some activities to do until I am finished talking." 4."An example of this is: If you do all of your classwork today without bothering others in the class, you will get an extra 'seed' for your good behavior garden."

1."An example of this is: If I skip down the hall, will the teacher be mad at me?"

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action? 1.Identify an object placed in the client's hand. 2.Identify 3 numbers or letters traced in the client's palm. 3.State whether 1 or 2 pinpricks are felt when the skin is pricked bilaterally in the same place. 4.Identify the smallest distance between 2 detectable pinpricks, made with 2 pins held at various distances.

1.Identify an object placed in the client's hand.

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? 1.Focus on a close object. 2.Focus on a distant object. 3.Close 1 eye and read letters on a chart. 4.Raise 1 finger when the sound is heard.

2.Focus on a distant object

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply. 1.Increased heart rate 2.Decline in visual acuity 3.Decreased respiratory rate 4.Decline in long-term memory 5.Increased susceptibility to urinary tract infections 6.Increased incidence of awakening after sleep onset

2.Decline in visual acuity 5.Increased susceptibility to urinary tract infections 6.Increased incidence of awakening after sleep onset

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? 1.Poor hygiene 2.Difficulty walking 3.Fear of the parents 4.Bald spots on the scalp

2.Difficulty walking

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? 1.Flashlight 2.Snellen chart 3.Reflex hammer 4.Ophthalmoscope

4.Ophthalmoscope

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1.The right eye is tested, followed by the left eye, and then both eyes are tested. 2.Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3.The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. 4.The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

1.The right eye is tested, followed by the left eye, and then both eyes are tested.

A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The clinic nurse should teach the group which point about this procedure? 1.Do the exam on the same day every month. 2.Do the exam 7 days after the start of the menstrual cycle. 3.Examine the left breast with the left hand and vice versa. 4.Use the tips of the fingers to increase the likelihood of feeling lumps.

1.Do the exam on the same day every month

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1.The right eye is tested, followed by the left eye, and then both eyes are tested. 2.Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3.The client is asked to stand at a distance of 40 ft (12 meters) from the chart and to read the largest line on the chart. 4.The client is asked to stand at a distance of 40 ft (12 meters) from the chart and to read the line that can be read 200 ft (60 meters) away by an individual with unimpaired vision.

1.The right eye is tested, followed by the left eye, and then both eyes are tested.

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. 1.Allergy to pollen 2.History of headaches 3.Previous back injury 4.History of hypertension 5.History of diabetes mellitus

2.History of headaches 3.Previous back injury 4.History of hypertension 5.History of diabetes mellitus

The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse should next ask the client to take which action? 1.Identify 3 objects placed in the hand, 1 at a time. 2.Identify 3 numbers or letters traced in the client's palm. 3.Identify the smallest distance between 2 skin pricks after pricking the skin with 2 pins at varying distances. 4.State whether 1 or 2 skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client's skin.

2.Identify 3 numbers or letters traced in the client's palm.

The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy? 1.Decreased absorption of digoxin 2.Increased risk for digoxin toxicity 3.Decreased therapeutic effect of digoxin 4.Increased risk for side effects related to digoxin

2.Increased risk for digoxin toxicity

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? 1.Near the lateral 12th rib 2.Just under the left clavicle 3.In the fifth intercostal space 4.Posteriorly under the left scapula

2.Just under the left clavicle

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1.Test the corneal reflexes. 2.Test the 6 cardinal positions of gaze. 3.Test visual acuity, using a Snellen eye chart. 4.Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

2.Test the 6 cardinal positions of gaze.

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? 1.To examine the testicles while lying down 2.That the best time for the examination is after a shower 3.To gently feel the testicle with 1 finger to feel for a growth 4.That TSEs should be done at least every 6 months

2.That the best time for the examination is after a shower

The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? 1.An involuntary rhythmic, rapid twitching of the eyeballs 2.A dorsiflexion of the ankle and great toe with fanning of the other toes 3.A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 4.A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

3.A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse? 1.A man who has moderate hypertension 2.A man who has newly diagnosed cataracts 3.A woman who has advanced Parkinson's disease 4.A woman who has early diagnosed Lyme disease

3.A woman who has advanced Parkinson's disease

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve? 1.Ask the client to clench the teeth. 2.Ask the client to read the letters in a line on a Snellen chart. 3.Ask the client to shrug the shoulders against the nurse's resistance. 4.Ask the client to close the eyes, occlude 1 nostril, and identify a specific odor such as coffee.

3.Ask the client to shrug the shoulders against the nurse's resistance.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? 1.Have 1 of the client's family members interpret. 2.Have the Spanish-speaking triage receptionist interpret. 3.Page an interpreter from the hospital's interpreter services. 4.Obtain a Spanish-English dictionary and attempt to triage the client.

3.Page an interpreter from the hospital's interpreter services.

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? 1.Focus only on the physical examination. 2.Obtain all information from family members. 3.Plan short sessions with the client to obtain data. 4.Use the primary health care provider's medical history.

3.Plan short sessions with the client to obtain data.

The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data? 1.Pedal pulses are present. 2.Temperature is 99.6º F (37.6º C). 3.Client reports difficulty sleeping at night. 4.Client has an apical pulse rate of 56 beats/min.

3.Client reports difficulty sleeping at night.

A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6º F (37º C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first? 1."Do you exercise regularly?" 2."Are you considering trying to lose weight?" 3."Is there a history of diabetes mellitus in your family?" 4."When was the last time you had your blood pressure checked?

4."When was the last time you had your blood pressure checked?

A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6º F (37º C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first? 1."Do you exercise regularly?" 2."Are you considering trying to lose weight?" 3."Is there a history of diabetes mellitus in your family?" 4."When was the last time you had your blood pressure checked?"

4."When was the last time you had your blood pressure checked?"

The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client? 1.Planning meals 2.Decorating the room 3.Scheduling haircut appointments 4.Allowing the client to choose social activities

4.Allowing the client to choose social activities

The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action? 1.Ask a second nurse to be present during the interview. 2.Defer both the health history and the neurological examination. 3.Defer the health history and proceed with the neurological examination. 4.Ask the client to give permission for a family member to stay during the interview.

4.Ask the client to give permission for a family member to stay during the interview.

The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time? 1.At ovulation time 2.7 to 10 days after menses 3.Just before menses begins 4.At a specific day of the month and on that same day every month thereafter

4.At a specific day of the month and on that same day every month thereafter

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? 1.Tapping the Achilles tendon using the reflex hammer 2.Gently pricking the client's skin on the dorsum of the foot in 2 places 3.Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument 4.Holding the sides of the client's great toe and, while moving it, asking what position it is in

4.Holding the sides of the client's great toe and, while moving it, asking what position it is in

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? 1.Over the second intercostal space at the left sternal border 2.Over the fourth intercostal space at the right sternal border 3.Over the second intercostal space at the right sternal border 4.Over the fifth intercostal space in the left midclavicular line

4.Over the fifth intercostal space in the left midclavicular line

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? 1.Assess for drainage from the wound. 2.Assess for redness around the wound edges. 3.Palpate for swelling around the wound edges. 4.Palpate for increased skin temperature around the wound edges.

4.Palpate for increased skin temperature around the wound edges

The nurse would perform which action to assess for a pulse deficit? 1.Count the carotid pulsations for 1 full minute. 2.Measure the blood pressure in both the arm and leg. 3.Auscultate the apical heartbeat while palpating the radial artery. 4.Place the diaphragm of the stethoscope directly over the skin at the mitral area.

4.Place the diaphragm of the stethoscope directly over the skin at the mitral area.

The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if 1 of the students states that which action should be performed? 1.Perform the exam after a cold shower. 2.Expect the exam to be slightly painful. 3.Perform the self-examination every other month. 4.Roll the testicle between the thumb and forefinger.

4.Roll the testicle between the thumb and forefinger.

A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the nurse include in the client's focused assessment? 1.Ability to drive a car 2.The normal everyday routine in the home 3.Ability to do light or heavy housework and to pay bills 4.Self-care needs such as toileting, feeding, and ambulating

4.Self-care needs such as toileting, feeding, and ambulating

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? 1.Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane." 2.Suggest to the client and daughter-in-law that they consider a nursing home for the client. 3.Say nothing because it is best for the nurse to remain neutral and wait to be asked for help. 4.Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.

4.Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status? 1.The client's ability to ambulate 2.The intactness of the tympanic membrane 3.The intactness of the retinal structure of the eye 4.The functional status of the vestibular apparatus in the inner ear

4.The functional status of the vestibular apparatus in the inner ear