NCLEX-RN examination- Health Assessment

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A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate. The client returns to the primary health care provider's (PHCP's) office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment? 1.Follow-up database 2.Emergency database 3.Complete health database 4.Problem-centered database

Correct: 1 Rationale: A follow-up database is used in evaluating the status of an identified problem at regular and appropriate intervals. An emergency database is used for rapid collection of data, often compiled concurrently with lifesaving measures. A complete health database is the framework for a complete health history and full physical examination. The information thus obtained describes the current and past health state and forms a baseline against which all future changes can be measured. An episodic (problem-centered) database is used for a limited or short-term problem. It focuses mainly on 1 problem or 1 body system.

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.

Correct: 1 Rationale: A problem-based assessment involves a history and physical examination that is limited to a specific problem or client complaint and is most often used in a walk-in clinic or emergency department. A screening assessment is a limited examination focused on disease detection. A complete assessment includes a complete health history and physical examination and forms a baseline database. It is performed on admission to a primary care or long-term care setting. An episodic or follow-up assessment is done when a client is being followed up for a previously identified or treated problem.

The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? 1.A tuning fork 2.A stethoscope 3.A tongue blade 4.A reflex hammer

Correct: 1 Rationale: A tuning fork is needed to perform the Weber test, during which the nurse places the vibrating tuning fork at the midline of the client's forehead or above the upper lip over the teeth. Normally the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in 1 ear, the sound is heard in the other ear. If the client has a conductive hearing loss in 1 ear, the sound is heard in that ear. The items identified in the remaining options are not needed to perform the Weber test.

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? 1.At the onset of menstruation 2.Every month during ovulation 3.Weekly at the same time of day 4.1 week after menstruation begins

Correct: 4 Rationale: The breast self-examination should be performed regularly, 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue

The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action? 1.Whisper a statement while the client blocks both ears. 2.Quietly whisper a statement and test both ears at the same time. 3.Whisper a statement with the examiner's back to the client. 4.Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal.

Correct: 4 Rationale: To perform a voice test, the examiner stands 1 to 2 ft (30 to 60 cm) away from the client and asks the client to block 1 external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. The client is not asked to block both ears, and the examiner should face the client during the test.

The clinic nurse is preparing to assess the client's apical pulse. The nurse correctly palpates over which area? (Answers were pictures)

Correct: Under left breast Rationale: The heart is located in the mediastinum. Its apex, or distal end, points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart's apex. Option 2 identifies palpation of the carotid pulse. Option 3 identifies palpation of the brachial pulse. Option 4 identifies palpation of the popliteal pulse.

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? 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

Correct: 1 Rationale: Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyper-resonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.

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.

Correct: 1 Rationale: Astereognosis is the inability to discern the form or configuration of common objects using the sense of touch. Graphesthesia is the inability to recognize the form of written symbols. The remaining options test for extinction phenomena and 2-point stimulation, respectively.

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? 1.The major bronchi 2.The trachea and larynx 3.The peripheral lung fields 4.The lower posterior thorax

Correct: 1 Rationale: Bronchovesicular breath sounds are heard over major bronchi. The upper sternum area is where major bronchi are located. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Vesicular breath sounds are heard over the peripheral lung fields

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

Correct: 1 Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

The nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The client complains of discomfort at the intravenous (IV) site, and the nurse notes that the site is cool, pale, and swollen and that the solution is infusing slowly. What action should the nurse take first? 1.Stop the IV infusion. 2.Apply ice to the catheter site. 3.Readjust the rate of IV administration. 4.Contact the primary health care provider.

Correct: 1 Rationale: The IV must be stopped immediately because it has infiltrated. The remaining options allow the IV solution to continue to flow and further exacerbate the infiltration rather than intervene to stop it.

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? 1.Mitral area 2.Right atrium 3.Right ventricle 4.Pulmonic valve

Correct: 1 Rationale: The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to the apical pulse. S1 (lub) and S2 (dub) should be distinguished. The pulse should be counted for a full minute. The right atrium, right ventricle, and pulmonic valve areas will not provide clear auscultation of the apical pulse.

A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child? 1.Assess the child's physical status. 2.Ask the child how the injury occurred. 3.Report the case as suspected child abuse. 4.Observe the interactions between the child and his friends.

Correct: 1 Rationale: The initial intervention is to assess the child's physical status. The child should be initially assessed for injury to the right arm and for bruises, burns, scars, and any other signs of abuse. The nurse would next report the case as suspected child abuse to the appropriate authorities. Option 2 may or may not be appropriate, depending on the situation because the child may be fearful of telling the truth about how the injury occurred. Option 4, although appropriate for some situations, is not appropriate as the initial intervention.

The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment of the client's smoking history? 1.Number of pack-years 2.Desire to quit smoking 3.Brand of cigarettes used 4.Number of past attempts to quit smoking

Correct: 1 Rationale: The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of pack-years, which is the standard method of documenting smoking history. The brand of cigarettes may give a general indication of tar and nicotine levels, but the information is of no immediate clinical use. Desire to quit and number of past attempts to quit smoking may be useful when the nurse develops a smoking cessation plan with the client.

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 1.After a shower or bath 2.While standing to void 3.After having a bowel movement 4.While lying in bed before arising

Correct: 1 Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing a TSE.

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

Correct: 1 Rationale: The nurse should instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the left breast is to be examined, the pillow would be placed under the left shoulder; therefore, all other options are incorrect.

The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this examination? 1.Pull the pinna up and back before inserting the speculum. 2.Pull the earlobe down and back before inserting the speculum. 3.Tilt the client's head forward and down before inserting the speculum. 4.Use the smallest speculum available to decrease the discomfort of the exam.

Correct: 1 Rationale: The nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back, and the nurse visualizes the external canal while slowly inserting the speculum. The remaining options are incorrect procedures.

The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex? 1.Stroking the foot from the heel to the toe 2.Gently inserting a gloved finger in the rectum 3.Directing a flashlight onto the pupils of the eyes 4.Using a tongue depressor and stimulating the back of the throat

Correct: 1 Rationale: The plantar reflex is assessed by stroking the outer plantar surface of the foot from the heel to the toe. The anal reflex is assessed by stimulating the perianal area or gently inserting a gloved finger in the rectum. Pupillary response is tested using a flashlight. The pharyngeal (gag) reflex is tested by touching the back of the throat with an object such as a tongue depressor. A positive response to each of these reflexes is considered normal.

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."

Correct: 1 Rationale: The spinal accessory nerve has only a motor component. This cranial nerve is assessed by asking the client to elevate the shoulders, which may be done with or without resistance. It can also be assessed by asking the client to turn the head from 1 side to the other, resist attempts to pull the chin toward midline, and push the head forward against resistance. The incorrect options are assessed as part of glossopharyngeal nerve (CN IX) and vagus nerve (CN X) testing, which are done together.

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

Correct: 1 Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses, and the client stands at a distance of 20 feet (6 meters) from the chart.

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."

Correct: 1 Rationale: Women who are in the postmenopausal phase are taught to do BSE on the same day of every month. Before menopause, women should do the procedure 7 days after the start of the menstrual cycle when the breasts are less tender. It is important for postmenopausal women to do BSE monthly because they can get breast cancer. Mammograms need to be performed more frequently than every 20 years and per American Cancer Association guidelines.

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.

Correct: 1 Rationale: Women who are postmenopausal are taught to do BSE on the same day every month. Before menopause, women should do the procedure 7 days after the start of the menstrual cycle, when the breasts are least tender. Each breast is examined with the opposite hand. The pads of the fingers, not the fingertips, should be used for palpation. The client may use a circular, up and down, or wedge method of assessment. Consistency of use of the same method is more important than the actual method used.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the primary health care provider (PHCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry? 1.It is painless and safe. 2.It causes only mild discomfort at the site. 3.It requires insertion of only a very small catheter. 4.It has an alarm to signal dangerous drops in oxygen saturation levels.

Correct: 1 Rationale: The nurse should reassure the client that pulse oximetry is a safe, painless, noninvasive method of monitoring oxygen saturation levels. No discomfort is involved because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe. The machine does have an alarm that will sound in response to interference with monitoring or when the percent of oxygen saturation falls below a preset level.

The nurse is caring for a pediatric client who just arrived at the emergency department with an extremity fracture. The nurse uses the 5 "Ps" to assess the extent of the client's injury. What are some of the 5 "Ps"? Select all that apply. 1.Pallor 2.Pain and point of tenderness 3.Paralysis distal to the fracture site 4.Pulses proximal to the fracture site 5.Sensation distal to the fracture site

Correct: 1,2,3,5 Rationale: If a child sustains a fracture, the extent of the injury is immediately assessed using the 5 "P's"-pain and point of tenderness, pulses distal (not proximal) to the fracture site, pallor, paresthesia (sensation) distal to the fracture site, and paralysis (movement distal to fracture site).

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply 1.Auscultating lung sounds 2.Obtaining the client's temperature 3.Assessing the strength of peripheral pulses 4.Obtaining information about the client's respirations 5.Performing a musculoskeletal and neurological examination 6.Asking the client about a family history of any illness or disease

Correct: 1,2,4 Rationale: A focused assessment focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

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).

Correct: 1,2,4 Rationale: When preparing the physical environment for an interview, the nurse should set the room temperature at a comfortable level. The nurse should provide sufficient lighting for the client and nurse to see each other. The nurse should avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment should be removed from the interview area. The nurse should arrange seating so that the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a desk or table because this creates a barrier. The distance between the nurse and the client should be set by the nurse at 4 to 5 ft (1.2 to 1.5 meters). If the nurse places the client any closer, the nurse will be invading the client's private space and may create anxiety in the client. If the nurse places the client farther away, the nurse may be seen as distant and aloof by the client.

Correct: 1,2,4 Rationale: When preparing the physical environment for an interview, the nurse should set the room temperature at a comfortable level. The nurse should provide sufficient lighting for the client and nurse to see each other. The nurse should avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment should be removed from the interview area. The nurse should arrange seating so that the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a desk or table, because this creates a barrier. The distance between the nurse and the client should be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If the nurse places the client any closer, the nurse will be invading the client's private space and may create anxiety in the client. If the nurse places the client farther away, the nurse may be seen as distant and aloof by the client.

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.

Correct: 2 Rationale: Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).

The nurse is preparing to interview a client to collect data about the client's health history. The nurse should take which actions to make sure that the physical environment is ready? Select all that apply 1.Provide sufficient lighting. 2.Set the room temperature at a comfortable level. 3.Ensure that the distance between the nurse and client is no more than 2 ft (60 cm). 4.Arrange seating so that the nurse sits behind the desk across from the client. 5.Make sure that the client will be seated comfortably at eye level with the nurse. 6.Leave equipment needed for the physical exam on the desk so it is readily available.

Correct: 1,2,5 Rationale: When preparing the physical environment for an interview, the nurse should provide sufficient lighting for the client and nurse to see each other. The nurse should avoid having the client face a strong light because the client would have to squint into the full light. The nurse should set the room temperature at a comfortable level. The nurse should arrange seating so that both the nurse and the client are seated comfortably at eye level. The distance between the nurse and the client should be set by the nurse at 4 to 5 ft (1.2 to 1.5 meters). If the nurse places the client any closer, the nurse will be invading the client's private space and may create anxiety in the client. If the nurse places the client farther away, the nurse may be seen by the client as distant and aloof. The nurse avoids facing the client across a desk or table because this creates a barrier. Distracting objects and equipment should be removed from the interview area.

The clinic nurse is performing an assessment for a client who is complaining of shortness of breath. The client admits to smoking 1 pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack-years? Fill in the blank.

Correct: 10 pack-years Rationale: The standard method for quantifying the smoking history is to multiply the number of packs smoked per day by the number of years of smoking. The result is then recorded as the number of pack-years. The calculation for the number of pack-years for the client in this question who smokes 1 pack per day for 10 years is 1 pack × 10 years = 10 pack-years.

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

Correct: 2 Rationale: Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, or emotional maltreatment. Sexual abuse can involve incest, molestation, exhibitionism, pornography, prostitution, or pedophilia. Many times the findings associated with sexual abuse may not be easily apparent in the child. The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may indicate physical neglect. Fear of the parents and bald spots on the scalp most likely are associated with physical abuse

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

Correct: 2 Rationale: Cranial nerve II (the optic nerve) is responsible for visual acuity. This may be tested by using a Snellen chart to assess distant vision. Another item that may be used to evaluate the optic nerve function is a Rosenbaum card to evaluate near vision. This is a hand-held card used to test visual acuity. The nurse records the smallest line seen as well as the distance that the card is held from the client. A flashlight is used to test the pupillary reaction. A reflex hammer is used to test reflexes. An ophthalmoscope is used to examine the retina.

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

Correct: 2 Rationale: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) have only motor components and control, in a coordinated manner, the 6 cardinal fields of gaze. This is tested by moving an object in 6 directions (involving horizontally and diagonally). Corneal reflex is the function of the trigeminal nerve (cranial nerve V). Pupillary response to light and accommodation is the function of cranial nerve III (oculomotor) alone.

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.

Correct: 2 Rationale: Graphesthesia is the ability to recognize the form of written symbols. The nurse can assess for this by tracing symbols, such as numbers, in the client's palm. Option 1 tests for stereognosis, which is the ability to identify the form of common objects using the sense of touch. Options 3 and 4 test for extinction phenomenon and 2-point stimulation, respectively

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

Correct: 2 Rationale: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Jaundice would be best noted in the sclerae of the eye. Cyanosis would be best noted in the palms of the hands and soles of the feet.

The nurse is documenting the findings of a physical examination in a client's record. Which findings should the nurse determine to be objective data? 1.The client experiences migraine headaches. 2.The client has a rash on the chest and arms. 3.The client reports having difficulty urinating. 4.The client reports taking atenolol for blood pressure.

Correct: 2 Rationale: Subjective data, collected during the health history, consist of information that the client says about himself or herself. Objective data are obtained through the physical examination and vital sign measurements, what the nurse observes, and laboratory study and diagnostic test results. The remaining options identify subjective data.

Correct: 2 Rationale: Testing the 6 cardinal positions of gaze is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with both eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).

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

Correct: 2 Rationale: The TSE is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps.

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

Correct: 2 Rationale: The apex of the lung is the rounded, uppermost part of the lung. The nurse would place the stethoscope just under the left clavicle. The other options are incorrect locations.

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.

Correct: 2 Rationale: The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles should feel equally strong on both sides. The nurse should try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Asking the client to puff out the cheeks tests the facial nerve. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/min. On the basis of this finding, which action is most appropriate? 1.Administer oxygen. 2.Document the findings. 3.Notify the primary health care provider. 4.Reassess the respiratory rate in 15 minutes.

Correct: 2 Rationale: The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/min. The normal apical heart rate is 90 to 130 beats/min, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? 1.Turn the flashlight on directly in front of the eye and watch for a response. 2.Ask the client to follow the flashlight through the 6 cardinal positions of gaze. 3.Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. 4.Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.

Correct: 2 Rationale: The nurse asks the client to follow the flashlight through the 6 cardinal positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI. Options 1 and 3 relate to pupillary response to light. Also, shining the light directly into the client's eye without asking the client to focus on a distant object is not an appropriate technique. Option 4 assesses accommodation of the eye.

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.

Correct: 2 Rationale: The nurse tests for accommodation by initially asking the client to focus on a distant object. This process dilates the pupils. The client is then asked to shift the gaze to a near object, such as a finger held about 3 in (7.5 cm) from the nose. A normal response includes pupillary constriction and convergence of the axes of the eyes.

The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test? 1.Tuning fork and audiometer 2.Cloves, peppermint, and soap 3.Flashlight, pupil size chart, and millimeter ruler 4.Safety pin, hot and cold water in test tubes, and cotton wisp

Correct: 2 Rationale: The sensory function of the olfactory nerve controls the sense of smell. To test this nerve, the nurse would ask the client to close the eyes and occlude 1 nostril and identify a nonirritating and familiar odor such as coffee, tea, cloves, soap, chewing gum, peppermint. The test is then repeated on the other nostril. The supplies noted in the remaining options are used for testing cranial nerves VIII, II, and V, respectively.

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive? 1.Absent bowel sounds 2.Client complaints of wound pain 3.Pain with dorsiflexion of the foot 4.Crackles on auscultation of the lungs

Correct: 3 Rationale: To elicit Homans' sign, the nurse would dorsiflex the client's foot and assess for pain in the calf area. The presence of pain may indicate a positive Homans' sign. Wound pain and absent bowel sounds are unrelated findings. Crackles on auscultation of the lungs may indicate a respiratory complication.

The nurse is conducting a health screening clinic and is preparing to test the visual acuity of a client using a Snellen chart. The nurse educates the client about the procedure. Which statement by the client indicates that the teaching has been effective? 1."Stand 10 ft (3 meters) from the chart and cover 1 eye." 2."Stand 20 ft (6 meters) from the chart and cover 1 eye." 3."Stand 30 ft (9 meters) from the chart and read the largest line on the chart." 4."Stand 40 ft (12 meters) from the chart and read the largest line on the chart."

Correct: 2 Rationale: Visual acuity is assessed in 1 eye at a time and then in both eyes together, with the client comfortably standing or seated. Visual acuity is measured with or without corrective lenses, and the client stands at a distance of 20 ft (6 meters) from the chart. The right eye is tested first with the left eye covered; then the left eye is tested with the right eye covered; and then both are tested together.

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.term-15 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.

Correct: 2 term-27 Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order tterm-7o read signs and to see far ahead. The client should be instructed to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness.

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

Correct: 2,3,4,5 Rationale: Fasciculations are fine muscle twitches that normally are not present. Muscle strength is graded from 0/5 (paralysis) to 5/5 (normal power). Symmetrical muscle movement is a normal finding. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal.

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

Correct: 2,3,4,5 Rationale: Previous neurological problems such as headache or back injury place the client at greater risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment for allergies is a routine part of the health history, regardless of the nature of the client's problem.

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply. 1.Sclerae 2.Tongue 3.Nail beds 4.Elbows and heels 5.Mucous membranes

Correct: 2,3,5 Rationale: Skin color may be more difficult to assess in the client with dark skin. The best areas to use to detect pallor and cyanosis include the tongue, nail beds, and mucous membranes. The sclerae are most useful in evaluating jaundice. Elbows and heels are not appropriate areas to assess for skin color changes.

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

Correct: 3 Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1.Lub-dub sounds 2.Scratchy, leathery heart noise 3.A blowing or swooshing noise 4.Abrupt, high-pitched snapping noise

Correct: 3 Rationale: A heart murmur is an abnormal heart sound and is described as a faint or loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are normal and represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound

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.

Correct: 3 Rationale: A pulse deficit is the difference between the apical and peripheral pulses and could indicate a dysrhythmia. If an irregularity in the pulse is noted, the nurse should check for a pulse deficit. To check for a pulse deficit the nurse would auscultate the apical heart rate and rhythm while palpating a peripheral artery and assess for a difference in the rates. A difference in the rates indicates a pulse deficit. Therefore, options 1, 2, and 4 are incorrect sites.

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

Correct: 3 Rationale: Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis. Bowel sounds will be more high-pitched and louder (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds

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

Correct: 3 Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

Correct: 3 Rationale: Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination? 1.Sims' position 2.Supine with the head and feet flat 3.Supine with the head raised slightly and the knees slightly flexed 4.Semi-Fowler's position with the head raised 45 degrees and the knees flat

Correct: 3 Rationale: During the abdominal examination, the client lies supine (flat on the back) with the head raised slightly and the knees slightly flexed. This position relaxes the abdominal muscles. Sims' position is a side-lying position and would not adequately expose the abdomen for examination. Placing the head and feet flat would result in the abdominal muscles being taut. The abdomen cannot be accurately assessed if the head is raised 45 degrees.

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client? 1.A wider than normal ear canal 2.A pearly gray tympanic membrane 3.Redness and swelling in the ear canal 4.An excessive amount of cerumen lodged in the ear canal

Correct: 3 Rationale: External otitis is a painful condition caused when irritating or infective agents come into contact with the skin of the external ear. Affected skin becomes red, swollen, and tender to touch or movement. Swelling of the ear canal narrows the canal and can lead to temporary hearing loss from obstruction. The tympanic membrane is not usually affected in external otitis. Cerumen does not cause external otitis; however, external otitis can result if the person uses a sharp or small object that traumatized the external ear when trying to remove the cerumen

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? 1.Complaints of ringing in the ear 2.An excessive amount of cerumen in the ear canal 3.Intolerance for sound levels that do not bother other people 4.Complaints of dizziness and sensations of being "off balance"

Correct: 3 Rationale: Hyperacusis is a change in hearing for a client and the intolerance for sound levels that do not bother other people. Ringing in the ears is known as tinnitus. An excessive amount of cerumen in the ear canal is not associated with hyperacusis. Complaints of dizziness and sensations of being "off balance" are known as vertigo.

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

Correct: 3 Rationale: In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years, it indicates the presence of central nervous system disease.

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? 1.An involuntary rhythmic, rapid, twitching of the eyeballs 2.A dorsiflexion of the 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

Correct: 3 Rationale: In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease.

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for? 1.A yellow tinge to the skin 2.Bluish discoloration of the skin 3.Loss of normal red tones in the skin 4.An ashen-gray appearance to the skin

Correct: 3 Rationale: In dark-skinned clients, pallor results in the loss of normal red tones in the skin. The brown-skinned client may have yellow-tinged skin when pallor is present. Bluish discoloration of the skin most often is associated with cyanosis. In the black-skinned client, pallor produces an ashen-gray color.

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? 1.Ataxia 2.Nystagmus 3.Pronator drift 4.Hyperreflexia

Correct: 3 Rationale: Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. Hyperreflexia is an excessive reflex action.

The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction? 1."TSE is performed once a month." 2."TSE should be performed on the same day each month." 3."It is best to do TSE first thing in the morning before a bath or shower." 4."The scrotum is held in 1 hand and the testicle is rolled between the thumb and forefinger of the other hand."

Correct: 3 Rationale: TSE is performed once a month and should be done on the same day of each month, as an aid to help the client remember to perform the exam. The scrotum is held in 1 hand and the testicle is rolled between the thumb and forefinger of the other hand. It is best to perform the exam during or after (not before) a warm shower or bath when the scrotum is most relaxed.

The nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment technique should the nurse perform next? 1.Palpate the abdomen for size. 2.Palpate the liver at the right rib margin. 3.Listen to bowel sounds in all 4 quadrants. 4.Percuss the right lower abdominal quadrant.

Correct: 3 Rationale: The appropriate sequence for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection to ensure that the motility of the bowel and bowel sounds are not altered by percussion or palpation. Therefore, after inspecting the skin on the abdomen, the nurse should listen for bowel sounds.

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.

Correct: 3 Rationale: The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.

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.

Correct: 3 Rationale: The best source of information is the client. Option 1 is incorrect; the physical examination is not part of the health history. Option 2 is incorrect because it refers to all information. Option 4 is incorrect because the primary health care provider's medical history provides data that are different from the nurse's assessment. All efforts should be made to obtain as much information as possible from the client, using short sessions and closed-ended questions.

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."

Correct: 3 Rationale: The confrontational method assumes that the examiner has normal peripheral vision. The client sits facing the examiner approximately 2 ft (60 cm) away. The eyes of the client and the examiner should be at the same level. Both the examiner and the client cover the eyes directly opposite to one another and stare at each other's uncovered eye. A small object is brought in from the peripheral visual field, and the superior, temporal, inferior, and nasal fields are evaluated. The client states when he or she sees the object.

When assessing a client's liver during an assessment, the nurse should palpate which abdominal quadrant? 1.Left upper quadrant 2.Left lower quadrant 3.Right upper quadrant 4.Right lower quadrant

Correct: 3 Rationale: The liver is located in the right upper quadrant of the abdomen; therefore, the locations in the remaining options are incorrect

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

Correct: 3 Rationale: The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and should be reported to the PHCP. Bruits normally are not present. The umbilicus should be in the midline with a concave appearance. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute.

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.

Correct: 3 Rationale: The purpose of a physical assessment is to collect both subjective data and objective data. Subjective data, collected during the health history, consist of information that the client says about himself or herself. Objective data are obtained through the physical examination and vital sign measurements, what the nurse observes, and laboratory study and diagnostic test results.

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff? 1.One half of the distance between the antecubital fossa and the shoulder 2.One third of the distance between the antecubital fossa and the shoulder 3.Two thirds of the distance between the antecubital fossa and the shoulder 4.One quarter of the distance between the antecubital fossa and the shoulder

Correct: 3 Rationale: The size of the blood pressure cuff is important. Cuffs that are too small will cause falsely elevated values, and those that are too large will cause inaccurate low values. The cuff should be positioned to cover two thirds of the distance between the antecubital fossa and the shoulder. It is also important for the nurse to remember that placing the stethoscope too firmly on the antecubital fossa causes error in auscultation and that sounds are difficult to hear in children because of low frequency and amplitude. Therefore, a pediatric stethoscope bell is often helpful.

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.

Correct: 3 Rationale: The spinal accessory nerve, cranial nerve XI, controls strength of the neck and shoulder muscles. One method of testing this nerve is to palpate and inspect the trapezius muscle as the client shrugs the shoulders against the nurse's resistance. Option 1 tests cranial nerve V, the trigeminal nerve. Option 2 tests cranial nerve II, the optic nerve. Option 4 tests cranial nerve I, the olfactory nerve.

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve? 1.Coffee beans 2.A tuning fork 3.A wisp of cotton 4.An ophthalmoscope

Correct: 3 Rationale: To assess the sensory function of cranial nerve V (the trigeminal nerve), the nurse would ask the client to close the eyes and then with a wisp of cotton lightly touch the client's forehead, cheeks, and chin, noting whether the touch is felt equally on both sides of the face. Cranial nerve I (the olfactory nerve) is assessed by testing the sense of smell (using a non-noxious aromatic substance such as coffee beans) in a client who reports the loss of smell. A tuning fork would be used to assess cranial nerve VIII (the acoustic nerve). An ophthalmoscope would be used to assess the internal structures of the eye

A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique? 1."I will ask the client to raise the legs up to the waist and then to lower the legs slowly." 2."I will ask the client to raise the legs and to try to lower them against pressure from my hand." 3."I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." 4."I will ask the client to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward."

Correct: 3 Rationale: To elicit Homans' sign, the nurse asks the client to extend the legs flat on the bed. The nurse then grasps the foot and dorsiflexes it forward. If this causes any discomfort or resistance, the nurse should notify the primary health care provider that Homans' sign may be present. The statements in the remaining options are incorrect descriptions of this assessment technique

A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? 1.Palpating over the lung apices in the supraclavicular area 2.Asking the client to repeat the word ninety-nine during palpation 3.Palpating over the breast tissue to assess and compare vibrations from 1 side to the other 4.Comparing vibrations from 1 side to the other as the client repeats the word ninety-nine

Correct: 3 Rationale: When assessing for tactile fremitus, the nurse should begin palpating over the lung apices in the supraclavicular area. The nurse should compare vibrations from 1 side to the other as the client repeats the word ninety-nine. The nurse should avoid palpating over female breast tissue because breast tissue usually blocks the sound

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)."

Correct: 3 Rationale: When recording visual acuity as measured by the Snellen chart, the nurse would record the numerical fraction noted at the end of the last line successfully read on the Snellen chart. The top number (numerator) indicates the distance the client is standing from the chart, and the denominator gives the distance at which a normal eye could have read that particular line. Thus 20/30 means that the client can read at a distance of 20 ft (6 meters) what a client with normal vision can read at 30 ft (9 meters). Normal visual acuity is 20/20. Legal blindness is defined as the best corrected vision in the better eye of 20/200 or less.

The nurse is making an initial home visit to a client who was recently discharged from the hospital after treatment for a myocardial infarction. The nurse should use which type of database initially to obtain information from the client? 1.An episodic database 2.A follow-up database 3.An emergency database 4.A complete health database

Correct: 4 Rationale: A complete health database is the framework for a complete health history and full physical examination. The information thus obtained describes the current and past health state and forms a baseline against which all future changes can be measured. The complete health database is used in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, women's health care agency, visiting nurse agency, or community health agency. An episodic database is used for a limited or short-term problem. It focuses mainly on 1 problem or 1 body system. A follow-up database evaluates an identified problem at regular and appropriate intervals. An emergency database is used for rapid collection of the data, often compiled concurrently with lifesaving measures.

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

Correct: 4 Rationale: A method of testing for proprioception is to hold the sides of the client's great toe and, while moving it, asking the client what position it is in. Tapping the Achilles tendon with a reflex hammer describes gastrocnemius muscle contraction. Pricking the skin on the dorsum of the foot in 2 different places describes 2-point discrimination. The plantar reflex is tested when the sole of the foot is stroked with a blunt instrument.

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? 1.Wheezes 2.Rhonchi 3.Crackles 4.Pleural friction rub

Correct: 4 Rationale: A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating. The sounds are localized over an area of inflammation on the pleura and may be heard in both the inspiratory and the expiratory phases of the respiratory cycle. Wheezes are musical noises heard on inspiration, expiration, or both and are the result of narrowed airway passages. Rhonchi are usually heard on expiration when there is an excessive production of mucus that accumulates in the air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together and indicate fluid in the alveoli.

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

Correct: 4 Rationale: ADLs refer to the client's ability to bathe, toilet, ambulate, dress, and self-feed. These functional abilities are always assessed by the home care nurse. The normal routine in the home is not a component of functional assessment. The capability to drive a car or do housework relates to instrumental ADLs.

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

Correct: 4 Rationale: Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by palpating for increased skin temperature. Redness around the wound edges may be difficult to note in the dark-skinned client. Swelling and drainage from the wound are not specific indicators of erythema

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

Correct: 4 Rationale: If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the same day every month. Options that recommend scheduling related to menses are inappropriate because the client who had a hysterectomy would not be menstruating. It is best not to perform the BSE at ovulation time because of the hormonal changes that occur.

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.

Correct: 4 Rationale: TSE is an excellent self-screening examination for testicular cancer, which predominantly affects men in their late teens and 20s. The examination is performed once a month, as is breast self-examination. As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand, and the testicle is rolled between the thumb and forefinger of the other hand. The examination should not be painful. It is easiest to do either during or after a warm shower (or bath), when the scrotum is relaxed.

The nurse is preparing to perform a Weber test on a client who reports a loss of hearing in 1 ear. To perform the test, the nurse places the tuning fork in which area? Click on the image to indicate your answer. 1. Top of head 2. Temporal area 3. Ear 4. Mandible

Correct: 4 Rationale: The Weber test is a valuable assessment test when a client reports hearing that is better with 1 ear than the other. In this test, a vibrating tuning fork is placed on the client's head over the midline of the client's skull. The client is then asked whether the tone sounds the same in both ears or better in 1 ear. The client should hear the tone by bone conduction through the skull, and it should sound equally loud in both ears.

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?"

Correct: 4 Rationale: The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the client's major modifiable risk factors

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

Correct: 4 Rationale: 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?

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test? 1.The client is asked to discriminate numbers from a chart composed of colored dots. 2.The room is darkened, and the client is asked to identify colored blocks and shapes when they appear in the visual field. 3.The examiner and client cover their right eyes and stare at each other's left eyes, and a small object is brought into the visual field. 4.The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.

Correct: 4 Rationale: The confrontational method assumes that the examiner has normal peripheral vision. The client sits facing the examiner, approximately 2 ft (60 cm) away. The eyes of the client and the examiner should be at the same level. Both the examiner and the client cover the eyes directly opposite each other and stare at each other's uncovered eye. A small object is brought from the peripheral visual field and tests the superior, temporal, inferior, and nasal field. The client states when he or she sees the object.

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

Correct: 4 Rationale: The first heart sound (S1) is heard loudest at the lower left sternal border or the apex of the heart. The apex is located at the fifth intercostal space in the left midclavicular line. Therefore, the locations in the remaining options are incorrect.

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.

Correct: 4 Rationale: The health history and physical assessment for a client with a neurological problem are very similar to those for any other client, with perhaps a more intense neurological examination. If the client is confused or agitated or has difficulty hearing or speaking, the nurse should ask the client to give permission for a family member or significant other to stay with him or her during the history taking to ensure accurate data. Deferring the health history and/or neurological examination will not obtain the assessment data. Having a second nurse present is of no benefit.

The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen chart. After the client's vision is tested with a Snellen chart, the results of testing are documented as 20/40. Which statement by the new RN indicates that the teaching has been effective? 1."The client's vision is normal, but the client may require reading glasses." 2."The client is legally blind, and glasses or contact lenses will not be helpful." 3."The client can read at a distance of 40 ft (12 meters) what a person with normal vision can read at 20 ft (6 meters)." 4."The client can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters)."

Correct: 4 Rationale: Vision that is 20/20 is normal; that is, the client is able to read at 20 ft (6 meters) what a person with normal vision can read at 20 ft (6 meters). A client with a visual acuity of 20/40 can read at a distance of only 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters).

A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used 1.Asks the client to cover 1 eye 2.Examiner covers eye opposite to the eye covered by the client 3.Asks the client to report when object is first noted 4.Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client 5.The examiner brings in an object gradually from periphery

Correct: 4, 1 , 2, 5, 3 Rationale: The confrontation test is a gross measure of peripheral vision. It compares the person's peripheral vision with the examiner's, whose vision is assumed to be normal. If the client does not see the object at the same time as the nurse, peripheral field loss is expected. The client should be referred to an eye care specialist. The procedure is conducted in the following order: stand 2 to 3 ft (60 to 90 cm) in front of the client and face him or her; client covers 1 eye on request; nurse covers the eye opposite the one covered by the client; an object is gradually brought inward from the periphery; and the client reports when the object is first noted.

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.

Correct:1 Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 ft (6 meters) from the chart.

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