NUR Exam 1 Quiz Questions

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a... 1-inch bell. 15-inch flexible tubing. 1-inch diaphragm. 1½-inch diaphragm.

1½-inch diaphragm.

The student nurse learns that examining the skin can do all of the following except? Allow early identification of potentially cancerous lesions Allow early identification of neurologic deficits Reveal overhydration Identify physical abuse

Allow early identification of neurologic deficits

An older adult client presents at the clinic with a painful ulcer on the left big toe. The client states that the ulcer is very painful and never seems to heal. An assessment of the ulcer shows a lesion with well-defined wound edges. When dependent, the base of the lesion is ruddy in appearance and exhibits signs of infection. What would the nurse suspect? Infected spider bite Venous ulcer Infected tick bite Arterial ulcer

Arterial ulcer

The nurse notes that an intervention provided to a client for a specific health problem was not effective. Which action should the nurse take next? Analyze the newly collected data Implement a new action Identify a new outcome Assess the status of the health problem

Assess the status of the health problem

A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply. Bleeding of a mole Asymmetrical Change in size Itching Flat Regular borders

Bleeding of a mole Asymmetrical Change in size Itching

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? Tuning fork Reflex hammer Coin or key Tongue depressor

Coin or key

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? Validate the data Collect objective data Collect subjective data Document the data

Collect subjective data

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? Basal cell carcinoma Cushing's disease Lupus erythematosus Iron deficiency anemia

Cushing's disease

A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply. Impaired Skin Integrity Disturbed Body Image Risk for Infection Ineffective Individual Coping Anxiety

Disturbed Body Image Ineffective Individual Coping Anxiety

When assessing your new client, you note that he has no hair on his legs. What might this indicate about the client? He has hypothyroidism He has hyperthyroidism He has peripheral artery disease He has a hormonal imbalance

He has peripheral artery disease

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse? Vitamin C deficiency Infection Hypoxia A normal finding

Hypoxia

Which of the following assessment findings most likely constitutes a secondary skin lesion? Facial acne Psoriasis Keloid formation at the site of an old incision Facial lesions associated with herpes simplex

Keloid formation at the site of an old incision

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.) Location Color Elevation Condition of surrounding skin Distribution pattern

Location Color Elevation Distribution pattern

You should use the bell of the stethoscope when auscultating what type of sounds? Sounds that are partially audible without a stethoscope High-frequency sounds Low-frequency sounds Abnormal sounds

Low-frequency sounds

The nurse has completed the physical examination of a hospitalized client who is lying in a supine position in the bed. The nurse puts the bed rails in the upright position. In order to ensure client safety, what is the most important thing the nurse should do prior to leaving the room? Turn off the lights. Offer the client a blanket. Draw the curtain. Lower the bed height.

Lower the bed height.

A client's risk for pressure sore development according to the Braden Scale is as follows: Sensory perception: 4 Moisture: 4 Activity: 2 Mobility: 2 Nutrition: 1 Friction and Shear: 3 From this assessment, the nurse determines that the client's risk for pressure sore development is: Mild risk Moderate risk High risk No risk

Mild risk

A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case? Dorsal surface Fingertips Palmar surface Finger pads

Palmar surface

Which of the following is a component of the general survey? Patient's state of hygiene Patient's blood pressure Patient's breath sounds Patient's oral temperature

Patient's state of hygiene

A client has sustained burns over 50% of the body. When planning care for this client, the nurse will include interventions to address which alteration in the skin's barrier function? (Select all that apply.) Synthesis of vitamin D Regulation of body temperature Penetration by microorganisms Mechanical or chemical injuries Loss of water and electrolytes

Penetration by microorganisms Mechanical or chemical injuries Loss of water and electrolytes

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What would the nurse do next? Document the benign findings. Refer the client for medical follow-up. Ask the client about a family history of cancer. Perform a random blood sugar test.

Perform a random blood sugar test.

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? Purpura Cherry angioma Ecchymosis Petechiae

Petechiae

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Alopecia, dermatitis, chemotherapy Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Psoriasis, fungal infections, trauma

Psoriasis, fungal infections, trauma

For which assessment would the nurse plan to use direct percussion? Sinuses Gallbladder Kidneys Liver

Sinuses

For which of the following assessments would the nurse plan to use light palpation? Size of liver Shape of abdominal mass Skin temperature Skin texture Skin rash

Skin temperature Skin texture Skin rash

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse? The client has chronic hypoxia The client has melanoma The client has COPD The client has asthma

The client has chronic hypoxia

A client has been prescribed tetracycline for acne. What is the most important point the nurse should make in client teaching about this medication? The client may experience photosensitivity The client may experience phototoxicity The medication may interfere with the menstrual cycle The medication may be inactivated by antacids

The client may experience photosensitivity

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment? The bell of the stethoscope can detect bowel sounds. Auscultation can be performed through clothing. The binaurals connect the tubing to the chest piece. The diaphragm should be held firmly against the body part.

The diaphragm should be held firmly against the body part.

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique? One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand. The middle finger of one hand is placed on the body surface and the other middle finger strikes. The ulnar surface of one hand is placed against the body surface and vibrations are felt. One to two fingers are placed over the body structure and the fingertips are used to tap the skin surface.

The middle finger of one hand is placed on the body surface and the other middle finger strikes.

Which is an example of auscultation? Select all that apply. The nurse notes a rhythmic lub-dub over the client's anterior thorax. The nurse notes crackling over the individual's thorax. The nurse notes hyperresonance over the client's thorax. The nurse notes gurgling sounds over the individual's abdomen. The nurse detects tympany over the client's lower abdomen.

The nurse notes a rhythmic lub-dub over the client's anterior thorax. The nurse notes crackling over the individual's thorax. The nurse notes gurgling sounds over the individual's abdomen.

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? To evaluate whether outcomes of treatment are met To collect subjective data related to the client's overall health To determine any changes from the baseline data To perform a rapid assessment for prompt treatment

To determine any changes from the baseline data

A nurse performing percussion over the area of the stomach should anticipate hearing which type of sound? Hyper-resonance Tympany Resonance Dullness

Tympany

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.) Wash hands. Dim the lighting to promote comfort. Turn on relaxing music of the client's choice. Identify ways to ensure client privacy. Obtain and check needed equipment.

Wash hands. Identify ways to ensure client privacy. Obtain and check needed equipment.

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed?

comprehensive

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is performed only by nurses. linear. completed on admission. continuous.

continuous.

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client? diaphoresis fainting vomiting diarrhea

fainting

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as stage IV. stage II. stage I. stage III.

stage II.

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern? "I will report these to the health care provider so that medication can be prescribed." "These areas need to be cleansed daily and covered with a dry gauze bandage." "These are considered a normal age-related change in the skin." "It means you have skin cancer and need to have them removed."

"These are considered a normal age-related change in the skin."

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? Are you allergic to foods, medications, or other substances? "What have you been doing to control the itching?" "Does anyone else in your family have a rash like this?" "Have you ever had a rash like this before?"

Are you allergic to foods, medications, or other substances?

The nurse is performing a health assessment with a client who presented to the emergency department after falling as a result of feeling dizzy. Which questions demonstrates that the nurse understands the initial purpose of effectively conducting a health assessment? Select all that apply. A. "Do you know what may have caused you to fall?" B. "Are you experiencing any pain at this time?" C. "Do you know what your blood pressure is usually?" D. "What do you think will help you from falling again?" E. "Are you feeling dizzy now?"

B, C, E

A nurse is preparing to evaluate an older client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose? Reflex (percussion) hammer Braden scale Penlight Snellen E chart

Braden scale

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? Collecting data regarding the nature of the pain Identifying pain management interventions with input from the client Planning care to help minimize the client's pain Teaching the client to draw knees to chest to help minimize the pain

Collecting data regarding the nature of the pain

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine whether the client has achieved the outcome criteria of the treatment?

Evaluation

During the integument health history, the nurse asks the client about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning? Identifying the client's risk for developing skin cancer Existence of systemic diseases that have skin manifestations History of previous medical health promotion care Minimizing the client's potential risk for pressure ulcer formation

Existence of systemic diseases that have skin manifestations

The nurse is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what? A focused assessment of the client complaint Data focusing on the client complaint Functional status Family history for the past three generations

Functional status

The nurse is assessing a client. Which body area will the nurse use the diaphragm of the stethoscope to assess? Select all that apply. Bruits Breath sounds Heart murmurs Heart sounds Bowel sounds

Heart sounds Bowel sounds Breath sounds

A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding?

Identify a nursing diagnosis of Ineffective Health Maintenance.

A client's fingernails are noted to be very thin and concave. The nurse knows the client needs medical follow-up for further assessment of which condition? Iron deficiency anemia Diabetes mellitus Peripheral vascular disease Vitamin deficiency

Iron deficiency anemia

Which of the following statements is true of the role of inspection in the physical examination? The acuity of the client will determine whether general or local inspection should be implemented in the examination. To maximize findings, local inspection should be conducted prior to general inspection. It should be performed after auscultation but before palpation and percussion. It is often the source of the most physical signs.

It is often the source of the most physical signs.

The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process? It involves independent nursing actions. It is ongoing and continuous. Each step is independent of the others. It is used primarily in acute care settings.

It is ongoing and continuous.

A nurse recognizes that it is best to begin the objective data collection with which procedure? Allow the client to undress and put on a gown Auscultation of all necessary body systems to prevent disturbing any organs Measure the client's vital signs, height, and weight Begin at the head and move in a systematic approach

Measure the client's vital signs, height, and weight

After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing?

Nursing diagnosis

An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that is has become difficult to cut the toenails because the nails have become hard and brittle. The client also states that the feet are always cold and they must wear socks to bed. Which nursing diagnosis can be confirmed from this data? Altered Tissue Perfusion Disturbed Body Image Risk for Impaired Skin Integrity Risk for Imbalanced Body Temperature

Risk for Impaired Skin Integrity

A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision? Opaque card Penlight Ophthalmoscope Snellen chart

Snellen chart

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client? The client changes position every 2 hours The client knows prevention measures for pressure ulcers The client exhibits no signs or symptoms of infection The client keeps the area clean and dry

The client exhibits no signs or symptoms of infection

The nurse is admitting a 79-year-old man for outpatient surgery. The client has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings? The client is elderly. The client may have been abused. The client may have a cognitive deficit. The client may have peripheral vascular disease.

The client may have been abused.

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition? The client's arterial blood will appear bluish when observed in the test tube. The cyanosis is a result of body tissue extracting less than usual amounts of oxygen from the blood. The cyanosis may be a result of a prolonged period of exposure to the cold. The client is demonstrating central cyanosis.

The cyanosis may be a result of a prolonged period of exposure to the cold.

Which is an example of inspection? Select all that apply. The nurse notes crackling over the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse notes a fine rash covering the individual's thorax. The nurse detects a small mass in the epigastric area. The nurse detects foul odor of the urine.

The nurse notes symmetry of the individual's thorax. The nurse notes a fine rash covering the individual's thorax. The nurse detects foul odor of the urine.

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer? There is a generalized rash on the client's lower back and buttocks. There is a non-blanching reddened area on the client's coccyx region. There is noticeable bruising on and around the client's coccyx region. There is scant, frank blood present on the skin surfaces surrounding the client's coccyx.

There is a non-blanching reddened area on the client's coccyx region.

How should the nurse place the ear of an adult when using the otoscope? Down and forward Up and back Up and forward Down and back

Up and back

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion? Pustule Wheal Papule Erosion

Wheal

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)?

focused or problem-oriented assessment.

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? perform a physical examination document the findings determine a problem list cluster the data

perform a physical examination

To assess an adult client's skin turgor, the nurse should... press down on the skin of the feet. use two fingers to pinch the skin under the clavicle. use the finger pads to palpate the skin at the sternum. use the dorsal surfaces of the hands on the client's arms.

use two fingers to pinch the skin under the clavicle.