PrepU Chapter 26

A nurse is caring for a client with paraplegia. Using observation to examine the client's skin, what finding might indicate the presence of a pressure injury? A) An intact red area on the buttocks. B) An area of swollen, pale red bumps on the front of the neck. C) A circular red, scaly area that itches on the top of the forearm arm. D) An intact faded purple area on the shoulder blades, with a yellowish tint.

A) An intact red area on the buttocks. Explanation: An intact reddened area of the skin in an area that comes in contact with a wheelchair may be a stage I pressure injury. The shoulder blades would be another area of contact for the wheelchair, but a faded purple area indicates a resolving bruise. The neck and forearm are not pressure areas for a paraplegic. Pale red bumps indicate urticaria (hives), while circular red scaly area indicates ringworm.

A nurse is teaching a young female client about breast cancer prevention. The client asks at what age she needs to begin having mammograms. What is the nurse's best response? A) "Your physician will decide when it is best for you to begin having mammograms based on your family history." B) "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." C) "Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s." D) "Why do you want to know? Do you have a history of breast or ovarian cancer in your family?"

B) "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." Explanation: Often during a physical assessment, clients indicate a desire for more health information. To help establish a trusting relationship and provide accurate teaching, the nurse's best response is to educate the client on the American Cancer Society or Canadian Cancer Society guidelines, which state that the first mammogram should be done at age 40 and then yearly. After providing that information to the client, questions on family history of breast or ovarian cancer are appropriate.

The nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding? A) Assess the client for dehydration. B) Assess the client for cardiovascular disorders. C) Report the finding as a positive sign for cystic fibrosis. D) Document a normal skin finding on the client chart.

A) Assess the client for dehydration. Explanation: Turgor is the fullness or elasticity of the skin. The client should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. When the client is dehydrated, the skin's elasticity is decreased, and the skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular disease nor cystic fibrosis.

The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? A) Check the client's ear canals for cerumen. B) Use facial expressions and sign language to communicate. C) Ask the client if he left his earplugs in his ears. D) Speak to the older adult client in a high-frequency tone of voice.

A) Check the client's ear canals for cerumen. Explanation: Ear wax (cerumen) becomes drier in older adults and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client's hearing loss was acute and requires further assessment. When speaking to older adults who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for older adults.

A nurse uses a bed scale to perform a client's daily weight. The nurse notes that today's weight is 3 kg less than the previous day's. What is the nurse's most appropriate action? A) Ensure that the scale is correctly calibrated and repeat the assessment. B) Increase the frequency of the client's weight assessments. C) Encourage the client to increase food and fluid intake. D) Report this finding promptly to the client's primary care provider.

A) Ensure that the scale is correctly calibrated and repeat the assessment. Explanation: If weight varies by more than 1 kg, the nurse should check the scale calibration and the accuracy of the assessment before taking further action, such as reporting to the health care provider or altering the client's diet.

A client is admitted to the emergency department. He is bleeding from a cut on his head and his skin color is pale, with diaphoresis. What nursing action should be performed first? A) Evaluate the blood pressure and pulse B) Provide a warm, quiet, dimly lit room C) Assess the cause of the client's wound D) Interview to obtain the health history

A) Evaluate the blood pressure and pulse Explanation: In this acute-care emergency situation, the nurse should assess the pulse and blood pressure, since the client seems to be presenting with signs and symptoms of shock.

Which components are included in the integumentary system? Select all that apply. A) Hair B) Skin C) Muscles D) Sweat glands E) Nails F) Arteries

A) Hair B) Skin D) Sweat glands E) Nails Explanation: The integumentary system includes the skin, hair, nails, sweat glands, and sebaceous glands. Arteries are included in the cardiovascular or peripheral vascular systems, and muscles are included in the musculoskeletal system.

A 57-year-old male client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last? A) Palpation B) Inspection C) Percussion D) Auscultation

A) Palpation Explanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds.

The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use? A) Palpation B) Inspection C) Percussion D) Auscultation

A) Palpation Explanation: The thyroid gland is palpated for size, shape, symmetry, tenderness, and the presence of any nodules. If palpable, the thyroid gland should feel soft but elastic. Hypothyroidism may be caused by a goiter, which is an enlarged thyroid gland. Inspection, percussion, and auscultation would not reveal an enlarged thyroid gland.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal? A) The tympanic membrane is translucent, shiny, and gray. B) The ear canal is rough and pinkish. C) The ear canal is smooth and white. D) The tympanic membrane is reddish.

A) The tympanic membrane is translucent, shiny, and gray. Explanation: The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.

To assess subjective data related to a client's elimination pattern, the nurse: A) asks the client about changes in elimination patterns. B) palpates the abdomen for pain or distention. C) notes the frequency, amount, and time the client voids. D) reviews the latest laboratory report of the urine.

A) asks the client about changes in elimination patterns. Explanation: The nurse should focus the interview on the client's normal urinary and bowel patterns, noting any recent changes.

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment? A) auscultation of short, high-pitched popping sounds during inspiration B) an anteroposterior to lateral ratio of 1:2 C) blowing, hollow sounds auscultated over the larynx D) palpation of muscle symmetry over the posterior thorax

A) auscultation of short, high-pitched popping sounds during inspiration Explanation: Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure. The other findings are normal.

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is: A) blurred. B) clouded. C) 20/20. D) clear.

A) blurred. Explanation: Visual problems with close objects occur more frequently after the age of 40.

The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider? A) circumoral cyanosis when the client is at rest B) the anterior fontanel bulging when the client cries C) a blue-black macular area over the sacral area D) the abdomen appearing large in relation to the pelvis

A) circumoral cyanosis when the client is at rest Explanation: Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider. Mongolian spot is a common variation of hyperpigmentation in newborns of African, Turkish, Asian, Native American/First Nations, and Hispanic heritage. It is a harmless blue-black to purple macular area of hyperpigmentation that is usually located at the sacrum or buttocks, but sometimes occurs on the abdomen, thighs, shoulders, or arms. The anterior fontanel bulging when the client cries and the abdomen appearing large in relation to the pelvis are normal findings.

When a client enters the acute care facility, the nurse should perform a: A) comprehensive health assessment. B) physical health assessment. C) focused health assessment. D) spiritual health assessment.

A) comprehensive health assessment. Explanation: A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living.

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of: A) fissure. B) crust. C) erosion. D) ulcer.

A) fissure. Explanation: A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin.

The nurse is performing a head and neck assessment for a client. When inspecting the face, the nurse notes that the skin, sclera, and mucous membranes appear yellowish. In the electronic medical record the nurse chooses which drop-down box selection to document this finding? A) jaundice B) cyanosis C) pallor D) erythema

A) jaundice Explanation: Jaundice is a yellow color of the skin resulting from elevated amounts of bilirubin in the blood; it is associated with liver and gallbladder disease, some types of anemia, and excessive hemolysis (breakdown of red blood cells). Erythema refers to redness of the skin and is caused by dilation of superficial blood vessels. Pallor refers to paleness of the skin and often results from a decrease in the amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues. Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate oxygenation.

During a health assessment, the nurse uses deep palpation to assess a client's: A) liver. B) perspiration. C) finger nodules. D) skin turgor.

A) liver. Explanation: The purpose of deep palpation is to locate organs, determine their size, and detect abnormal masses.

Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature? A) the dorsum B) the knuckles C) the fingertips D) the palm

A) the dorsum Explanation: The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur. The fingertips are concentrated with nerve endings and can sense fine difference in texture and consistency. The knuckles are not used in palpation.

A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require? A) tuning fork B) ophthalmoscope C) otoscope D) Snellen chart

A) tuning fork Explanation: Rinne and Weber tests are performed in order to assess sound conduction; both require a tuning fork. A Rinne test evaluates hearing loss by comparing air conduction to bone conduction. The nurse strikes a tuning fork and places it on the mastoid bone behind one ear. When the client can no longer hear the sound, they signal to the nurse. The nurse then moves the tuning fork to the ear canal. When the client can no longer hear that sound, they once again signal the nurse. The nurse records the length of time the client hears each sound. In the Weber test, the nurse strikes a tuning fork and places it on the middle of the client's head, and the client indicates where the sound is best heard: the left ear, the right ear, or both equally. A Snellen chart is an eye chart that can be used to measure visual acuity. An otoscope is an instrument designed for visual examination of the eardrum and the passage of the outer ear, typically having a light and a set of lenses. An ophthalmoscope is an instrument for inspecting the retina and other parts of the eye.

To assess a client's visual accommodation, the nurse has the client:

look at a close object, then at a distant object. Explanation: Accommodation can be tested by having the client look at a close object and then look at a distant object. Reference:

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation? A) "Do you know what day this is?" B) "Can you tell me where you are right now?" C) "How are you feeling?" D) "Have you been more confused?"

B) "Can you tell me where you are right now?" Explanation: Asking the client to identify where he or she is represents an open-ended question and allows the nurse to assess the client's level of consciousness without ambiguity. Asking the client open-ended questions is a better way to assess level of consciousness than asking closed-ended questions that can be answered with a simple yes or no response. Asking the client how he or she feels will not assess orientation to person, place, or time.

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? A) "Are you having any pain?" B) "What brings you here today?" C) "What medications do you normally use?" D) "Do you have any allergies?"

B) "What brings you here today?" Explanation: The first subject usually discussed in a client interview is the client's specific reason for seeking care, commonly called the "chief complaint" or "chief concern." Other questions (e.g., about pain, medications and allergies) would be used as the client interview continues.

A parent of a school-age child is told that her child has normal vision. The school nurse explains that the child's vision is: A) 20/40 or 6/12. B) 20/20 or 6/6. C) 20/200 or 6/60. D) 20/60 or 6/18.

B) 20/20 or 6/6. Explanation: Normal vision is at or near 20/20 or 6/6, full field of vision, and tricolor vision (red, green, blue).

The nurse is completing the admission assessment on a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most significant? A) Thick overgrown toenails B) An absent popliteal pulse C) 2+ edema to lower extremities D) Hairless, shiny legs

B) An absent popliteal pulse Explanation: Priority assessments address the ABCs. Absence of a pulse (circulation) is a significant finding, which without intervention could lead to loss of limb. The other listed integumentary changes do not pose a short-term threat, even though they are clinically significant.

The nurse assesses a male client's genitalia and finds that the scrotal contents are asymmetrical. What action does the nurse take? A) Call the health care provider and request diagnostic testing. B) Ask the client about any usual genital observations. C) Insert an indwelling urinary catheter to ensure urine flow. D) Request a prostate-specific antigen diagnostic blood test.

B) Ask the client about any usual genital observations. Explanation: The nurse finds abnormal physical assessment data and asks the client for subjective information. This helps the nurse know if this is a pre-existing issue, a chronic condition, or an acute finding. Unless the client exhibits acute symptoms, there is no need to contact the health care provider for testing. A prostate-specific antigen test assesses for prostate cancer and does not offer diagnostic information about abnormal scrotal contents. There is no indication the client has difficulty voiding.

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider? A) Auscultation of gurgles and clicks B) Auscultation of a bruit C) Umbilicus centrally located D) Auscultation of bowel sounds every 30 seconds

B) Auscultation of a bruit Explanation: A bruit may be heard in the presence of stenosis (narrowing) or occlusion of an artery. Bruits may also be caused by abnormal dilation of a vessel. The other findings are normal.

A gerontologic nurse is inspecting the genitalia of an older adult male client. Which assessment findings are of the most concern? Select all that apply. A) Scant amount of pubic hair B) Bulge to the left inguinal area C) Less firmness of the testes D) Decreased penis size E) Scant yellow discharge

B) Bulge to the left inguinal area C) Scant yellow discharge Explanation: A bulge in the left inguinal area could indicate a hernia and needs further assessment. Yellow discharge could indicate an infection and requires further assessment. Decreased penis and testes size, less firmness of the testes, and decreased pubic hair are normal with aging of the male client's genitalia.

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply. A) Symmetrical shape B) Change in the mole C) Larger than 1/4 inch in diameter D) Single color E) Irregular edges

B) Change in the mole C) Larger than 1/4 inch in diameter E) Irregular edges Explanation: The lesions of melanoma are asymmetrical (that is, if a line is drawn through a mole, the two halves will not match) with uneven or irregular borders and a variety of colors or shades within the lesion. The size is larger in diameter than the size of the eraser on a pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected. The lesions are evolving, which means that any change—in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting—points to danger.

A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment? A) Ongoing assessment B) Comprehensive assessment C) Emergency assessment D) Focused assessment

B) Comprehensive assessment Explanation: A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations.

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action? A) Assess for asthma. B) Document normal breath sounds. C) Recommend testing for pneumonia. D) Suspect an inflamed pleura rubbing against the chest wall.

B) Document normal breath sounds. Explanation: Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse's scope of practice. Asthma usually results in wheezing.

The nurse is preparing to assess a client's abdomen. Arrange the steps of the assessment in the correct order. A) Palpation B) Inspection C) Auscultation D) Percussion

B) Inspection C) Auscultation D) Percussion A) Palpation Explanation: The order of the techniques for the abdominal assessment differs from that for the other systems. This is the preferred approach because performing palpation and percussion before auscultation may alter the sounds heard on auscultation.

A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern? A) Coarse brown hair B) Pink labia lesions C) Whitish vaginal discharge D) Dark pink vulva

B) Pink labia lesions Explanation: Lesions on the labia may be the result of an infection such as herpes or syphilis, which is a concern. Coarse hair is to be expected, although the genitalia may be shaven. Clear or whitish vaginal discharge may be normal. Other signs would need to be present for this finding to be a concern. The vulva has more pigmentation than other skin areas and is often darker pink in color.

The nurse has performed a Romberg test in the context of a client's neurologic assessment. The client has failed the test. The nurse should consequently identify what nursing diagnosis? A) Chronic Confusion B) Risk for Falls C) Acute Confusion D) Disturbed Thought Processes

B) Risk for Falls Explanation: Romberg test assesses balance; an unsuccessful test constitutes a likely risk for falls. This test does not relate to the client's cognition.

The nurse is preparing a client for an emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action? A) Document that the preoperative medication was administered. B) Verify that the procedural consent form is signed. C) Locate the laboratory test results in the chart. D) Ensure that the preoperative check list is completed.

B) Verify that the procedural consent form is signed. Explanation: Although the physician is responsible for obtaining the client's signed consent for procedures, it is most important for the nurse to verify that the consent form is signed and in the chart before the client goes to the operating room. Ensuring the completion of the preoperative check list, the presence of the lab results in the chart, and documentation that the preoperative medications were administered are not the most important nursing actions.

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse? A) Uncover the client to expose the chest and abdomen. B) Warm the diaphragm of the stethoscope. C) Palpate the abdomen before auscultating. D) Assist the client to a sitting position.

B) Warm the diaphragm of the stethoscope. Explanation: Client comfort is essential when performing an assessment, especially when the assessment involves touching the client. To promote maximum client comfort, equipment should be warmed prior to touching the client. This assessment is done while the client is in the supine position, not the sitting position. Since physical assessment typically takes place while clients are undressed (or wearing only a loose examination gown), they generally appreciate being covered with a drape to provide modesty. The abdomen is always inspected and then auscultated (in that sequence) before using palpation or percussion techniques. Touching or manipulating the abdomen can alter bowel sounds, thus producing invalid findings.

The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for? A) a client in the Intensive Care Unit after having a stroke yesterday B) a client in the Intensive Care Unit for acute pancreatitis asking for pain medications C) a client with a brain tumor who is in the hospital because of respiratory depression D) a client recovering from brain surgery for repair of an aneurysm

B) a client in the Intensive Care Unit for acute pancreatitis asking for pain medications Explanation: Although acute pancreatitis can be fatal if the client is asking for pain medications, she is at the very least alert. Clients who are being treated for a stroke, brain tumor, or who are recovering from brain surgery need to be monitored closely for level of consciousness.

The nurse should use the bell of the stethoscope during auscultation of: A) a client's bowel sounds. B) a client's heart murmur. C) a client's apical heart rate. D) a client's breath sounds.

B) a client's heart murmur. Explanation: The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.

Upon admission to the hospital, the client states, "I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy." This statement reflects the client's: A) objective assessment. B) chief concern. C) symptoms. D) review of systems.

B) chief concern Explanation: The first subject discussed in a client interview is the client's specific reason for seeking care. The subject is often called the client's chief complaint or chief concern.

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order? A) inspection, percussion, auscultation, palpation B) inspection, auscultation, percussion, palpation C) percussion, auscultation, inspection, palpation D) palpation, percussion, inspection, auscultation

B) inspection, auscultation, percussion, palpation Explanation: In an abdominal assessment, start with inspection, then auscultation, percussion, and palpation. This is the preferred approach because palpation and percussion before auscultation may alter the sounds heard.

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as: A) miosis. B) ptosis. C) entropion. D) ectropion.

B) ptosis. Explanation: Ptosis is drooping of the upper lids and is an abnormal finding. Inward turning of the lower lid is termed entropion. Outward turning of the lower lid is termed ectropion. Miosis is constriction of the pupil, which is often caused by medications.

A nurse is gathering equipment needed for a basic physical assessment. Which supplies will be required? Select all that apply. A) stethoscope B) tongue blade C) ophthalmoscope D) drapes E) cotton balls

B) tongue blade D) drapes A) stethoscope Explanation: For a basic physical assessment, the nurse needs gloves, an examination gown, cloth or paper drapes, a scale, a stethoscope, a sphygmomanometer, a thermometer, a pen light or flashlight, a tongue blade, an assessment form, and a pen. The nurse does not need cotton balls or an ophthalmoscope.

The nurse is assessing the skin of a veteran who has returned from deployment in the middle east. Which statement by the nurse reflects the best strategy to gain cooperation of the client? A) "I am going to look at your skin now." B) "I need to look at your skin to see if you have any problems." C) "May I look at your skin to determine if there are any issues?" D) "Take off your clothes so I can look at your skin."

C) "May I look at your skin to determine if there are any issues?" Explanation: Asking permission to look at the client's skin and explaining why prepares the client for the assessment and may gain the clients cooperation. The nurse will need to consider the possibility of posttraumatic stress disorder (PTSD) or other emotional issues related to the client's military service. By directing the client and not explaining the assessment it is likely the client will resist the nurse.

The nurse at the neighborhood family clinic is teaching a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client? A) "You need to sign up for the clinic's stop smoking program." B) "It is important for you to do 30 minutes of exercise three times a week." C) "Take your blood pressure medications exactly as your doctor prescribed them." D) "You should decrease your intake of fried foods."

C) "Take your blood pressure medications exactly as your doctor prescribed them." Explanation: Hypertension is a risk factor for heart disease that can be modified and controlled with medication(s). Smoking is a contributory risk factor for heart disease, but hypertension is a major risk factor. Reduction of fats in the diet is preventive of atherosclerosis, and reversing a sedentary lifestyle by exercising is important, but controlling hypertension will reduce the risk of heart disease.

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, A) "What does that mean?" How should the nurse respond? B) "Your vision is better than average; you can read from 30 ft (9 m) what a person with normal vision can read from 20 ft (6 m)." C) "You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." D) "Your vision is perfect; you can read the entire chart, and you do not need glasses." E) "Your vision in your right eye is slightly different than that of your left eye."

C) "You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." Explanation: The first number indicates the distance the person is standing from the chart; the second number gives the distance at which a normal eye can see it. It is not appropriate or correct to tell the client that vision is perfect, that one eye is better than the other, or that vision is better than average.

What percentage of weight change in 6 months is considered abnormal? A) 1% B) 5% C) 10% D) 2%

C) 10% Explanation: A 10% change in weight in 6 months is considered abnormal.

A nurse assesses a postoperative client's level of consciousness and documents the following: the client's eyes open spontaneously; the client accurately responds to instructions, converses, and is oriented to time, place, and person. What score would this client receive on the Glasgow Coma Scale? A) 4 B) 8 C) 15 D) 12

C) 15 Explanation: The Glasgow Coma Scale (GCS) evaluates three key categories of behavior: eye opening, verbal response, and motor response. Within each category, each level of response is given a numerical value. The maximal score is 15, indicating a fully awake, alert, and oriented client.

An older client presents to the clinic with reports of dyspnea upon exertion and when lying down as well as feeling tired all the time. The nurse notes that the client's ankles and feet are swollen. What cardiac assessment technique would the nurse use? A) Inspection B) Palpation C) Auscultation D) Percussion

C) Auscultation Explanation: Auscultation would reveal if the client's heartbeat is rapid or irregular, and if there are any additional heart sounds such as an S3, which could be an indicator of heart failure. Palpation and inspection may reveal an irregular heartbeat, but they will not disclose extra heart sounds. Percussion is a limited assessment that could be used to outline the cardiac boarder.

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? A) Fremitus B) Inflammation C) Crepitus D) Arthritis

C) Crepitus Explanation: Problems with the temporomandibular joint include pain or a grating feeling called crepitus.

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing? A) Hypertension and circulatory overload B) Impaired kidney function C) Decreased cardiac output D) Inflammation of a vein

C) Decreased cardiac output Explanation: Abnormal findings when assessing the peripheral pulses include an absent, weak, thready pulse (which may indicate a decreased cardiac output), a forceful or bounding pulse (seen in hypertension and circulatory fluid overload), and an asymmetric pulse (related to impaired circulation). Inflammation of a vein would not result in a weak or thready pulse.Impaired kidney function would not be related to the decrease in amplitude of peripheral pulses.

A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." Which action should the nurse take first? A) Check her chart for allergy information. B) Review her medication record. C) Inspect the area of itchy skin. D) Review her medical history.

C) Inspect the area of itchy skin. Explanation: Inspecting the back of the client's legs and buttocks is the first step in determining the nature of the client's problem. Checking the chart for known allergies and reviewing the medical history and medication record may provide helpful information, but assessing the skin gives firsthand information about the problem.

The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first? A) Lightly palpate the left leg, assessing for edema. B) Palpate the popliteal and posterior tibial pulses of both legs. C) Inspect the left lower leg for areas of redness. D) Assess for pain by deeply palpating the left leg.

C) Inspect the left lower leg for areas of redness. Explanation: Inspection is the initial step in peripheral vascular assessment of the extremities. Palpating the popliteal and posterior tibial pulses in both legs would be the second assessment step to take. Palpation of the leg with DVT to assess for edema and pain is contraindicated because of the risk of dislodging the blood clot and the formation of a pulmonary embolism.

A nurse is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment? A) Bladder scanner B) Syringe C) Penlight or flashlight D) Doppler ultrasound

C) Penlight or flashlight Explanation: A penlight or flashlight is necessary to gauge pupillary response and to visualize the client's mouth. Doppler ultrasound, a bladder scanner and a syringe are not necessary in order to perform a basic physical assessment.

A nurse is examining a client and is testing the client's cranial nerves. Which action would the nurse use to evaluate cranial nerve III? Select all that apply. A) Visual acuity B) Visual fields C) Pupillary reaction to light D) Blink reflex E) Ability to open and close eyelids

C) Pupillary reaction to light E) Ability to open and close eyelids Explanation: Cranial nerve III is the oculomotor nerve. It is a motor nerve that is involved with pupil constriction and raising the eyelids. The nurse would test the pupillary reaction to light and the client's ability to open and close eyelids. Visual field and visual acuity testing would be used to evaluate cranial nerve II or the optic nerve. Blink reflex is not used to test the cranial nerves.

A nurse is completing a neurologic assessment of an 84-year-old client. Which principle should guide the nurse's interpretation of the results? A) The client will likely have difficulty expressing or understanding abstract concepts. B) The client's arm and leg strength will be more asymmetric than that of a younger client. C) The client's reaction time will likely be slower than that of a younger adult. D) The client will experience lapses in short- and long-term memory.

C) The client's reaction time will likely be slower than that of a younger adult. Explanation: Reaction time often decreases with age, even in the absence of pathologic conditions. Each of the other listed findings would be considered abnormal, even in an older adult.

A nurse is percussing a client's abdomen. Which finding would the nurse document as normal? A) Resonant B) Flat C) Tympany D) Dull

C) Tympany Explanation: Characteristically, percussion of the abdomen is tympanic, hyperinflated lung tissue is hyperresonant, normal lung tissue is resonant, the liver is dull, and bone is flat.

A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 0 to 10 when he is asked to turn. The nurse should: A) have the client turn from side to side and assess pain. B) elevate the legs, bending at the knee while the client is supine. C) avoid a position change that requires turning. D) have the client lay on his right side, then palpate the area.

C) avoid a position change that requires turning. Explanation: Addressing pain early in the health assessment allows the nurse to individualize the rest of the assessment, avoiding positioning and techniques that are especially uncomfortable for the client.

When percussing the liver, the sound should be: A) resonant. B) flat. C) dull. D) hyperresonant.

C) dull. Explanation: The percussion of the liver is dull. Percussion of the abdomen is tympanic, hyperinflated lung tissue is hyperresonant, normal lung tissue is resonant, and bone is flat.

A nurse is caring for a postoperative client 1 day after coronary artery bypass surgery. Which nursing interventions demonstrate the skill of assessment? Select all that apply. A) helping the client to bathe and brush their teeth B) reviewing morning lab results C) inspecting the abdominal incision D) taking the client's blood pressure E) assisting the client to sit up in a chair

C) inspecting the abdominal incision D) taking the client's blood pressure B) reviewing morning lab results Explanation: Before the nurse can determine what care a person requires, the nurse must determine the client's needs and problems. This requires the use of assessment skills, or acts that involve collecting data, which include interviewing, observing, and examining the client. Inspecting the incision, taking blood pressure, and reviewing lab results are all examples of data collection. Assisting a client in a chair and performing ADLs are caring interventions.

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? A) fine crackles B) stertorous breathing C) wheezes D) pleural friction rub

C) wheezes Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations.

A community nurse is participating in a health promotion fair and has been asked by a middle-aged woman about the necessity of breast self-examination(BSE). How should the nurse respond to the woman's inquiry? A) "Breast self-examination should be limited to women of childbearing age." B) "Breast self-examination is a useful practice, but it is only recommended for women 65 years and older." C) "Breast self-examination is no longer a recommended screening activity." D) "Breast self-examination is a valuable tool and should be done once a month.

D) "Breast self-examination is a valuable tool and should be done once a month. Explanation: BSE is a useful tool in the detection of breast cancer. While other methods are more definitive such as mammogram and ultrasound, the BSE assists with early detection of breast cancer.

A nurse is preparing to assess a client with abdominal pain. Which statement is most appropriate for the nurse to use to gain cooperation from the client? A) "Open your shirt, I need to look at your abdomen." B) "I need to report what is going on to your health care provider. C) Can I look at your abdomen?" D) "Let me explain what I am going to do and how you can help." E) "I am going to examine your abdomen."

D) "Let me explain what I am going to do and how you can help." Explanation: The nurse should explain the assessment procedure which allows the client to be prepared and encourages cooperation. Requesting to examine the client's abdomen without any explanation may cause anxiety and increase the client's pain and decrease the chance of cooperation. The results of the assessment should be reported to the health care provider. The nurse does not need to avoid conversation during the assessment.

The nurse is caring for a client admitted with a head injury. Which question should the nurse ask to determine the client's remote memory? A) "What is meant by 'an ounce of prevention is worth a pound of cure'?" B) "What are the three objects I told you earlier?" C) "What did you eat for dinner last night?" D) "What are the month, date, and the year of your birth?"

D) "What are the month, date, and the year of your birth?" Explanation: Asking the client to explain the meaning of a common proverb allows the nurse to assess the client's abstract reasoning. The nurse needs to ask a question that may be corroborated to confirm a past or remote memory, so asking what the newly admitted client ate at dinner would not be able to be corroborated. The client's birthdate is available in the medical record and can be corroborated. Asking the client to repeat three objects that the nurse told the client earlier in the interview assesses recent memory.

The nurse is assessing the glossopharyngeal nerve on a client diagnosed with a cerebrovascular accident. Which actions should the nurse take? A) Lightly touch around the jawline using a piece of cotton wool then a blunt pin B) Observe the uvula while the client says "Ahhhh" C) Ask the client to open the mouth while applying resistance D) Ask client to move tongue side to side

D) Ask client to move tongue side to side Explanation: The motor function of the glossopharyngeal nerve can be tested by eliciting a gag reflex. This can be done by placing a tongue depressor on the back of the tongue and having the client move the tongue from side to side. Having the client open the mouth against resistance tests motor supply. Lightly touching with different sensations will test the trigeminal nerve (cranial nerve V) and observing the uvula will test the vagus nerve.

The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which action, if observed, would require the charge nurse to intervene? A) Occlusion of one of the client's nostrils while the client breathes through the nose B) Warming of a stethoscope before assessing a client's breath sounds C) Placing a tongue blade at the side of the tongue while the client pushes it to the left and right D) Palpation of both carotid arteries at the same time

D) Palpation of both carotid arteries at the same time Explanation: Palpation of both carotid arteries at once can obstruct blood flow to the brain, potentially causing dizziness or loss of consciousness. The other assessments are correct as described.

A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol use. She's on bed rest with bathroom privileges and has just been up to use the toilet. While helping the client to stand so she can wipe herself, the nurse notices a few drops of blood on top of the semiliquid, clay-colored stool in the toilet. What action should the nurse take next? A) Ask the client if her gums bled this morning when she brushed her teeth. B) Ask the client if she feels dizzy. C) Nothing. The nurse shouldn't alarm her unnecessarily. D) Ask the client if she has noted any blood in her stools lately.

D) Ask the client if she has noted any blood in her stools lately. Explanation: Any blood in the stool indicates an abnormal condition that needs to be assessed further. Clients with liver failure can develop coagulation problems that can lead to bleeding tendencies, such as bleeding gums. However, at this time it is more important to investigate the cause of the blood on the client's stool. Asking her if she's dizzy is a very broad, closed-ended question that would not elicit information specifically related to the rectal bleeding.

The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment? A) Warm the equipment. B) Place the client in a semi-Fowler's position. C) Measure height and weight. D) Ask the client to empty her bladder.

D) Ask the client to empty her bladder. Explanation: Before palpating or percussing the abdomen, the client should empty their bladder to avoid discomfort or pressure during the examination. The only equipment used during the assessment of the abdomen is a stethoscope and the nurse's hands. Both can be warmed with the hands at the time of use. The client should be placed in a flat position with the arms at the sides. It is not necessary to obtain height and weight prior to the assessment.

A 66-year-old female client is reporting abdominal pain. The nurse assesses the client's abdomen by first inspecting the abdomen. What should the nurse do next? A) Palpate the abdomen. B) Percuss the abdomen. C) Measure abdominal girth. D) Auscultate the abdomen.

D) Auscultate the abdomen. Explanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds.

Which technique should the nurse use to assess the pupillary light reflex on a client? A) Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye. B) Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction. C) Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. D) Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

D) Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. Explanation: To test the pupillary light reflex, the nurse should advance a light in from the temple and note the direct and consensual pupillary constriction. The diagnostic positions test and test for accommodation will not provide the pupillary reflex information.

Mr. Martinez is a 55-year-old male who was brought to the emergency department (ED). He reports abdominal pain in his right lower quadrant (RLQ) and nausea without vomiting. The nurse performs a physical assessment on the client and documents the following: Neurologic status: awake and alert; Cardiovascular: radial pulses 90, bounding, and equal; Skin: warm and dry; Respirations: 24 and regular; Gastrointestinal: abdominal pain with rebound tenderness in RLQ; Musculoskeletal: sitting up in bed with knees bent. Identify which findings involved the assessment technique of palpation. Select all that apply. A) Musculoskeletal: sitting up in bed with knees bent B) Respirations: 24 and regular C) Neurologic: awake and alert D) Cardiovascular: radial pulses 90, bounding, and equal E) Gastrointestinal: abdominal pain with rebound tenderness in RLQ F) Skin: warm and dry

D) Cardiovascular: radial pulses 90, bounding, and equal F) Skin: warm and dry E) Gastrointestinal: abdominal pain with rebound tenderness in RLQ Explanation: Palpation involves the sense of touch. The hands and fingers are sensitive tools and can assess skin temperature, turgor, texture, and moisture, as well as vibrations, pulsations, and shapes within the body. Neurologic assessment findings of awake and alert, respirations of 24 and regular, and musculoskeletal assessment of the client observed sitting up in bed with knees bent are examples of inspection.

A nurse admitting a new client to the hospital needs to determine the client's needs and current problems. What is the priority action of the nurse? A) Contact the health care provider. B) Review the client's past medical records. C) Assist the client with activities of daily living. D) Complete an assessment.

D) Complete an assessment. Explanation: Before the nurse can determine what care a person requires, the nurse must determine the client's needs and problems. This requires the use of assessment skills and data collection, which include interviewing, observing, and examining the client, and in some cases, the client's family. Following the assessment, the nurse can also use the client's medical record and contact other health care providers.

Cranial nerve function is important for normal sensory functioning. Which cranial nerve is important for the sense of smell? A) Cranial nerve II B) Cranial nerve III C) Cranial nerve IV D) Cranial nerve I

D) Cranial nerve I Explanation: Cranial nerve I is important for a person's sense of smell. Cranial nerves II, III, and IV are important for vision.

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean? A) It is normal. B) It is dissecting. C) It is inflamed. D) It is distended.

D) It is distended. Explanation: Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel.

The nurse is palpating a client's precordium. Which result is an expected clinical finding? A) Palpable vibration over the right sternal border B) Palpable heave over the pulmonic area C) Palpable thrill over the aortic area D) Palpable pulsation over the mitral area

D) Palpable pulsation over the mitral area Explanation: A palpable pulsation over the mitral area is a normal finding (apical impulse). The other findings listed are abnormal.

The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply. A) Peripheral pulses +3 B) Skin warm and dry C) Hypoactive bowel sounds in all four quadrants D) Reports of abdominal pain of 4 on a 0 to 10 point scale E) Client informs the nurse there is a floater in the left eye F) The client states, "I feel nauseated."

D) Reports of abdominal pain of 4 on a 0 to 10 point scale E) Client informs the nurse there is a floater in the left eye F) The client states, "I feel nauseated." Explanation: Subjective data includes any reports or information that the client gives. These include: Reports of abdominal pain of 4 on a 0 to 10 point scale, The client states, "I feel nauseated", and the client informs the nurse there is a floater in the left eye. Objective data is assessment data that are gathered by the nurse and are inspected, palpated, percussed, or auscultated by the health care team.

Which statement accurately represents a characteristic of the third or fourth heart sound? A) S3 is best heard with the stethoscope bell at the mitral area, with the client lying on the right side. B) S4 is the fourth heart sound, represented by "lub-dub-dee." C) S4 is considered normal in children and adults but abnormal in older adults. D) S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.

D) S3 is considered normal in children and young adults and abnormal in middle-aged and older adults. Explanation: S3, the third heart sound, is considered normal in children and young adults and abnormal in middle-aged and older adults. This sound is best heard with the stethoscope bell at the mitral area, with the client lying on the left side. S4 is represented by "dee-lub-dub" and is considered normal in older adults but abnormal in children and adults.

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply. A) Blowing, hollow sounds auscultated over the larynx and trachea B) Sonorous or coarse sounds with a snoring quality auscultated during inspiration and expiration C) Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly D) Soft, low-pitched, whispering sounds heard over most of the lung fields E) Bubbling, crackling, or popping sounds auscultated during inspiration and expiration F) Musical or squeaking sounds, or high-pitched continuous sounds auscultated during inspiration and expiration

D) Soft, low-pitched, whispering sounds heard over most of the lung fields C) Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly A) Blowing, hollow sounds auscultated over the larynx and trachea Explanation: Vesicular breath sounds are soft, low-pitched, whispering sounds heard over most of the lung fields, with sound on inspiration being longer than expiration. Bronchovesicular sounds are heard over the mainstem bronchus and are moderate blowing sounds, with inspiration equal to expiration. Bronchial sounds heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. Musical or squeaking sounds describe a sibilant wheeze. Sonorous or coarse sounds with a snoring quality describe a sonorous wheeze. Bubbling, crackling, or popping sounds describe crackles.

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation? A) Enlist the help of another nurse to hold the client steady during the procedure. B) Administer a sedative to the client and try again when the sedative takes effect. C) Reassure the client that the procedure will only take a few minutes. D) Stop lifting the client and reassure him.

D) Stop lifting the client and reassure him. Explanation: The nurse should stop lifting the client and reassure him. If the client continues to be agitated, the nurse lowers the client back to the bed, and reevaluates the necessity of obtaining weight at that exact time. Continuing to lift the client may result in injury. An order for sedation would only be requested if it was absolutely necessary to obtain the client's weight at this time. Another nurse holding the client steady does not address the client's agitation.

The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment? A) The skin is less elastic with aging. B) The skin has normal turgor. C) The client is overhydrated. D) The client is dehydrated.

D) The client is dehydrated. Explanation: The nurse assesses for skin turgor by gently pinching the skin under the clavicle. This technique provides information about the client's hydration status as well as skin mobility and elasticity. Skin is less elastic with aging, but the turgor should remain normal (less than 3 seconds) and not tent, or remain in the pinched position. When a client is dehydrated, the skin will tent for more than 3 seconds. When a client is overhydrated, edema will be present with the skin, and the skin turgor would be normal, or taunt because of excess fluid.

A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse? A) The client reports pain at the surgical site. B) The client reports thirst. C) The client is sleepy from the anesthesia. D) The client makes noises when he breathes.

D) The client makes noises when he breathes. Explanation: Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Reports of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are expected findings. Feeling sleepy from the anesthesia is an expected outcome.

A client recently was diagnosed with Bell's palsy and is back to the clinic for a follow-up visit. What would the nurse observe during the assessment of cranial nerve VII if the client's symptoms are resolving? A) The client is able to turn the head to the side and shrug the shoulders against resistance. B) The client's tongue remains midline when it protrudes from the mouth. C) The palate and pharynx move as the client says "ah." D) The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows.

D) The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. Explanation: Bell's palsy is usually a temporary condition that presents with left or right facial weakness or paralysis. Cranial nerve VII controls the muscles of the face. Normal results would be symmetrical appearance and movement as the client smiles, frowns, and raises the eyebrows. Swallowing and speaking is demonstrated with cranial nerve X. Cranial nerve XII is assessed with movement of the tongue. The movement of shoulder muscles assesses cranial nerve XI.

To obtain subjective data about a newly admitted client's sleep pattern, the nurse: A) documents the client's affect and yawning. B) inspects the client's eyes for redness. C) determines how frequently the client naps. D) asks the client what promotes sleep.

D) asks the client what promotes sleep. Explanation: The assessment of sleep and rest focuses on the client's normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep.

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of: A) subjective data. B) comprehensive data. C) baseline data. D) objective data.

D) objective data Explanation: Objective data can be directly observed or measured, such as vital signs or appearance. The results of auscultation are considered to be objective because they do not depend on the client's subjective description. Baseline data is obtained on first contact with the client.

Mrs. Harris was admitted to the psychiatric unit 3 days ago with a diagnosis of major depressive disorder. The client answers assessment questions with barely audible "yes" or "no" responses and tells the nurse that she has been depressed for a long time. She wants the door closed and the curtains drawn to darken her room. She refuses visitors, eats only 25% of her meals, and tells the nurse that the food makes her nauseous. The nurse observes the client biting her fingernails. She cries often and sleeps a lot. The nurse documents which client actions as objective assessment data? Select all that apply. A) The client says that the food makes her nauseous. B) The client bites her fingernails. C) The client sleeps a lot. D) The client states that she has been depressed for a long time. E) The client answers questions in a barely audible voice. F) The client eats 25% of her meals.

E) The client answers questions in a barely audible voice. B) The client bites her fingernails. F) The client eats 25% of her meals. C) The client sleeps a lot. Explanation: Objective data are directly observed or elicited through physical examination techniques. Observing that the client talks in a low voice, does not eat all her food, sleeps a lot, and bites her fingernails is a means of attaining objective findings. Subjective data are experienced or known only by the client (e.g., pain and nausea) and are gathered by verbal report.