Assessment Midterm

22. A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following? A) "How would you describe your pain? Is it sharp? Is it an ache?" B) "Has the pain changed over time?" C) "Would you describe the pain as being constant or as intermittent?" D) "Is there anything that makes the pain worse or better?"

A) "How would you describe your pain? Is it sharp? Is it an ache?"

25. The nurse is beginning the inspection of a young adult client's breasts. The client states, "My left breast has always been a bit bigger than the right." How should the nurse best respond to the client's statement? A) "Many women have this, and it's rarely a sign of a health problem." B) "That's very normal, and it usually resolves over time as you get older." C) "If you lose some weight, the size disparity will likely decrease." D) "I'll make sure to refer to the doctor to get this assessed further."

A) "Many women have this, and it's rarely a sign of a health problem."

13. A client has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the "P"? A) "What makes it worse?" B) "When did it start?" C) "How does it feel?" D) "How would you rate your pain?"

A) "What makes it worse?"

24. The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure? A) 44 mm Hg B) 92 mm Hg C) 114 mm Hg D) 184 mm Hg

A) 44 mm Hg

29. In which of the following male clients would gynecomastia be considered to be an expected assessment finding? A) A 14-year-old boy who began puberty last year B) An older adult who takes antihypertensive medications C) A 59-year-old man who has been exposed to heavy metals in the workplace D) A male client who has been diagnosed with breast cancer

A) A 14-year-old boy who began puberty last year

6. A nurse who works at an outpatient ophthalmic clinic has a large number of clients. Which client would be at the highest risk for developing cataracts? A) A 55-year-old female client B) A 40-year-old with arteriosclerosis C) A client who has severe environmental allergies D) A male client who is obese

A) A 55-year-old female client

8. A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal? A) Acromegaly B) Brain tumor C) Paget disease D) Parkinson disease

A) Acromegaly

2. During a prenatal class, a participant says that she was told that her breasts are not large enough to breastfeed. When responding to this client, the nurse should understand that the functional capacity of the breast is primarily determined by which of the following variables? A) Amount of glandular tissue B) Breast size and weight C) Amount of fatty tissue D) Depth of the subcutaneous fat layer

A) Amount of glandular tissue

7. A nurse has completed a client's initial assessment and is now interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process? A) Analysis B) Planning C) Implementation D) Evaluation

A) Analysis

13. 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? A) Are you allergic to foods, medications, or other substances? B) Does anyone else in your family have a rash like this? C) How painful is your rash? D) What have you been doing to control the itching?

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

4. A 55-year-old client is being evaluated for a suspected hearing impairment. Which of the nurse's health interview questions is most likely to yield relevant data? A) Are you having difficulty hearing high-frequency sounds? B) Do you notice any drainage from your ears? C) Are you experiencing any pain in your ears? D) Have you felt any popping sensations in your ears?

A) Are you having difficulty hearing high-frequency sounds?

27. The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The nurse knows that a normal breathing rate is between approximately 10 and 20 breaths per minute, but the client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding? A) Ask the client if she has recently exerted herself. B) Report the finding to the client's primary care provider. C) Ask the client if she has smoked recently. D) Palpate the client's anterior and posterior thorax.

A) Ask the client if she has recently exerted herself.

7. A nurse is assessing an adult client's eyes and vision. When performing the cover test, the nurse would cover one of the client's eyes and then do which of the following? A) Ask the client to focus on a distant object, looking for movement in the other eye. B) Ask the client to close the other eye then open that eye quickly. C) Ask the client to follow the nurse's finger with the other eye. D) Ask the client to look directly at a light with the other eye.

A) Ask the client to focus on a distant object, looking for movement in the other eye.

29. The nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding? A) Auscultate the client's apical pulse. B) Palpate the client's ulnar pulse. C) Administer a dose of nitroglycerin. D) Reposition the client in a side-lying position.

A) Auscultate the client's apical pulse.

10. The nurse is auscultating a client's blood pressure and identifies the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds. This is known as which of the following? A) Auscultatory gap B) Korotkoff sounds C) Phase V D) Diastolic value

A) Auscultatory gap

15. A nurse is observing the red reflex in a client during an eye assessment. During this component of the assessment, the client states, I hope you can see it because I have cataracts. What finding should the nurse expect? A) Black spokes pointing inward B) White arc around the limbus C) Thickened bulbar conjunctiva D) A red spot on the retina

A) Black spokes pointing inward

29. During the nurse's assessment of the client's exercise and activity habits, the client laughs and then states, "Unless you're including channel surfing, I don't really do much of anything." How should the nurse best follow up this client's statement? A) Briefly describe some of the potential benefits of regular exercise. B) Ask the client if he understands the risk factors for heart disease and diabetes. C) Explain to the client that he should be performing aerobic exercise for 20 to 30 minutes at least three times a week. D) Document the nursing diagnosis of Risk for Activity Intolerance related to sedentary lifestyle.

A) Briefly describe some of the potential benefits of regular exercise.

30. A nurse has performed the corneal light reflex test during a client's eye examination. During this test, the nurse held a penlight 1 foot from the client's eyes and appraised the client's eye alignment in which of the following ways? A) By comparing the reflection of the light on the client's eye surface B) By comparing the speed of pupillary constriction C) By comparing how quickly the client blinks each eyelid D) By comparing the relative color of the sclerae before and after light exposure

A) By comparing the reflection of the light on the client's eye surface

9. A nurse provides care in a rural hospital that serves a community that has few minority residents. When interviewing a client from a minority culture, the nurse has enlisted the assistance of a "culture broker." How can this individual best facilitate the client's care? A) By interpreting the client's language and culture B) By evaluating the client's culturally based health practices C) By teaching the client about health care D) By making the client feel comfortable and safe

A) By interpreting the client's language and culture

12. A nurse observes the posture of a male client and finds him leaning forward and bracing himself while sitting on the exam table. Which of the following would the nurse most likely suspect? A) Chronic obstructive pulmonary disease B) Neurological deficit C) Metabolic disorder D) Vestibular disorder

A) Chronic obstructive pulmonary disease

19. A nurse is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives? A) Circle B) Square C) Triangle D) Rectangle

A) Circle

17. While performing the initial assessment of a client, the client tells the nurse that this is his first hospitalization and that he has no previous surgeries. The nurse should document which of the following? A) Client denies prior hospitalizations and surgeries B) Client has not been hospitalized before nor has he had any surgery C) Client answered no to previous hospitalizations or surgery D) Negative for past hospitalizations

A) Client denies prior hospitalizations and surgeries

4. A client weighs 106 pounds and is 5 feet 5 inches tall. As a result, her ideal body weight is 120 pounds. After determining the client's percentage of ideal body weight, which of the following should the nurse conclude? A) Client is mildly malnourished. B) Client is experiencing moderate malnutrition. C) Severe malnutrition is present. D) The client's body weight is within 10% of ideal body weight.

A) Client is mildly malnourished.

7. A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. Which of the following assessment findings should the nurse anticipate along with this condition? A) Crepitus over the maxillary sinuses B) Frontal sinuses nontender to palpation C) Red, tender tympanic membrane D) Increased amounts of saliva production

A) Crepitus over the maxillary sinuses

19. Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following? A) Discrete B) Linear C) Annular D) Confluent

A) Discrete

23. During a new client's nutritional assessment, the nurse asks the client's height and usual weight. The client states that he has no idea how much he weighs. How should the nurse respond? A) Do you feel like your weight has increased, decreased, or stayed the same lately? B) Why do you feel that it's not important to monitor your weight? C) In a typical day, what do you eat and drink? D) How would you describe your feelings around your body type and body mass?

A) Do you feel like your weight has increased, decreased, or stayed the same lately?

6. The nurse should prioritize assessments related to overhydration for a client experiencing which of the following health problems? A) Early congestive heart failure B) Chronic emphysema C) Newly diagnosed hepatitis C virus infection D) Adult respiratory distress syndrome

A) Early congestive heart failure

5. Which of the following factors should a nurse include when discussing risk factors about breast cancer for a group of women? A) Early menarche B) One or more pregnancies before age 20 C) Consumption of a high-protein diet D) Early menopause

A) Early menarche

2. A nurse is preparing to assess an adult client's body temperature. At which time of the day would the nurse expect to obtain the lowest body temperature? A) Early morning B) Early afternoon C) Late afternoon D) Late evening

A) Early morning

10. A nurse is performing an eye assessment of an 81-year-old male client. Which of the following would the nurse document as a normal finding? A) Ectropion B) Episcleritis C) Chalazion D) Exophthalmos

A) Ectropion

5. The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system? A) Endocrine B) Neurologic C) Cardiovascular D) Genitourinary

A) Endocrine

2. A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a client's anxiety during the physical exam. Which of the following would be most appropriate? A) Ensuring client's privacy by providing an examination gown B) Providing a comfortable, warm room temperature C) Arranging exam equipment on a bedside tray table D) Explaining why standard precautions are being used

A) Ensuring client's privacy by providing an examination gown

1. A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? A) Establishing a trusting relationship B) Determining the client's strengths C) Identifying potential health problems D) Making clinical inferences

A) Establishing a trusting relationship

9. A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says Absolutely not! There's no way I'll let you do that to me! Which response by the nurse would be most appropriate? A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam. B) Tell the client that this is the only way she can be checked for cancer. C) Ask the client if she would prefer another practitioner to perform the exam. D) Proceed with the pelvic exam and document the client's protests in the health record.

A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

4. The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? A) Far, then near B) Lateral, then near C) Near, then far D) Lateral, then far

A) Far, then near

28. A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. The nurse has lowered the client's arm and observed how long it takes for venous filling, then raised the same arm and watched how long it takes to empty. After determining that venous filling and emptying each take approximately 10 seconds, the nurse should perform further assessments related to what health problem? A) Fluid volume deficit B) Third spacing C) Ascites D) Malnutrition

A) Fluid volume deficit

3. The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What might the nurse expect to hear when auscultating the lungs of a client with this fluid volume deficit? A) Friction rub B) Decreased breath sounds C) Sibilant wheeze D) Stridor

A) Friction rub

11. The nurse is assessing an older adult client whose health problems include receding gums. The nurse notes gum ischemia and worn tooth surfaces. Which question would be most important for the nurse to ask? A) Have you lost any teeth recently? B) How would you describe your typical diet? C) Has your dentist screened you for oral cancer recently? D) Are you able to taste the food you eat?

A) Have you lost any teeth recently?

13. The nurse analyzes the data obtained from a client's nutritional assessment and develops a health promotion diagnosis related to nutrition for a client. Which of the following would be the best example? A) Health-seeking behaviors related to desire and request to alter amount of food intake B) Imbalanced nutrition: less than body requirements related to inadequate caloric intake C) Imbalanced nutrition: more than body requirements related to excessive caloric intake D) Ineffective thermoregulation related to decreased adaptability to cold secondary to decreased subcutaneous tissue

A) Health-seeking behaviors related to desire and request to alter amount of food intake

9. When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. Which of the following should the nurse examine first? A) Hearing acuity B) Thyroid gland C) Mental status D) Lymph nodes

A) Hearing acuity

17. In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? A) Heart sounds B) Bowel sounds C) Breath sounds D) Femoral pulses

A) Heart sounds

11. When evaluating nutrition in an adult female client, which laboratory value would most concern the nurse? A) Hemoglobin A1c of 9% B) Serum albumin of 4.9 g/dL C) Total protein of 6.7 g/dL D) Hematocrit of 39%

A) Hemoglobin A1c of 9%

3. A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea? A) History of allergies B) Incomplete immunization record C) History of epistaxis (nosebleeds) D) Prolonged tonsillar enlargement

A) History of allergies

22. The nurse is assessing a client who enjoys good health overall but who has brought a complaint of chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize? A) How often do you use over-the-counter nasal sprays? B) How often do you take Tylenol? C) How many drinks of alcohol do you have in a typical day? D) Would you say that you eat a balanced diet?

A) How often do you use over-the-counter nasal sprays?

9. A client has a history of emphysema. During the respiratory assessment, the nurse percusses the client's chest, expecting to find which of the following? A) Hyperresonance B) Dullness C) Resonance D) Tympany

A) Hyperresonance

2. A nurse is assessing a female client whose worsening sciatica has prompted her to seek care. Which of the client's following statements would the nurse most likely need to validate? A) I don't generally have problems with pain. B) I feel very weak and tired right now. C) I've had two cesarean deliveries. D) My mother died of breast cancer in her sixties.

A) I don't generally have problems with pain.

13. The nurse has completed a focused ear and hearing assessment and gathered the following data: the client speaks very softly, denies hearing loss, and has never had and cannot afford additional hearing tests; the client fails the whisper test. Which nursing diagnosis would be most appropriate? A) Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing B) Impaired social interaction, related to decreased ability to maintain contact with friends C) Impaired verbal communication, related to lack of understanding of hearing deficit D) Readiness for enhanced communication related to auditory integrity and need for hearing therapy

A) Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing

26. A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first? A) Inspection B) Palpation C) Percussion D) Auscultation

A) Inspection

20. A group of students is preparing for a quiz on breast assessment and the assessment findings that are associated with breast cancer. The students demonstrate understanding of the material when they identify which of the following? Select all that apply. A) Irregular, firm lumps B) Elastic, tender, mobile lumps C) Dimpling and nipple retraction D) Orange peel-like appearance E) Redness and warmth with smooth texture F) Breast fullness and pain

A) Irregular, firm lumps C) Dimpling and nipple retraction D) Orange peel-like appearance

11. A nurse is providing in-service training to a group of nurses in a facility that has just begun to use an integrated cued checklist for documentation. Which of the following would the nurse identify as a major advantage of this type of documentation? A) It helps nurses to cluster assessment data. B) It provides lines for the nurses' comments. C) It includes specialized data particular to each client. D) It standardizes data collection.

A) It helps nurses to cluster assessment data.

12. A group of nursing students is reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes? A) It provides a chronologic source of client assessment data. B) It creates a database for care that was not rendered to the client. C) It replaces the client acuity classification system. D) It directly formulates the nursing diagnoses.

A) It provides a chronologic source of client assessment data.

19. After teaching a group of students about the external and internal structures of the eye, the instructor determines that the teaching was successful when the students identify which of the following as external structures? Select all that apply. A) Lacrimal apparatus B) Conjunctiva C) Lens D) Iris E) Sclera F) Caruncle

A) Lacrimal apparatus B) Conjunctiva F) Caruncle

11. The nurse is preparing to auscultate the client's thorax. Which of the following actions is the priority during this component of assessment? A) Listen at each site for at least one complete respiratory cycle. B) Have the client breathe deeply through his or her nose. C) Encourage the client to cough before auscultating each site. D) Have the client hold the breath for a few seconds after auscultating each site.

A) Listen at each site for at least one complete respiratory cycle.

15. A nurse has completed the assessment of a client's breasts. The nurse should suspect that the client has fibroadenomas based on which findings? A) Lobular, ovoid, or round lesions B) Irregular, firm cysts C) Round, defined mobile cysts D) Nondefined, mobile cysts

A) Lobular, ovoid, or round lesions

18. A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency? A) Monthly B) Bimonthly C) Quarterly D) Yearly

A) Monthly

6. The nurse is preparing to assess an older adult client's near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use? A) Newspaper B) Snellen chart C) Ophthalmoscope D) Penlight

A) Newspaper

14. Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities? A) Nodularity B) Tenderness C) Enlargement D) Bruits

A) Nodularity

26. A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which of the following actions? A) Observing the eye's reaction when a light is shone into the opposite eye B) Shining a light into one eye while covering the other eye with an opaque card C) Moving a finger into the client's peripheral vision field and asking the client to state when he or she sees the finger D) Comparing the difference between the client's dilated pupil and a constricted pupil

A) Observing the eye's reaction when a light is shone into the opposite eye

28. A 20-year-old female client has presented to the clinic, and the nurse is preparing to perform a comprehensive assessment. The client states, I'd really like to have my mom in the room. That's okay, isn't it? How should the nurse best respond to the client's request? A) Of course. There's a chair in the exam room where she can sit. B) That's no problem. I'll just have to get you to sign a privacy waiver first. C) That's fine, but be aware that some of the examinations might be embarrassing for you or her. D) It's best to undergo the examination alone in order to make sure I get accurate data, but if you really want her present, we can do that.

A) Of course. There's a chair in the exam room where she can sit.

21. The nurse's assessment of an older adult client's ears and hearing suggests the possible presence of conductive hearing loss. Which of the following is the most likely etiology of this abnormal assessment finding? A) Otitis media B) Cranial nerve VIII damage C) Trauma to the temporal lobe D) Age-related hearing changes

A) Otitis media

20. During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches? A) Pain radiating from eye to temporal region B) Throbbing and severe pain C) Report of ringing in the ears prior to headache D) Complaint of sensitivity to light

A) Pain radiating from eye to temporal region

7. A nurse is eliciting a client's health history and the client asks, "Can I take the herb ginkgo biloba with my other medications?" What action would be best if the nurse is unsure of the answer? A) Promise to find out the information for the client. B) Change the subject and return to this topic later. C) Teach the client to only take prescribed medications. D) Encourage the client to ask the pharmacist or primary care provider.

A) Promise to find out the information for the client.

7. The nurse is assessing a client who has been admitted with signs and symptoms that are consistent with malnutrition. Which of the following physiological phenomena would the nurse recognize as an early indicator of malnutrition? A) Protein stores are lower than normal B) Bone is metabolized to compensate for missing nutrients C) Calcium levels decrease D) Hemoglobin levels decrease

A) Protein stores are lower than normal

13. A nurse is assessing the eyes of a 3-year-old child. Which finding would the nurse document as normal? A) Pseudostrabismus B) Tropia C) Nystagmus D) Exotropia

A) Pseudostrabismus

22. A surgical client's pain has become increasingly severe overnight, and she has received her maximum current doses of analgesics. The nurse has consequently phoned the surgeon to obtain a new order for analgesia. After the surgeon tells the nurse the new order, how should the nurse best validate this information? A) Read the order back to the surgeon for confirmation. B) Compare the order with the standard timing and dosage of the analgesic. C) Compare the order to the client's existing medication administration record (MAR). D) Have another nurse read the order that the nurse has transcribed.

A) Read the order back to the surgeon for confirmation.

10. A woman reports a sudden onset of spontaneous nipple discharge. Which of the following would be the nurse's most appropriate action? A) Refer the client for cytologic study of the discharge. B) Observe the breast for eversion of the nipples. C) Reassure the woman that this is a result of hormonal fluctuations. D) Collect a sample for culture and sensitivity testing.

A) Refer the client for cytologic study of the discharge.

9. The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next? A) Refer the client immediately for further evaluation. B) Assess for foreign body impaction. C) Examine for postauricular cysts. D) Position the patient to facilitate drainage.

A) Refer the client immediately for further evaluation.

23. A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral? A) Referral for further assessment of thyroid function B) Referral for assessment of cranial nerve function C) Referral for assessment of lymphatic system function D) Referral for further assessment of swallowing ability

A) Referral for further assessment of thyroid function

1. Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. Which of the following nursing diagnoses would be the nurse's priority? A) Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination B) Imbalanced nutrition: more than body requirements related to diabetes C) Potential complication: hypertension D) Powerlessness related to diabetes self-care and management

A) Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination

18. A group of students is reviewing information about the salivary glands and their secretions. The students demonstrate understanding of the information when they identify which of the following as components of saliva? Select all that apply. A) Salts B) Proteins C) Fats D) Mucus E) Amylase

A) Salts D) Mucus E) Amylase

25. The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age- related changes? A) Slight kyphosis B) Inaudible posterior lung sounds C) Audible wheeze D) Asymmetrical chest expansion

A) Slight kyphosis

1. When assessing whispered pectoriloquy, the nurse should instruct a client to do which of the following? A) Softly repeat the words one-two-three. B) Say the number ninety-nine. C) Cough each time the stethoscope is moved. D) Say the letter e until instructed to stop.

A) Softly repeat the words one-two-three.

5. A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following? A) Subjective data and objective data B) Interpretation and inference C) Observation and inspection D) Data and results

A) Subjective data and objective data

2. The nurse's assessment reveals that a client is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate? A) Teaching the client muscle-building exercises B) Discussing ways to increase body fat stores C) Assisting client in reducing the amount of fluid build-up D) Encouraging the use of a multivitamin supplement

A) Teaching the client muscle-building exercises

3. The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first? A) Temperature B) Pulse C) Respiration D) Blood pressure

A) Temperature

29. The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test? A) The client has unilateral hearing loss. B) The client has suspected otitis externa. C) The client is older than age 65. D) The client has a history of stroke.

A) The client has unilateral hearing loss.

4. A client has sustained a brain stem injury and is being treated in the intensive care unit. Which of the following would the nurse need to consider when assessing this client's respiratory status? A) The client will have a loss of involuntary respiratory control. B) The client will respond negatively to increased stimuli. C) The client will have greatly increased respiratory effort. D) The client will exhibit Cheyne-Stokes respirations.

A) The client will have a loss of involuntary respiratory control.

8. The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first? A) The client's sensory abilities B) The client's general intelligence C) The presence of any phobias D) The client's judgment and insight

A) The client's sensory abilities

21. The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs? A) The right lung has three lobes, while the left lung has two lobes. B) The lungs are structurally symmetrical but functionally differently. C) The right lung is approximately one-third larger than the left lung. D) The lower lobes of both lungs are primarily located toward the anterior chest wall.

A) The right lung has three lobes, while the left lung has two lobes.

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

A) There is a nonblanching reddened area on the client's coccyx region.

29. A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection (thrush). On inspection of the patient's tongue, the nurse should anticipate what appearance? A) Thick, white plaques on the tongue surface B) Dry appearance with fissures present C) Diffuse reddened lesions that bleed easily D) Firm, raised nodules that are pink or red

A) Thick, white plaques on the tongue surface

4. During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem? A) Trigeminal neuralgia B) Migraine headache C) Meningitis D) Temporomandibular joint dysfunction

A) Trigeminal neuralgia

27. A community health nurse is conducting a home visit to a client who requires wound care. The nurse observes that the client is diaphoretic and wishes to measure the client's temperature. The nurse asks if the client has a thermometer in her home, and she states that she owns an ear thermometer. What principle should guide the nurse's use of a tympanic thermometer? A) Tympanic temperature is slightly higher than oral temperature. B) Tympanic temperature is only used if all other methods are unavailable. C) Tympanic temperature varies more widely than oral, rectal, and axillary temperatures. D) In adults, tympanic temperature is equal to axillary temperature.

A) Tympanic temperature is slightly higher than oral temperature.

13. The nurse is preparing to palpate the breasts of a female client. Which technique should the nurse utilize during this aspect of assessment? A) Use the flat pads of three fingers. B) Use the fingertips of both hands. C) Gently pinch the skin between two fingers. D) Use the palm of one hand.

A) Use the flat pads of three fingers.

24. The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon? A) Vasoconstriction B) Hyperglycemia C) Hypoxemia D) Cardiopulmonary insufficiency

A) Vasoconstriction

28. The nurse is assessing a dark-skinned client whose forearms are hands have distinct regions of depigmentation. The nurse should document the presence of what health problem? A) Vitiligo B) Striae C) Angiomas D) Albinism

A) Vitiligo

25. A nurse health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients how to clean their ears, what action should the nurse recommend? A) Washing with a warm, moist washcloth B) Gently irrigating with normal saline C) Cleaning with cotton-tipped applicator D) Irrigating with mildly soapy water

A) Washing with a warm, moist washcloth

14. A nurse is preparing an in-service education program for a group of staff nurses about documentation, including documentation of assessment data. The nurse demonstrates understanding of the significance of documentation by including a discussion of which of the following as playing a role in this area? Select all that apply. A) Joint Commission B) State nurse practice act C) Medicare D) Local or city government E) Institutional agency

A, B, C, E A) Joint Commission B) State nurse practice act C) Medicare E) Institutional agency

1. A nurse has completed the general survey of a client who has been transferred to the unit. The information gathered during the general survey primarily provides the nurse with which of the following? Select all that apply. A) An indication of the level of physical distress experienced by the client B) Clues about the overall health of the client C) A direct link to the client's medical diagnosis D) Indications about normal variations in the status of body systems E) Data relating to the patient's level of social support

A, B, D A) An indication of the level of physical distress experienced by the client B) Clues about the overall health of the client D) Indications about normal variations in the status of body systems

24. The nurse is evaluating the setting prior to beginning a client's physical examination. The nurse should confirm the presence of which of the following? Select all that apply. A) Adequate lighting B) Cool room temperature C) Quiet surroundings D) Soft chair or table E) Table for equipment F) Door or curtain

A, C, E, F A) Adequate lighting C) Quiet surroundings E) Table for equipment F) Door or curtain

26. The nurse is completing a review of systems for a client. Which of the following information would the nurse document related to the client's musculoskeletal system? Select all that apply. A) Joint stiffness B) Rhinorrhea C) Shortness of breath D) Chest pain E) Muscle strength F) Knee swelling

A, E, F A) Joint stiffness E) Muscle strength F) Knee swelling

7. After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases? A) Assessment B) Planning C) Implementation D) Evaluation

ANS: A) Assessment

16. A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify? A) Expansion of health care networks B) Decrease in client participation in care C) The shrinking cost of medical care D) Public mistrust of physicians

ANS: A) Expansion of health care networks

26. 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? A) Identify a nursing diagnosis of Ineffective Health Maintenance. B) Identify a collaborative problem that should involve the occupational therapist. C) Make a referral to the unit's social work department. D) Reassess the client's blood glucose level.

ANS: A) Identify a nursing diagnosis of Ineffective Health Maintenance.

23. A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data? A) Inspection B) Therapeutic communication C) Interviewing D) Active listening

ANS: A) Inspection

14. An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession? A) Natural senses B) Biomedical knowledge C) Simple technology D) Critical pathways

ANS: A) Natural senses

8. The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason? A) Reassess previously detected problems B) Provide information for the client's record C) Address areas previously omitted D) Determine the need for crisis intervention

ANS: A) Reassess previously detected problems

4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first? A) Review the client's medical record. B) Obtain basic biographic data. C) Consult clinical resources explaining the client's diagnosis. D) Validate information with the client.

ANS: A) Review the client's medical record.

19. A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify? A) The client's feelings of happiness B) The client's posture C) The client's affect D) The client's behavior

ANS: A) The client's feelings of happiness

27. The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? A) The client's motivation for change B) The client's medical comorbidities C) The client's learning style D) The client's prognosis for recovery

ANS: A) The client's motivation for change

21. The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. A) I feel so tired sometimes. B) Weight: 145 lbs C) Lungs clear to auscultation D) Client complains of a headache E) My father died of a heart attack. F) Pupils equal, round, and reactive to light

ANS: A, D, E

9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment? A) A 14-year-old girl who is crying because she thinks she is pregnant B) A 45-year-old man with chest pain and diaphoresis for 1 hour C) A 3-year-old child with fever, rash, and sore throat D) A 20-year-old man with a 3-inch shallow laceration on his leg

ANS: B) A 45-year-old man with chest pain and diaphoresis for 1 hour

13. The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral? A) An 80-year-old client who lives with her daughter B) A 50-year-old client newly diagnosed with diabetes C) An adult presenting for an influenza vaccination D) A teenager seeking information about contraception

ANS: B) A 50-year-old client newly diagnosed with diabetes

30. A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? A) Review the client's medication administration record for analgesic use. B) Ask the client about the most recent experiences of pain. C) Meet with the client's spouse and daughter to discuss the client's pain. D) Collaborate with the physician who is treating the client.

ANS: B) Ask the client about the most recent experiences of pain.

2. A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment? A) Gastroenterologist B) ED nurse C) Admissions clerk D) Diagnostic technician

ANS: B) ED nurse

6. In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation? A) Current physiologic status B) Effect of health on functional status C) Past medical history D) Motivation for adherence to treatment

ANS: B) Effect of health on functional status

24. The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment? A) Focus the assessment on the client as a member of her age group. B) Interpret the information about the client in context. C) Corroborate the client's statements with trusted sources. D) Gather information from a variety of sources.

ANS: B) Interpret the information about the client in context.

3. 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? A) Each step is independent of the others. B) It is ongoing and continuous. C) It is used primarily in acute care settings. D) It involves independent nursing actions.

ANS: B) It is ongoing and continuous.

5. Which of the following client situations would the nurse interpret as requiring an emergency assessment? A) A pediatric client with severe sunburn B) A client needing an employment physical C) A client who overdosed on acetaminophen D) A distraught client who wants a pregnancy test

ANS: C) A client who overdosed on acetaminophen

11. The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? A) Family history B) Occupation C) Appearance D) History of present health concern

ANS: C) Appearance

17. A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation? A) Guaranteeing a continual assessment process B) Identifying abnormal data C) Assuring valid conclusions from analyzed data D) Allowing for drawing inferences and identifying problems

ANS: C) Assuring valid conclusions from analyzed data

10. A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following? A) Determine if pertinent data has been omitted B) Identify the need for referral C) Avoid biases and judgments D) Construct a plan of care

ANS: C) Avoid biases and judgments

18. A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, which of the following should the nurse do first? A) Collect objective data. B) Validate important data. C) Collect subjective data. D) Document the data.

ANS: C) Collect subjective data.

25. A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? A) Comprehensive assessment B) Ongoing assessment C) Focused assessment D) Emergency assessment

ANS: C) Focused assessment

29. A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable? A) The client's age B) The unit's protocols C) The client's acuity D) The nurse's potential for liability

ANS: C) The client's acuity

20. A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice? A) The focused assessment should be done before the physical exam. B) The focused assessment replaces the comprehensive database. C) The focused assessment addresses a particular client problem. D) The focused assessment is done after gathering subjective data.

ANS: C) The focused assessment addresses a particular client problem.

22. The nurse has been applying the nursing process in the care of an adult client who is being treated for acute pancreatitis. Place the nurse's actions in their proper sequence from first to last. A) Identifying outcomes B) Determining client's nursing problem C) Collecting information about the client D) Determining outcome achievement E) Carrying out interventions

ANS: C, B, A, E, D C) Collecting information about the client B) Determining client's nursing problem A) Identifying outcomes E) Carrying out interventions D) Determining outcome achievement

28. A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? A) Identify the most appropriate forms of medical intervention for the client. B) Determine the most likely prognosis for the client's health problem. C) Identify the status of the client's airway, breathing, and circulation. D) Establish a baseline for the comparison of future health changes.

ANS: D) Establish a baseline for the comparison of future health changes.

1. A nurse on a postsurgical unit is admitting a client following the client's cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client? A) Collecting accurate data B) Assisting the primary care provider C) Validating previous data D) Making clinical judgments

ANS: D) Making clinical judgments

12. An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem? A) Encourage the client to increase oral fluid intake. B) Provide the client with a bedtime protein snack. C) Assist the client with personal hygiene. D) Measure the client's blood glucose four times daily.

ANS: D) Measure the client's blood glucose four times daily.

15. When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force? A) Documentation B) Informatics C) Diversification D) Technology

ANS: D) Public mistrust of physicians

7. A 42-year-old female client says she does not perform breast self-examination because she believes that mammograms are more thorough. Which response by the nurse would be most appropriate? A) "You should do the exam. It's the best way to detect breast cancer early." B) "Be sure to have your breasts checked by a doctor and have a mammogram every year." C) "Mammograms don't always detect the lumps that you might feel." D) "Once you hit age 50, you really won't have a choice about doing them."

B) "Be sure to have your breasts checked by a doctor and have a mammogram every year."

21. During the interview, the client states, "Is today the 12th? My wife died 2 months ago today." Which of the following responses would be most appropriate? A) "What was the cause of your wife's death?" B) "How does that make you feel right now?" C) "You probably must be sad." D) "Are you feeling sad, depressed, angry, or upset?"

B) "How does that make you feel right now?"

28. A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, "I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?" How should the nurse best explain the rationale for obtaining a health history? A) "In general, it's necessary for us to gather as much information about each client as possible." B) "We want to make sure your nursing care matches your needs as closely as possible." C) "The care team needs to cross-reference your diagnostic testing with the information that I'm asking you about." D) "We don't want to make the mistake of focusing solely on the medical problem that brought you here."

B) "We want to make sure your nursing care matches your needs as closely as possible."

28. The nurse is palpating the axillary lymph nodes of a client who has been experiencing recent malaise. The nurse should consider a lymph node to be enlarged if its diameter exceeds what size? A) 0.5 cm B) 1 cm C) 2 cm D) 2.5 cm

B) 1 cm

12. A nurse weighs a client today and finds that the client's weight has increased 2.2 lbs from the previous day. The nurse interprets this finding as suggesting a fluid gain of which amount? A) 0.5 liters B) 1.0 liters C) 1.5 liters D) 2.0 liters

B) 1.0 liters

25. During an initial prenatal visit, the nurse is performing a nutritional assessment of a woman who has just learned that she is pregnant for the first time. The nurse has determined that the client has an average stature and is 5 feet, 3 inches tall. What is this client's ideal body weight? A) 105 lbs. B) 115 lbs. C) 125 lbs. D) 135 lbs.

B) 115 lbs.

19. Due to a change in the client's level of consciousness, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4∫F. Which finding would the nurse interpret as corresponding most closely to the client's previous temperature? A) 97.0 F B) 97.4 F C) 98.9 F D) 99.4 F

B) 97.4 F

3. The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve? A) Abducens (VI) B) Accessory (XI) C) Hypoglossal (XII) D) Trochlear (IV)

B) Accessory (XI)

20. Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following? A) Oxygen deficiency B) Acute illness C) Psoriasis D) Trauma

B) Acute illness

23. The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his history of environmental allergies, the client states, I'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies. How can the nurse begin to identify the specific allergens that cause the man's symptoms? A) Ask the client if his allergies respond to OTC antihistamines. B) Ask the client about the timing of his allergy symptoms. C) Perform a detailed inspection of the client's ears and throat using an otoscope. D) Perform transillumination of the client's sinuses.

B) Ask the client about the timing of his allergy symptoms.

17. During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? A) Ask the client to identify which medications taken every day. B) Ask the client to bring all the medications and supplements to an interview. C) Ask the caregiver whether the client is taking prescribed medications. D) Ask the client about the use of any over-the-counter medications.

B) Ask the client to bring all the medications and supplements to an interview.

24. The nurse has completed the assessment of a client's breast and lymphatic system. The nurse has ended the assessment by offering to teach the client how to perform breast self-examination (BSE). The client states, "That's alright. I already know how to do that." What should the nurse do next? A) Encourage the client to perform BSE as often as possible. B) Ask the client to demonstrate BSE. C) Encourage the client to promote BSE to her peers. D) Reiterate the correct technique for BSE.

B) Ask the client to demonstrate BSE.

1. A client tells the clinic nurse that she has sought care because she has been experiencing excessive tearing of her eyes. Which assessment should the nurse next perform? A) Inspect the palpebral conjunctiva. B) Assess the nasolacrimal sac. C) Perform the eye positions test. D) Test pupillary reaction to light.

B) Assess the nasolacrimal sac.

11. A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. During assessment using the mnemonic ABCDE, which finding would the nurse identify as being most suggestive of melanoma? A) Solid, dark brown color B) Asymmetric, irregular borders C) Diameter of 3 mm D) Flat with silvery scales

B) Asymmetric, irregular borders

16. Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies? A) Fungal infection B) Bacterial infection C) Yeast infection D) Circulatory disorder

B) Bacterial infection

7. A nurse practitioner is performing a comprehensive physical examination of a 51-year- old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following? A) Parasites B) Blood C) Bacteria D) Fungus

B) Blood

23. During the health interview, the nurse asks a middle-aged client at what age she began menstruating. This question addresses a risk factor for what health problem? A) Mastitis B) Breast cancer C) Benign breast disease D) Paget's disease

B) Breast cancer

18. A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status? A) Flat, firm abdomen B) Brittle hair C) Pink mucous membranes D) Elastic skin

B) Brittle hair

28. A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, Do you wear sunglasses during exposure to the sun? the nurse is addressing a known risk factor for what health problem? A) Presbyopia B) Cataracts C) Nystagmus D) Glaucoma

B) Cataracts

17. During a nutritional assessment, the client asks the nurse for suggestions to improve her diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to desire to improve diet. Which of the following suggestions would be most appropriate? A) The majority of your diet should consist of whole grains. B) Choose low-fat versions of milk products such as yogurt. C) Drink at least 2 to 3 glasses of fruit juices a day. D) Eat fewer orange vegetables and more dark green vegetables daily.

B) Choose low-fat versions of milk products such as yogurt.

29. The nurse is inspecting the dominant hand of an older adult client and notes the presence of irregularly shaped brown lesions on the dorsal surface of the client's hand. What action should the nurse perform next? A) Obtain a tissue sample for pathology B) Compare the appearance of the client's other hand C) Palpate the lesions for tenderness and warmth D) Perform health promotion teaching about sun protection

B) Compare the appearance of the client's other hand

2. A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated? A) Asking the client to flex his or her neck B) Compressing the arteries bilaterally C) Performing the examination while the client is seated D) Asking the client to swallow water

B) Compressing the arteries bilaterally

30. A 12-year-old boy has been brought to the emergency department after being hit in the head with a pitch during a baseball game. The emergency department nurse's comprehensive assessment includes examination of the boy's ears with an otoscope. What assessment finding would suggest trauma to the middle ear or inner ear? A) White spots on the tympanic membrane B) Dark red or bluish tympanic membrane C) Yellowish, bulging tympanic membrane D) Clear tympanic membrane

B) Dark red or bluish tympanic membrane

17. The nurse is admitting a client to surgical daycare and is assessing the client's vital signs. When obtaining the client's oral temperature, where should the nurse insert the thermometer? A) At the gum line between the check and tongue B) Deep in the posterior sublingual pocket C) On either side of the frenulum at gingival level D) Just past the teeth, below the tongue

B) Deep in the posterior sublingual pocket

16. A nurse is assessing a client for possible fluid overload. Which of the following assessment findings is most consistent with this diagnosis? A) Venous filling of 3 seconds B) Distended neck veins with head elevated at 45 degrees C) Moist, plump tongue D) Boggy eyeball

B) Distended neck veins with head elevated at 45 degrees

20. A group of students is reviewing information from class about the purposes of assessment documentation. The students demonstrate understanding of the material when they state which of the following? A) Documentation helps support reimbursement but gives little epidemiologic data. B) Documentation provides a permanent legal record of care given and not given. C) Documentation is a viable means of communication but is repetitious. D) Documentation helps determine client education needs but not staff mix.

B) Documentation provides a permanent legal record of care given and not given.

10. When examining a child who complains of a sore throat, the nurse notes swelling on either side of the child's oropharynx. The nurse would include which of the following when documenting this finding? A) Enlarged pharyngeal tonsils B) Enlarged palatine tonsils C) Enlarged adenoids D) Enlarged lingual tonsils

B) Enlarged palatine tonsils

20. A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first? A) Collaborate with the client to identify problems. B) Explain the purpose of the interview. C) Determine the client's vital signs. D) Obtain family health history data.

B) Explain the purpose of the interview.

9. A client's history suggests a need to assess eye muscle strength and cranial nerve function. What assessment should the nurse consequently perform? A) Corneal light reflex test B) Eye positions test C) Cover test D) Visual fields test

B) Eye positions test

20. A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which of the following actions? A) Depressing the skin 1 to 2 centimeters with the dominant hand B) Feeling the surface structures using a circular motion C) Placing the nondominant hand on top of the dominant hand D) Using one hand to apply pressure and the other hand to feel the structure

B) Feeling the surface structures using a circular motion

19. A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data? A) Open-ended form B) Focused assessment form C) Frequent assessment form D) Ongoing assessment form

B) Focused assessment form

20. Which of the following, if obtained during the health history, would alert the nurse to a possible risk factor for ear-related problems? A) Frequent use of acetaminophen (Tylenol) B) Frequent use of cotton-tipped applicators inside the ear C) Preference for showers rather than baths D) In adequate hygiene practices

B) Frequent use of cotton-tipped applicators inside the ear

4. The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms? A) Parasitic infection B) Fungal infection C) Bacterial infection D) Allergic reaction

B) Fungal infection

21. A nurse is completing a comprehensive health history of a 69-year-old woman who is a new client of the clinic. Which of the nurse's interview questions most directly addresses the client's risk for developing cataracts? A) Do you exercise regularly? B) Have you ever been tested for diabetes? C) Do you ever take over-the-counter pain medications? D) At what age did you first start wearing glasses?

B) Have you ever been tested for diabetes?

13. The nurse is completing the general survey of a client and determines that the client's temperature is 102∞F. Which of the following would the nurse also expect to find? A) Weak, thready pulse B) Heart rate greater than 100 bpm C) Respiratory rate between 12 and 20 breaths/minute D) Diastolic blood pressure 10 mm Hg greater than normal

B) Heart rate greater than 100 bpm

23. During a health screening event, the nurse is assessing a client's risk factors for lung cancer. When addressing the most significant risk factor for lung cancer, the nurse should question the client about which of the following? A) Childhood exposure to air pollution B) History of tobacco use C) History of working in a factory or smelter D) History of recurrent lung infections

B) History of tobacco use

21. A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which of the following statements? A) What would you like to do to address this client's nausea? B) I think this client would benefit from an antiemetic. C) This client has no recent history of any nausea or vomiting. D) This client rates his nausea as seven out of ten.

B) I think this client would benefit from an antiemetic.

26. A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction? A) I'm going to press on several different places below and in front of your ear. B) I'm going to put my fingers in front of your ears and ask you to open your mouth wide. C) Turn so I can see the side of your face and then open your mouth wide like you're yawning. D) When I place my hands on your cheeks, clench your teeth and then relax them.

B) I'm going to put my fingers in front of your ears and ask you to open your mouth wide.

16. A nurse is performing an otoscopic exam of a client's right tympanic membrane. At which location would the nurse document seeing the cone of light if it were in the appropriate place? A) In the center of the membrane B) In the 5 o'clock position C) In the 7 o'clock position D) In the upper left quadrant

B) In the 5 o'clock position

19. A nurse is teaching an older adult client about breast self-examination. The nurse includes teaching on expected changes in the client's breasts due to aging. Which of the following would the nurse include? A) Increase in glandular tissue B) Increase in fatty tissue C) Larger nipple area D) Less "granular" in texture

B) Increase in fatty tissue

14. A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic? A) Increased thickness and hair loss B) Increased thinness C) Pallor D) Erythema

B) Increased thinness

14. The nurse is performing an ear assessment of an adult client. Which of the following actions constitutes the correct procedure for using an otoscope when examining the client's ears? A) Keeping the dominant hand away from the client's head B) Inserting the speculum down and forward into the ear canal C) Using the smallest speculum on the otoscope head D) Holding the otoscope in the nondominant hand

B) Inserting the speculum down and forward into the ear canal

6. During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition? A) Diabetes mellitus B) Iron deficiency anemia C) Vitamin A deficiency D) Peripheral vascular disease

B) Iron deficiency anemia

20. A nurse is presenting a class to a local community group about vision and eye health. As part of the presentation, the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation? A) It refers to a client's subjective appraisal of his or her vision. B) It begins with light rays striking the retina. C) It primarily involves the lens of the eye. D) It allows the eyes to focus on near objects.

B) It begins with light rays striking the retina.

2. A client asks why cerumen is important, stating, It just clogs up the ears anyway. How should the nurse best describe the purpose of cerumen? A) It helps protect the delicate ear drum from loud noise that may be damaging. B) It helps to keep the ear drum soft and functioning well. C) It helps to amplify the sound waves through the inner ear. D) It helps create the translucent, pearly color of the ear drum.

B) It helps to keep the ear drum soft and functioning well.

30. An obese teenage boy from a culture that values increased body mass has been referred to the clinic. The nurse is assessing him for malnutrition based on his electronic health record and current health complaints. His mother questions the nurse's rationale, stating, Anyone can see he's not malnourished. Just look at the size of him! How should the nurse best respond? A) People sometimes become obese because their bodies are storing up nutrients that they often lack. B) It's actually very possible for a person to be overweight but have inadequate nutrition. C) Assessment for malnutrition is a standard component of a larger nutritional assessment, which is very important for your son's health. D) Actually, there's very little relationship between body mass and nutritional state.

B) It's actually very possible for a person to be overweight but have inadequate nutrition.

8. The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing? A) Extremity edema B) Joint flexion/extension C) Two-point discrimination D) Vibratory sensation

B) Joint flexion/extension

1. The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow-up? A) Thrush B) Leukoplakia C) Gingivitis D) Canker sore

B) Leukoplakia

16. A nurse is using a nursing minimum data set to document findings following the assessment of a client. This nurse is most likely providing care in which setting? A) Acute care facility B) Long-term care facility C) Urgent care center D) Health clinic

B) Long-term care facility

30. A nurse is conscientious in adhering to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) when providing care for clients. What action best meets these legal requirements for care? A) Having a colleague audit the nurse's documentation to ensure objectivity B) Maintaining the privacy and confidentiality of clients' medical records C) Using electronic records whenever possible, rather than paper-based records D) Collaborating with the client and his or her family prior to documenting

B) Maintaining the privacy and confidentiality of clients' medical records

22. A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which of the following principles? A) The thyroid gland is not normally palpable in female clients. B) Many clients have an additional (third) thyroid lobe. C) The thyroid gland is not normally palpable until clients are in their thirties or forties. D) Palpation creates a risk of rupturing the thyroid gland in some older adult clients.

B) Many clients have an additional (third) thyroid lobe.

16. A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? A) Recent eye trauma B) Narcotic use C) Macular degeneration D) Recent peripheral nervous system injury

B) Narcotic use

15. The nurse inspects a client's mouth and notes the presence of a bifid uvula. The nurse understands that this finding is most common in which ethnic group? A) Italian Americans B) Native Americans C) African Americans D) Non-Hispanic Americans

B) Native Americans

8. The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. The nurse should document this as which of the following? A) Limited expansion B) Normal expansion C) Hypoexpansion D) Hyperexpansion

B) Normal expansion

15. A client has been admitted following an unexplained weight loss of 15 pounds over the past 3 months. How should the nurse best assess the subjective component of the client's nutritional status? A) Ask the client to explain MyPlate. B) Obtain a 24-hour diet recall. C) Ask about the contents of one typical meal. D) Elicit the client's favorite foods.

B) Obtain a 24-hour diet recall.

1. The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location? A) On each side of the client's face, anterior and inferior to the ears B) On each side between the top of the ear and the eye C) Bilaterally, parallel to and anterior to the sternomastoid muscle D) Inferior to the lower jaw beneath the client's tongue

B) On each side between the top of the ear and the eye

18. The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first? A) Center of the client's forehead B) On the client's mastoid process C) In front of the client's external auditory canal D) At the base of the client's skull

B) On the client's mastoid process

2. When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. The nurse would document this as which of the following? A) Physiologic cup B) Optic disc C) Retinal vessels D) Fovea

B) Optic disc

8. A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect which of the following health problems? A) Otitis media B) Otitis externa C) Ruptured tympanic membrane D) Mastoiditis

B) Otitis externa

26. A client has presented with a terrible head cold, and the nurse is assessing for signs and symptoms of sinusitis. The nurse should utilize what assessment techniques? Select all that apply. A) Inspection B) Palpation C) Auscultation D) Percussion E) Transillumination

B) Palpation D) Percussion E) Transillumination

9. A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the presence of which of the following? A) Macule B) Papule C) Nodule D) Pustule

B) Papule

20. A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably stooped posture. How should the nurse best follow up this abnormal assessment finding? A) Facilitate a referral to the hospital's rheumatology department B) Perform a focused assessment of the client's musculoskeletal system C) Obtained a detailed family health history from the client D) Document the assessment finding and inform the anesthesiologist

B) Perform a focused assessment of the client's musculoskeletal system

3. 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. Which of the following should the nurse do next? A) Document the benign findings. B) Perform a random blood sugar test. C) Ask the client about a family history of cancer. D) Refer the client for medical follow-up.

B) Perform a random blood sugar test.

10. 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? A) Purpura B) Petechiae C) Ecchymosis D) Cherry angioma

B) Petechiae

28. A nurse is conducting a focused ear and hearing assessment of an adult client who has a history of mild hearing loss. When performing the whisper test, what instruction should the nurse begin with? A) Please close your eyes and listen carefully to what I say. B) Please cover your ear that has the weakest hearing. C) Please tell me when you can hear me talking. D) Please repeat the words that I say.

B) Please cover your ear that has the weakest hearing.

25. A nurse at an ambulatory clinic is preparing to begin the collection of objective assessment data from a female client. After meeting the client and bringing her into the examination room, what instruction should the nurse provide? A) I'll get you to lay down flat on the exam table, please. B) Please have a seat on the edge of the exam table. C) I'll start the assessment with you standing up and then help you onto the table. D) Where would you like me to conduct your health assessment?

B) Please have a seat on the edge of the exam table.

27. The nurse is using an ophthalmoscope to examine a client's inner eye structures. What action should the nurse perform in order to accurately examine the client's optic disc? A) Slowly approach the client's eye from a 90-degree angle, maintaining a focus on the pupil. B) Position the scope close to the client's eye and look through the pupil at a 15- degree angle. C) From a distance of 3 to 5 cm, examine the pupil from a 45- to 50-degree angle. D) While looking through the ophthalmoscope, approach the client's eye slowly from the side.

B) Position the scope close to the client's eye and look through the pupil at a 15- degree angle.

6. A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client's complaint? A) Ignore the complaint for now and return to it later in the assessment. B) Provide a laundry list of descriptive words. C) Restate the question using simpler terms. D) Wait in silence until the client can determine the correct words.

B) Provide a laundry list of descriptive words.

14. The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next? A) Facilitate blood testing for human immunodeficiency virus (HIV). B) Refer the client to a primary care provider for medication. C) Asses the client's laboratory values for zinc deficiency. D) Assess the client for signs of jaundice.

B) Refer the client to a primary care provider for medication.

5. When examining the mouth of an adult client with recent cognitive changes, the nurse notes a distinct bluish-black line along the client's gum line. Which action should be the nurse's priority? A) Determining whether the client is receiving phenytoin therapy B) Referring the client for further evaluation C) Encouraging the client to enroll in a smoking cessation program D) Providing the client with information on proper mouth care

B) Referring the client for further evaluation

27. The nurse is percussing the area over the client's lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following? A) Flatness B) Resonance C) Tympany D) Dullness

B) Resonance

21. The nurse is preparing to examine an older adult client. Which of the following would be most appropriate for the nurse to do during the examination? A) Complete the examination as quickly as possible. B) Speak clearly and slowly when explaining a procedure. C) Begin the examination with auscultation instead of inspection. D) Maintain the supine position for each part of the examination.

B) Speak clearly and slowly when explaining a procedure.

8. A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer? A) Stage I B) Stage II C) Stage III D) Stage IV

B) Stage II

12. A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation? A) Sternocleidomastoid muscle B) Sternal notch C) Submental space D) Supraclavicular space

B) Sternal notch

17. The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle? A) Infraspinous B) Sternomastoid C) Trapezius D) Platysma

B) Sternomastoid

13. The nurse is preparing to assess the peripheral pulses of a client. The nurse should place the client in which position? A) Sitting upright B) Supine C) Sims position D) Prone

B) Supine

4. When taking a health history for a female client, which factor should the nurse identify as placing the client at increased risk for breast cancer? A) The client smokes six to eight cigarettes per day B) The client had her first child at age 38 C) The client breast-fed her child for a full year D) The client has a low body mass index

B) The client had her first child at age 38

29. A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? A) The client has a full-time caregiver. B) The client is consistently incontinent of urine. C) The client has a surgical diagnosis. D) The client adheres to a vegetarian diet.

B) The client is consistently incontinent of urine.

24. The nurse's assessment of an 81-year-old client's hearing has corroborated her recent history of hearing loss. The nurse questions the client about her use of hearing aids, to which the client responds, I've got enough frustration in my life without having to fiddle with those. The nurse should suspect which of the following? A) The client may misunderstand the factors underlying her hearing loss. B) The client may have had a negative experience with hearing aids in the past. C) The client may be unable to afford the cost of hearing aids. D) The client may be unwilling to adhere to treatment regimens.

B) The client may have had a negative experience with hearing aids in the past.

21. A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? A) The client's current medication regimen B) The client's ability to change position C) The pigmentation of the client's skin D) The client's history of integumentary disorders

B) The client's ability to change position

29. The nurse is providing care for a client with a history of chronic heart failure. The client is in bed with the head of her bed at 45 degrees, and the nurse is assessing the client's neck veins. What assessment finding would be most consistent with a nursing diagnosis of fluid volume excess related to chronic heart failure? A) The client's carotid arteries are not palpable. B) The client's jugular veins are clearly visible and firm to palpation. C) The client's carotid pulses are asymmetrical and difficult to palpate. D) The client's carotid pulses are easier to palpate than the jugular pulses.

B) The client's jugular veins are clearly visible and firm to palpation.

30. The nurse is assessing the characteristics and positioning of the client's uvula, which deviates asymmetrically when the nurse has the client say aaah. This finding should prompt the nurse to focus on which of the following during subsequent assessment? A) The client's nutritional status B) The client's neurological status C) The client's immune function D) The client's respiratory function

B) The client's neurological status

4. A nurse is reviewing a colleague's documentation of a client assessment. The nurse reads that the client's radial pulse was 2+. How should the nurse interpret this assessment finding? A) The client's radial pulse occluded easily. B) The client's radial pulse occluded with moderate pressure. C) The client's radial pulse occluded with very firm pressure. D) The client's radial pulse could not be manually occluded.

B) The client's radial pulse occluded with moderate pressure.

8. The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate? A) The cuff is wrapped loosely around the arm. B) The cuff is placed about 1 inch above the antecubital area. C) The bladder inside the cuff encircles 50% of the arm circumference. D) The nurse can fit three to four fingers under the inflated cuff.

B) The cuff is placed about 1 inch above the antecubital area.

19. A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which of the following statements should guide the nurse's use of a stethoscope during this phase of assessment? A) Auscultation can be performed through clothing. B) The diaphragm should be held firmly against the body part. C) The bell of the stethoscope can best detect bowel sounds. D) Use of the bell is reserved for advanced practice nurses.

B) The diaphragm should be held firmly against the body part.

27. The nurse is reviewing and analyzing data from the initial assessment of a newly admitted client who is a 79-year-old man. What assessment finding most clearly indicates a need for further data? A) The man has male pattern baldness. B) The man has a diffuse rash on his torso. C) The man's heart rate is 63 beats per minute. D) The man had an inguinal hernia repair in 2008.

B) The man has a diffuse rash on his torso.

24. A hospital nurse is performing a nutritional assessment of a 39-year-old obese client who has been recently diagnosed with type 2 diabetes. The nurse has completed the collection of subjective data and is preparing to proceed with objective data collection. Which principle should guide the nurse's subsequent actions? A) There are likely to be inconsistencies between subjective data and objective data. B) The nurse should be aware that the client may find assessment embarrassing. C) The nurse should avoid performing anthropometric measurements due to the client's obesity. D) The assessment should be performed over a series of brief sessions rather than one continuous assessment.

B) The nurse should be aware that the client may find assessment embarrassing.

19. A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which of the following would the nurse describe? A) Young children have a tendency to stick objects into their ear canal. B) The size and shape of children's eustachian tubes makes them vulnerable. C) Children's immune systems lack the maturity to fight infections. D) Children generally have poorer hygiene than adults.

B) The size and shape of children's eustachian tubes makes them vulnerable.

12. The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which of the following actions would be most appropriate? A) Omit intrusive parts of the exam. B) Try to minimize position changes. C) Allow client to remain dressed. D) Dim the room light to ensure privacy.

B) Try to minimize position changes.

15. A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates correct technique for this assessment? A) Application of firm pressure on the wrist area along the side of the fifth digit B) Use of two middle fingers lightly applied to wrist area along the thumb side C) Use of the thumb and index finger applied to obliterate the wrist area along the thumb side D) Application of the bell of the stethoscope to the antecubital area of the upper extremity

B) Use of two middle fingers lightly applied to wrist area along the thumb side

4. A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? A) Standing while the client is seated B) Using a moderate amount of eye contact C) Sitting across the room from the client D) Minimizing facial expressions

B) Using a moderate amount of eye contact

1. A nurse is completing the intake assessment of an older adult who has just relocated to a long-term care facility. Which of the following nursing actions would be most important to ensure accurate data when gathering the resident's information? A) Documenting the data B) Validating the data C) Identifying client support systems D) Determining client needs

B) Validating the data

17. A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax? A) Midaxillary line B) Vertebral line C) Right midclavicular line D) Sternal line

B) Vertebral line

12. An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess? A) Papule B) Vesicle C) Bulla D) Crust

B) Vesicle

22. A client has sought care at the clinic, telling the nurse, This ringing in my ears has gone on for weeks, and it's driving me crazy. The patient denies exposure to excessive noise levels. The nurse recognizes the likely presence of tinnitus and should follow up with which of the following questions? A) Did your parents even complain of something similar? B) What medications are you currently taking? C) How would you describe your overall level of health? D) How do you usually clean your ears?

B) What medications are you currently taking?

2. A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview? A) Introductory B) Working C) Summary D) Closing

B) Working

27. A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify? Select all that apply. A) Sternocleidomastoid muscle B) Hyoid bone C) Cricoid cartilage D) Carotid artery E) Esophagus

B, C B) Hyoid bone C) Cricoid cartilage

5. A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement? A) "Tell me about your relationship with your children?" B) "Tell me what you eat in a normal day?" C) "Are you allergic to any medications?" D) "What is your typical day like?"

C) "Are you allergic to any medications?"

3. The nurse has asked a female client if she has noticed any lumps or swelling in her breasts. After the client responds "yes," which question should the nurse ask next? A) "Have any of the other women in your family had this happen?" B) "Has there been any corresponding change in your breast size?" C) "Does the lump change over the course of your menstrual cycle?" D) "What do you think is causing this change?"

C) "Does the lump change over the course of your menstrual cycle?"

16. A client's elevated body mass index (BMI) has prompted the nurse to assess the client's activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise? A) "I walk briskly on the treadmill once or twice a week." B) "I play basketball with a team every Friday night without fail." C) "I go to a step class for an hour three times a week." D) "I swim for at least half an hour each Saturday morning."

C) "I go to a step class for an hour three times a week."

23. The nurse is obtaining information about a client's past health history. Which client statement would best reflect this component of assessment? A) "My mom's still alive, but my dad died 10 years ago of heart failure." B) "I have a brother with leukemia and a sister with hypertension." C) "I had surgery 5 years ago to repair an inguinal hernia." D) "I have been having some pain when I urinate for the last several days."

C) "I had surgery 5 years ago to repair an inguinal hernia."

14. A medical nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems? A) "High school diploma plus 2 years of college" B) "Caregiver reliable source of information" C) "Menarche at age 13" D) "Lungs clear to auscultation bilaterally"

C) "Menarche at age 13"

12. A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history? A) "Do you have adequate health insurance coverage?" B) "Are you generally fairly healthy?" C) "What is your major health concern at this time?" D) "Did you bring all your medications with you?"

C) "What is your major health concern at this time?"

3. A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental? A) "How often do your adult children typically visit you?" B) "Your husband's death must have been very difficult for you." C) "You must quit smoking because it affects others, not only you." D) "How would you describe your feelings about getting older?"

C) "You must quit smoking because it affects others, not only you."

14. A woman appears restless and is wringing her hands prior to having a clinical breast examination performed. Which statement by the nurse would be most appropriate? A) "I know you are worried, but your risk for cancer is low." B) "You need to pay attention to these instructions so we can finish as quickly as possible." C) "You seem to be anxious. Can you tell me what you are thinking?" D) "You appear restless but I can assure you that your doctor is very good."

C) "You seem to be anxious. Can you tell me what you are thinking?"

8. The nurse is inspecting a client's tonsils and notes that they make contact with the client's uvula. The nurse would document this finding as which of the following? A) 1+ B) 2+ C) 3+ D) 4+

C) 3+

15. A nurse in the intensive care unit is calculating an acutely ill client's 24-hour fluid balance. The nurse should include insensible fluid losses of what volume when performing this assessment? A) 100 to 300 mL B) 450 to 650 mL C) 800 to 1000 mL D) 1200 to 1400 mL

C) 800 to 1000 mL

29. A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis? A) Audible referred breath sounds at the site of the thyroid B) An audible S3 sound at the site of the thyroid C) A sound of turbulent blood flow in the thyroid D) Irregular S1 and S2 rhythms in the thyroid

C) A sound of turbulent blood flow in the thyroid

29. While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding? A) Possible pressure ulcer observed over client's coccyx region. B) Reddened area noted on skin surface superficial to client's coccyx. C) Area of nonblanching erythema noted over client's coccyx, 2 cm x 2 cm. D) Impaired Skin Integrity related to decreased mobility.

C) Area of nonblanching erythema noted over client's coccyx, 2 cm ◊ 2 cm.

20. When assessing a client for possible oral cancer, the nurse should most closely inspect which area? A) Buccal mucosa B) Hard palate C) Area under the tongue D) Along the gum line

C) Area under the tongue

11. Which of the following would the nurse expect to assess when examining the eyes of a client who reports a history of severe allergies? A) Generalized redness B) Pinguecula C) Areas of dryness D) Nodular appearance

C) Areas of dryness

21. A client has presented for care to the clinic, stating, "I'm pretty sure that I feel a new lump in my breast." After confirming the presence of a lump, what action should the nurse take? A) Arrange for the client to be brought to the hospital emergency department immediately. B) Tell the client to monitor the lump for the next three weeks and seek care if it increases in size. C) Arrange for a prompt referral to her primary care provider. D) Facilitate a referral to an oncologist if more lumps emerge in the coming weeks.

C) Arrange for a prompt referral to her primary care provider.

23. A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next? A) Attempt to remove the splinter using sterile forceps. B) Irrigate the eye with dilute hydrogen peroxide. C) Arrange for worker to be promptly assessed by an eye specialist. D) Encourage the worker to see an optometrist as soon as possible.

C) Arrange for worker to be promptly assessed by an eye specialist.

16. The nurse is assessing the skin condition and color of an African-American client. Which of the following would the nurse document as an abnormal finding? A) Evenly distributed color B) Light to medium dark brown skin C) Ashen gray skin color D) Lack of visible pores

C) Ashen gray skin color

10. While using an otoscope to assess the ears of an 8-year-old boy, the nurse observes white spots on the boy's tympanic membrane. The nurse also observes that no redness is present. Which action would be most appropriate? A) Assess the boy for previous trauma to his skull. B) Determine whether impacted cerumen is present. C) Ask the mother whether the child has had numerous ear infections. D) Assess the child for further symptoms of acute otitis media.

C) Ask the mother whether the child has had numerous ear infections.

28. The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. How should the nurse respond to this assessment finding? A) Call a code blue from the bedside and prepare for resuscitation. B) Assess the client's jugular venous pressure. C) Assess the client's pulse at the carotid site. D) Palpate the client's femoral pulse.

C) Assess the client's pulse at the carotid site.

28. The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform? A) Obtain a full set of vital signs. B) Percuss the client's thyroid. C) Auscultate the client's thyroid. D) Perform a swallowing assessment.

C) Auscultate the client's thyroid.

21. A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae? A) C3 B) C5 C) C7 D) T2

C) C7

9. The nurse is preparing to perform a nutritional assessment of a newly admitted client. Which of the following questions would be most appropriate to use when initiating the assessment? A) Did you eat breakfast today? B) How many meals do you eat each day? C) Can you tell me what you've eaten in the last 24 hours? D) How often do you eat out?

C) Can you tell me what you've eaten in the last 24 hours?

12. During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. Which of the following would be most important for the nurse to assess? A) Asking if the client experiences dry mouth often B) Inspecting for inflammation of the tonsils C) Checking for a deviated nasal septum D) Performing a focused respiratory assessment

C) Checking for a deviated nasal septum

7. Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would recognize this as a tripod position and suspect the presence of which of the following medical problems? A) Pleural effusion B) Heart failure C) Chronic obstructive pulmonary disease D) Pneumonia

C) Chronic obstructive pulmonary disease

8. A 54-year-old client is receiving a follow-up assessment in a clinic, following abnormal findings on her recent mammogram. Which of the following statements best reflects appropriate documentation by the nurse? A) Client depressed because of fear of breast biopsy B) Client with lower back pain C) Client has unkempt appearance and avoids eye contact D) Client has good lung sounds in right and left lungs

C) Client has unkempt appearance and avoids eye contact

11. After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative? A) Client moves the feet apart during the test B) Client sways slightly during the test C) Client maintains the position during the test D) Client keeps his or her eyes close during the test

C) Client maintains the position during the test

3. A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following? A) Direct reflex B) Optic chiasm C) Consensual response D) Accommodation

C) Consensual response

10. A task force has been established at a hospital with the aim of overhauling the assessment forms that are used throughout the facility. Which of the following options is most likely to help standardize the process of data collection? A) Open-ended form B) Integrated cued checklist form C) Cued or checklist form D) Nursing minimum data set

C) Cued or checklist form

30. A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which of the following findings should the nurse attribute to age-related physiological changes? A) Increased size of a single thyroid nodule B) A nonpalpable carotid pulse C) Decreased strength of temporal artery pulsations D) Tenderness of lymph nodes on palpation

C) Decreased strength of temporal artery pulsations

30. A young man has presented to the clinic with a 2-week history of head congestion, fever, and malaise. What assessment technique should the nurse utilize to assess for sinus tenderness? A) Light palpation B) Deep palpation C) Direct percussion D) Blunt percussion

C) Direct percussion

21. A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer? A) Would you say that you're prone to getting mouth ulcers? B) Do you brush and floss daily? C) Do you use tobacco, whether smoking or chewing? D) How often do you usually go to the dentist in a year?

C) Do you use tobacco, whether smoking or chewing?

14. When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate assessment data? A) Finger pad surface B) Palmar hand surface C) Dorsal hand surface D) Ulnar hand surface

C) Dorsal hand surface

22. An older adult client has a body mass index of 15.5 and is consequently considered to be underweight. The client lives alone and states that she has never been a heavy eater. How can the nurse most accurately assess the client's nutritional habits? A) Assess the client's waist circumference and waist-to-hip ratio. B) Measure the client's mid-arm circumference. C) Elicit the client's 24-hour food recall. D) Have the client describe an ideal meal.

C) Elicit the client's 24-hour food recall.

17. The nurse is preparing to examine a client's skin. Which of the following actions would be most important for the nurse to do? A) Ensure that the room is hot to prevent chilling. B) Wear gloves when preparing to inspect the skin and nails. C) Expose only the body part that is being examined. D) Have the client remove clothing from the upper body.

C) Expose only the body part that is being examined.

8. The nurse is assessing a client whose electronic health record notes a diagnosis of esotropia. When examining this client, the nurse should expect what finding? A) Eye turning outward B) Eye malalignment C) Eye turning inward D) Eye oscillating

C) Eye turning inward

7. A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause? A) Safe use of firearms B) Safe use of machinery C) Falls prevention D) Domestic violence prevention

C) Falls prevention

16. When percussing the scapula of a client, which of the following would the nurse expect to hear? A) Resonance B) Dullness C) Flatness D) Hyperresonance

C) Flatness

12. A client has large, pendulous breasts. Which of the following would be most appropriate to ensure better access while examining the client's breasts for retraction and dimpling? A) Have the client stand and lean forward B) Have the client lie on her side C) Have the client sit and then lean forward D) Have the client lie flat on her back

C) Have the client sit and then lean forward

18. An instructor is describing various ways that a nurse can validate data to a group of nursing students. The instructor determines that additional teaching is necessary when the students identify which of the following as a reliable method? A) Repeating the assessment B) Asking additional questions C) Having the client repeat what was said D) Checking findings with another health care professional

C) Having the client repeat what was said

17. When palpating a female client's axillae, which of the following actions is most appropriate? A) Have the client hold the arm of the side being examined slightly away from the body. B) Tell the client to raise her arm on the side being examined up over her head. C) Hold the client's elbow of the side being examined with one hand. D) Have the client lean forward from the waist with arms outstretched.

C) Hold the client's elbow of the side being examined with one hand.

22. The nurse is conducting the health interview of an adult client who has sought care because of a wicked cough leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask? A) Does your cough often cause you to be short of breath? B) Do you experience chest pain when you cough? C) How long have you been experiencing your cough? D) Are you now or have you ever been a smoker?

C) How long have you been experiencing your cough?

2. In the course of the nurse's health interview, a client reports an occasional blockage in the upper portion of his nasal passage. What is the most pronounced effect that this will have on the client? A) Decreased sense of taste B) Difficulty hearing C) Impaired sense of smell D) Occasional dizziness

C) Impaired sense of smell

28. There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many caregivers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite? A) Increased influence for the nursing profession B) Elimination of documentation C) Improved continuity of care D) Reduced nursing workload

C) Improved continuity of care

28. A nurse is caring for a patient whose diagnosis of cystic fibrosis results in the production of large amounts of sticky mucus. The client has a history of repeated hospital admissions for complications of his disease and receives daily treatments to mobilize the secretions. When planning the care of this client, what nursing diagnosis is most plausible? A) Readiness for Enhanced Breathing Patterns B) Risk for Impaired Oral Mucous Membranes related to mouth breathing C) Ineffective Airway Clearance related to respiratory secretions D) Ineffective Breathing Pattern: Hyperventilation related to cystic fibrosis

C) Ineffective Airway Clearance related to respiratory secretions

9. Which of the following would be most important for the nurse to do when assessing a client's blood pressure? A) Palpate the pulsations of the ulnar artery. B) Hold the client's arm slightly flexed with palm down. C) Inflate the cuff 30 mm Hg above where the radial pulse disappears. D) Deflate the cuff about 5 mm Hg per second.

C) Inflate the cuff 30 mm Hg above where the radial pulse disappears.

3. A client's electronic health record states that he has been diagnosed with sensorineural hearing loss. Which condition should the nurse most likely identify as a cause? A) Perforated eardrum B) Otosclerosis C) Inner ear problem D) Otitis media

C) Inner ear problem

5. A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first? A) Assess the client's tympanic membrane. B) Palpate the client's tragus. C) Inspect the client's external ear canal. D) Perform hearing assessments.

C) Inspect the client's external ear canal.

23. An audit of a hospital unit's incident reports reveals that several errors have resulted from incomplete or inaccurate information during change-of-shift handoff. In order to prevent such errors, what practice should be encouraged on the unit? A) Delegate handoff reports to unlicensed care providers who have fewer demands on their time. B) Use an intermediary to receive report from the first nurse and then provide the handoff report to the second nurse. C) Involve as few people as possible in the verbal report. D) Encourage nurses to perform handoff as quickly as possible.

C) Involve as few people as possible in the verbal report.

6. While assessing a woman's breasts, the nurse notes a pronounced and asymmetric pattern of veins on the client's breasts. Follow-up care is ordered because the nurse should suspect which of the following? A) Pregnancy B) Fibrocystic changes C) Malignancy D) A low platelet count

C) Malignancy

19. The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. Which of the following would the nurse most likely assess? A) Sunken face B) Drooping of one side C) Masklike expression D) Asymmetry of earlobes

C) Masklike expression

20. The nurse needs to obtain the height of a client who is unable to stand. Which of the following would the nurse do? A) Estimate the height while the client is lying in bed. B) Measure the distance from the top of the client's head to his ankles. C) Measure from client's arm span using one of his arms outstretched. D) Extend a ruler from the forehead to the tip of the client's toes.

C) Measure from client's arm span using one of his arms outstretched.

10. A nurse is assessing a client's skeletal muscle mass in the context of a comprehensive nutritional assessment. Which measurement would yield the most valid and reliable data? A) Body mass index B) Triceps skin fold measurement C) Mid-arm circumference D) Waist circumference

C) Mid-arm circumference

5. During a health history, a 62-year-old male client reveals that he occasionally sees spots before his eyes. The nurse interprets this finding as the result of which of the following? A) Increased ocular pressure B) Vitamin A deficiency C) Normal findings for client's age D) Vascular spasm

C) Normal findings for client's age

17. While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following? A) Scarring from previous infections B) Otitis media C) Normal tympanic membrane D) Otitis externa

C) Normal tympanic membrane

18. An older adult client has been admitted to the medical unit after suffering an exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following should the nurse do to assess the depth of the client's respirations? A) Count the respirations for 30 seconds and multiply by 2. B) Place the client's arm across the chest while palpating the pulse. C) Observe the client's chest expansion bilaterally. D) Percuss the client's posterior thorax

C) Observe the client's chest expansion bilaterally.

6. A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about which of the following assessment findings related to the client's sputum? A) White or cream-colored B) Yellowish and foul-smelling C) Pink and frothy D) Rust-tinged

C) Pink and frothy

6. The nurse is caring for a client with influenza symptoms and is documenting the initial and ongoing assessment database. Which of the following would the nurse emphasize as the major rationale for this action? A) Reducing the fragmentation of care B) Maximizing the efficiency of care C) Promoting communication between disciplines D) Facilitating achievement of professional standards

C) Promoting communication between disciplines

24. A nurse is teaching a recent nursing graduate about the significance of verbal and nonverbal communication during client care. The new graduate demonstrates an understanding of these techniques by citing what example of verbal communication? A) Maintaining an open attitude B) Using silence appropriately C) Providing a laundry list of descriptors when needed D) Maintaining an open and encouraging facial expression

C) Providing a laundry list of descriptors when needed

25. The nurse is using her fingerpads to palpate a client's body part during the physical examination. Which of the following would the nurse best be able to detect? A) Temperature B) Vibrations C) Pulses D) Fremitus

C) Pulses

25. Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data? A) RC: Thyroid crisis B) RC: Cerebrovascular accident C) RC: Cushing's syndrome D) RC: Acromegaly

C) RC: Cushing's syndrome

25. Assessment of a client's mouth reveals a lesion on the client's buccal membrane that is approximately 0.5 cm in diameter. On further questioning, the client states that the lesion has been present for 3 months and that it bleeds intermittently. How should the nurse follow up this assessment finding? A) Swab the lesion to obtain a sample for culture and sensitivity testing. B) Recommend that the client gargle with saltwater twice daily for several days. C) Refer the client to her primary care provider promptly. D) Determine whether the lesion can be removed with a sterile cotton-tipped applicator.

C) Refer the client to her primary care provider promptly.

28. The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem? A) Risk for injury related to potential esophageal trauma B) Risk for oral infection related to dysphagia C) Risk for aspiration related to decreased swallowing ability D) Risk for excess fluid volume related to decreased peristalsis

C) Risk for aspiration related to decreased swallowing ability

5. A nurse is reviewing the laboratory test results of an adult client who has numerous chronic health challenges. Which assessment result would alert the nurse to potential malnutrition? A) Hemoglobin of 13.1 g/dL B) Hematocrit of 40% C) Serum albumin of 2.6 g/dL D) Total protein of 7 g/dL

C) Serum albumin of 2.6 g/dL

22. The nurse is using the mnemonic "COLDSPA" to assess a client's complaint of lower abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint? A) Character B) Onset C) Severity D) Pattern

C) Severity

5. A nurse has gathered the necessary equipment for the physical assessment of an adult client. For which of the following assessments would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement? A) Mid-arm circumference B) Client's height C) Skin lesion size D) Pupillary size

C) Skin lesion size

18. The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position? A) At the level of the diaphragm B) Near the level of the eighth rib C) Slightly above the clavicle D) At about the tenth rib

C) Slightly above the clavicle

6. Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? A) Alcohol abuse B) Recreational drug use C) Smokeless tobacco use D) Multiple sex partners

C) Smokeless tobacco use

12. An adult client has been diagnosed with bronchitis. Which of the following would the nurse most likely hear on auscultation? A) Sibilant wheezes B) Fine crackles C) Sonorous wheezes D) Coarse crackles

C) Sonorous wheezes

2. When preparing to assess a client's thoracic cage, the nurse should locate which landmark when determining where to begin the assessment of the ribs and intercostal spaces? A) Scapula B) Suprasternal notch C) Sternal angle D) Sternal border

C) Sternal angle

18. A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding? A) Diameter: 0.75 cm B) Mobile C) Tender D) Discrete

C) Tender

1. When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment? A) Darwin tubercle B) Red, flaky cerumen C) Tender tragus D) Pearly gray tympanic membrane

C) Tender tragus

25. A hospital nurse is admitting a client with a documented history of acute pancreatitis, liver cirrhosis, malnutrition, and frequent traumatic injuries. What assessment finding would most clearly warrant validation? A) The client's blood pressure is 148/88 mm Hg. B) The client is oriented to person and place but not to time. C) The client states that she only drinks alcohol on a social basis. D) The client states, My skin's kind of yellow because of my liver.

C) The client states that she only drinks alcohol on a social basis.

6. A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the client's blood pressure reading in light of what principle? A) The client's blood pressure will be slightly highly than the client's norm. B) Position rarely affects the client's blood pressure. C) The client's blood pressure will be slightly lower than standing readings. D) There will be questionable accuracy of the blood pressure reading.

C) The client's blood pressure will be slightly lower than standing readings.

22. An 84-year-old man has been admitted to the emergency department from an extended care facility. Facility staff suspect that the client has pneumonia, and his malaise, productive cough, shortness of breath, and adventitious breath sounds are consistent with this diagnosis. However, the nurse's assessment of the client's vital signs yields an oral temperature of 97.5∞F. How should the nurse best interpret this assessment finding? A) The client likely has a cardiac health problem, not a respiratory health problem. B) The client's signs and symptoms are related to hypothermia rather than infection. C) The client's normothermic temperature does not rule out the presence of an infection. D) The client's infection is no longer localized and has become systemic.

C) The client's normothermic temperature does not rule out the presence of an infection.

14. A review of a client's history reveals cranial nerve IV paralysis. Which of the following findings would the nurse expect to assess? A) The eye cannot look to the outside side. B) Ptosis will be evident. C) The eye cannot look down when turned inward. D) The eye will look straight ahead.

C) The eye cannot look down when turned inward.

27. The nurse is assessing an adult client's areolas and nipples. What assessment finding would most clearly warrant referral? A) Small Montgomery tubercles are present on the areolas. B) Supernumerary nipples are present. C) The patient's nipple has recently become inverted. D) The patient's areola puckers upon palpation.

C) The patient's nipple has recently become inverted.

4. The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. Which of the following would be most appropriate for the nurse to include? A) Sit with the head of the bed at 45 degrees during meals. B) Be aware of the possibility of temporomandibular joint pain. C) Thoroughly chew small amounts of food with each mouthful. D) Drink fluids before and after, but not during, meals.

C) Thoroughly chew small amounts of food with each mouthful.

23. The nurse is gathering the necessary equipment preparatory to examining a client's ears. The nurse will be checking bone and air conduction of sound. Which of the following should the nurse obtain? A) Penlight B) Tongue depressor C) Tuning fork D) Otoscope

C) Tuning fork

1. The nurse is assessing a client's breasts. When assessing the area of the breast most vulnerable to breast cancer, where should the nurse to assess? A) Upper inner quadrant B) Lower inner quadrant C) Upper outer quadrant D) Lower outer quadrant

C) Upper outer quadrant

7. A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing? A) Limiting loud noise exposure to 1 hour per day B) Taking a 10-minute break every 2 hours C) Wearing ear protection when in the work environment D) Cleaning ears regularly to prevent ear infections

C) Wearing ear protection when in the work environment

3. A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which of the following actions? A) Performing hand hygiene between examinations of each body part B) Discarding in the trash can the safety pin that was used to assess sensory perception C) Wearing gloves to palpate the tongue and buccal membranes D) Wearing a gown, gloves, and mask during the physical exam

C) Wearing gloves to palpate the tongue and buccal membranes

19. When obtaining the nutritional health history from a female client, which of the nurse's questions would best elicit information about the client's knowledge of her own health status? A) Are you now or have you been on a diet recently? B) How much fluid do you drink in a day? C) What are your height and usual weight? D) Can you tell me what you consider to be a healthy meal?

C) What are your height and usual weight?

3. A client who had a mastectomy is being discharged home on postoperative day 1. Knowing that the client lives alone, which data would be most important for the nurse to validate for this client? A) If the client has transportation for follow-up appointments B) If the client usually functions independently C) What support systems are in place to assist the client D) If the client has a religious belief regarding illness

C) What support systems are in place to assist the client

23. A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. During which of the following components of the assessment should the nurse wear gloves? A) When palpating the texture of the client's skin B) When palpating the client's hair C) When palpating lesions on the client's skin D) When palpating the client's nail beds for texture and capillary refill

C) When palpating lesions on the client's skin

18. An instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following? A) Plastic tubing should be longer than 3 feet. B) The bell is used after using the diaphragm. C) When using the bell, push on it lightly. D) A diaphragm picks up low-pitched sounds.

C) When using the bell, push on it lightly.

25. The admission of a new resident to a long-term care facility has necessitated a thorough health history. Place the following focuses in the correct sequence in which the nurse should perform them, beginning with the section obtained first. A) Family health history B) Reason for seeking care C) Biographic data D) Review of body systems E) History of present concern F) Past health history

C, B, E, F, A, D C) Biographic data B) Reason for seeking care E) History of present concern F) Past health history A) Family health history D) Review of body systems

26. A client's recent complaints of polyuria have prompted a full diagnostic work-up for diabetes mellitus, including a nutritional assessment. To determine the client's body mass index (BMI), the nurse must know which of the following assessment parameters? Select all that apply. A) Gender B) Age C) Weight D) Waist circumference E) Height

C, E C) Weight E) Height

27. The nurse is completing an assessment of a 50-year-old female client who has sought care for recurrent migraines that have not responded to treatment. Following the review of systems, how should the nurse best document unremarkable results of the subjective portion of the gastrointestinal assessment? A) "Client's gastrointestinal health is within reference ranges for age." B) "Client denies GI signs and symptoms." C) "Gastrointestinal problems are absent." D) "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain."

D) "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain."

18. The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data? A) "Do you always wear your seatbelt when driving?" B) "How much beer, wine, or alcohol do you drink?" C) "Do you use condoms with each sexual encounter?" D) "Could you describe how you perform self-breast exams?"

D) "Could you describe how you perform self-breast exams?"

11. A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe? A) "This helps us to complete your health record accurately." B) "This helps us to establish a trusting interpersonal relationship." C) "This helps us to evaluate the seriousness of your risk factors for disease." D) "This helps us have an appropriate focus for the physical examination."

D) "This helps us have an appropriate focus for the physical examination."

10. Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate? A) "Our schedule is very busy also. We got to you as soon as we could." B) "No one is forcing you to be here, and you are free to leave at any time." C) "Would you like to report your complaints to someone with power?" D) "You're certainly justified in being upset, but I am ready to begin your exam now."

D) "You're certainly justified in being upset, but I am ready to begin your exam now."

3. An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following? A) 12 B) 18 C) 25 D) 28

D) 28

24. An experienced nurse is aware that receding gums are an expected finding in some clients whereas in other clients this finding is abnormal. In which of the following clients would the nurse identify receding gums as an expected assessment finding? A) A 4-year-old girl who has all of her primary teeth B) A 20-year-old man who has type 1 diabetes mellitus C) A 39-year-old woman who has just finished a course of oral antibiotics D) A 77-year-old man who describes himself as being healthy

D) A 77-year-old man who describes himself as being healthy

24. A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers? A) Teaching about genetic screening B) A nutritional health program C) Teaching about monthly self-examination D) A smoking cessation program

D) A smoking cessation program

17. A nurse is assessing a client who is suspected to have optic atrophy. Which of the following assessment findings is most consistent with this diagnosis? A) Obscured retinal vessels B) No visible physiologic cup C) Increased appearance of the disc vessels D) A white appearance of the optic disc

D) A white appearance of the optic disc

22. The nurse assists a client into the dorsal recumbent position. Assessment of which area is contraindicated when the client is in this position? A) Chest B) Head C) Peripheral pulses D) Abdomen

D) Abdomen

27. Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding? A) Repeated ear infections B) Trauma C) Age-related changes D) Acute otitis media

D) Acute otitis media

29. The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process? A) Air leaking from the alveoli into the pleural space B) Air being diverted from the trachea to the bronchi C) Air increasing in turbulence in a wide passage D) Air passing through constricted passageways

D) Air passing through constricted passageways

16. After teaching a group of young women about breast self-examination, the nurse determines that the teaching was successful when the women state that they will palpate their breasts using which pattern? A) A circular pattern B) A clockwise pattern C) A random pattern D) An up-and-down pattern

D) An up-and-down pattern

21. An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize? A) Do you use any over-the-counter dietary supplements? B) Are you familiar with the USDA's MyPlate recommendations? C) Have you ever been diagnosed with heart disease? D) Are you currently taking any diuretic medications?

D) Are you currently taking any diuretic medications?

21. A nurse is completing a general survey of a client's health and is beginning by measuring the client's vital signs. What assessment question constitutes the fifth vital sign? A) Can you tell me the date and month? B) Can I check your oxygen saturation level? C) Are you experiencing any shortness of breath? D) Are you having any pain right now?

D) Are you having any pain right now?

26. The nurse has assisted a 74-year-old woman from a chair to the examination table during an assessment, and the nurse observes that the client moves particularly slowly and stiffly. The nurse should question the client regarding a possible history of what health problem? A) Rhabdomyolysis B) Diabetes C) Kyphosis D) Arthritis

D) Arthritis

6. While examining a client's mouth, the nurse notes the presence of fasciculations (fine tremors) of the client's tongue. How should the nurse best respond to this assessment finding? A) Have the client provide a 24-hour diet recall. B) Review the client's medication regimen. C) Prepare the client for a thyroid screening. D) Assess the client's cranial nerve function.

D) Assess the client's cranial nerve function.

16. A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands? A) At the angle of the client's mandible B) At the base of the client's skull C) On the area behind the client's ears D) Behind the tip of the client's mandible

D) Behind the tip of the client's mandible

16. The emergency department (ED) nurse is assessing for kidney tenderness in a client who has presented with complaints of dysuria and back pain. What assessment technique should the nurse utilize? A) Deep palpation B) Indirect percussion C) Moderate palpation D) Blunt percussion

D) Blunt percussion

15. While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document which of the following? A) Vesicular breath sounds B) Bronchovesicular breath sounds C) Adventitious breath sounds D) Bronchial breath sounds

D) Bronchial breath sounds

5. The nurse is conducting an assessment of an older adult client who has a diagnosis of chronic heart failure. How can the nurse best assess the effects of the client's stroke volume? A) Take the blood pressure while the client is standing. B) Measure the strength of the radial pulse. C) Add the radial pulse and the systolic blood pressure. D) Calculate the difference between the diastolic and systolic pressures.

D) Calculate the difference between the diastolic and systolic pressures.

20. A nursing instructor is discussing cultural variations in the size of the thorax and impact on lung capacity. Which group would the instructor identify as typically having a larger thorax? A) African Americans B) Asian Americans C) Native Americans D) Caucasians

D) Caucasians

13. The nurse is performing a respiratory assessment of a client who is palliative due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate? A) Biot's B) Bradypnea C) Kussmaul's D) Cheyne-Stokes

D) Cheyne-Stokes

16. On inspection, the nurse observes a line across the tip of an 8-year-old client's nose. The nurse should consequently focus on which area of assessment? A) History of abuse B) Chronic nose picking C) Mucosal polyps D) Chronic allergies

D) Chronic allergies

15. An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess? A) Integumentary B) Digestive C) Neurologic D) Circulatory

D) Circulatory

1. A client has presented to the clinic for the treatment of an ovarian cyst. Which of the following would be most important for the nurse to do immediately before performing this woman's physical exam? A) Explain the purpose of the interview to the client. B) Construct the client's family genogram. C) Establish the client's reliability as historian. D) Collect necessary equipment essential to the exam.

D) Collect necessary equipment essential to the exam.

24. During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide? A) I'm going to ask you to slowly walk forward until the last line of the chart become clear. B) Please stand at a comfortable distance from the chart and I'll get you to read each of the letters. C) Hold this chart and start to read out the letters after covering one of your eyes. D) Cover one of your eyes and then read out the letters on the chart, starting from the top.

D) Cover one of your eyes and then read out the letters on the chart, starting from the top.

13. When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? A) Penlight B) Tongue depressor C) Centimeter-scale ruler D) Cup of water

D) Cup of water

9. A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document? A) Liver palpation normal B) No tenderness on palpation C) Bowel sounds normoactive D) Decreased range of motion in right shoulder

D) Decreased range of motion in right shoulder

5. A client describes her frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines? A) Do they occur after you have been tense or anxious? B) When you consume alcohol, do you get a headache? C) Do you have any eye symptoms, such as tearing? D) Do you have any visual changes before the headache?

D) Do you have any visual changes before the headache?

27. The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse consequently ask? A) Has anyone in your family ever been diagnosed with skin cancer? B) Have you ever been assessed for diabetes? C) What dietary supplements do you usually take? D) Do you take steroid medications on a regular basis?

D) Do you take steroid medications on a regular basis?

14. The nurse is completing the assessment of a client who takes a beta-adrenergic blocker and a diuretic. Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents? A) Noting a widened pulse pressure B) Asking whether the client is experiencing headaches C) Assessing for a rise in blood pressure when standing D) Evaluating for orthostatic hypotension

D) Evaluating for orthostatic hypotension

25. A nurse is conducting an assessment of a client's eyes and vision and has completed the positions test. Following this test, the nurse will be able to document data that address what aspects of eye health? Select all that apply. A) Distant visual acuity B) Near visual acuity C) Accommodation D) Eye muscle strength E) Cranial nerve function

D) Eye muscle strength E) Cranial nerve function

11. The nurse is to collect a throat culture from a client who has signs and symptoms of a respiratory infection, including frequent, productive coughing. The nurse demonstrates the best adherence to standard precautions by using which of the following pieces of equipment? A) Eye goggles B) Face mask C) Cover gown D) Face shield

D) Face shield

22. A client has sought care because she states that she has begun to see halos around headlights and streetlights when she is out at night. The nurse should recognize the need to refer the client for further assessment related to what health problem? A) Episcleritis B) Strabismus C) Macular degeneration D) Glaucoma

D) Glaucoma

10. While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. Which of the following actions should the nurse do first? A) Refer the client for further medical evaluation. B) Auscultate for egophony. C) Perform bronchophony. D) Have the client cough, then listen again.

D) Have the client cough, then listen again.

15. A nurse is assessing an adult client's neck. Which of the following would be most appropriate when auscultating the client's thyroid gland for bruits? A) Hyperextend the client's neck. B) Turn the client's head to the right. C) Have the client swallow water. D) Have the client hold his or her breath.

D) Have the client hold his or her breath.

23. A clinic client's primary complaint is earache (otalgia). Consequently, the nurse's assessment is focusing on potential causes of the client's pain. What question should the nurse include in the health interview? A) What do you do for a living? B) Do you know if your vaccinations are up to date? C) Do you take over-the-counter medications or supplements? D) Have you been swimming lately?

D) Have you been swimming lately?

22. A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? A) Repeated sunburns in childhood may explain the presence of some of your moles. B) This is one of the assessments we use to determine whether your parents took good care of your skin when you were young. C) When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older. D) Having bad sunburns when you're a child puts you at risk for skin cancer later in life.

D) Having bad sunburns when you're a child puts you at risk for skin cancer later in life.

24. The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states, It shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker. The nurse should recognize the need to teach the client about what topic? A) Strategies for making her husband quit smoking B) Genetic causes of lung cancer C) Age-related changes to respiratory function D) Health risks of secondhand smoke

D) Health risks of secondhand smoke

5. During the health interview, a client tells the nurse that he can't breathe all that well at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for which of the following health problems? A) Pneumonia B) Tuberculosis C) Bronchitis D) Heart failure

D) Heart failure

26. A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion? A) Test whether gentle abrasion with an emery board is painful. B) Apply hydrogen peroxide to see whether the client's pruritus is relieved. C) Perform a trial with a topical antibiotic. D) Illuminate the area using a Wood's light.

D) Illuminate the area using a Wood's light.

13. While performing an elderly client's admission assessment, the nurse notes the presence of deep tongue fissures. Which of the following responses should take priority? A) Anterior-posterior and lateral chest x-ray B) Complete blood count with differential C) Dietitian referral D) Intravenous fluid replacement

D) Intravenous fluid replacement

4. When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason? A) Health care institutions have established policies regarding documentation. B) Incorrect conclusions may be made without documentation of the nurse's opinions. C) It satisfies legal standards established by health care organizations and institutions. D) It becomes the foundation for the entire nursing process.

D) It becomes the foundation for the entire nursing process.

7. The nurse is completing an initial assessment of a client who is new to the ambulatory clinic. Before assessing the client's blood pressure, a nurse asks him what his usual blood pressure is. The nurse bases this action primarily on what rationale? A) It provides identifiable data about the client. B) It verifies the client's cardiac function. C) It assesses the client's distant memory recall. D) It indicates the client's involvement in his health care.

D) It indicates the client's involvement in his health care.

8. A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. Which of the following conclusions is suggested if the client has no reaction? A) It indicates high cholesterol and triglyceride levels. B) It shows a sacrifice of skeletal muscle proteins and blood proteins. C) It is indicative of unhealthy dietary habits. D) It may be immunosuppression resulting from undernourishment.

D) It may be immunosuppression resulting from undernourishment.

11. When assessing an older adult client with osteoporotic thinning and vertebral collapse, which of the following findings would the nurse expect to identify? A) Lordosis B) Increased arm swing C) Narrowed gait D) Kyphosis

D) Kyphosis

18. When palpating a female client's axillae, which finding would the nurse document as normal? A) Node size is 1.2 cm. B) Nodes are fixed. C) Nodes are hard. D) Nodes are discrete.

D) Nodes are discrete.

18. A nurse is performing an eye and vision assessment on a client who has an inner ear disorder. This disorder may contribute to what finding during the client's eye positions test? A) Strabismus B) Phoria C) Tropia D) Nystagmus

D) Nystagmus

2. The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis? A) Nail beds B) Sclerae C) Palms D) Oral mucosa

D) Oral mucosa

27. The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis? A) Resonance on percussion B) Dull sounds C) Tympanic sounds D) Pain on percussion

D) Pain on percussion

11. A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique? A) Inspection B) Auscultation C) Palpation D) Percussion

D) Percussion

24. A client has illuminated his call light and tells the nurse that he is having ten out of ten pain. The nurse's initial inspection reveals that the client is watching videos on his tablet computer and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain? A) Ask the client to repeat his rating of his pain. B) Observe the client for several seconds to see if his demeanor or his behavior changes. C) Consult the client's medication administration record (MAR) to check for recent analgesic use. D) Perform further assessments addressing various aspects of the client's pain.

D) Perform further assessments addressing various aspects of the client's pain.

7. In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds? A) Psoriasis B) Multiple sclerosis C) Malignant melanoma D) Peripheral vascular disease

D) Peripheral vascular disease

19. The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which of the following findings would a nurse interpret as being normal? A) Absence of red glow on transillumination of sinuses B) Nasal mucosa pale pink and swollen C) Tonsils 2+ D) Pinkish, spongy soft palate

D) Pinkish, spongy soft palate

12. During a client's eye assessment, the nurse is testing for consensual pupillary constriction. Which technique should the nurse implement? A) Hold a pencil about 12 inches from the tip of the nose. B) Use an ophthalmoscope to inspect the inner eye. C) Shine a light directly into one eye of the client. D) Place a barrier between the client's eyes.

D) Place a barrier between the client's eyes.

30. The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique? A) Keep the client's shirt or gown in place to maintain privacy. B) Begin with the bell of the stethoscope on the client's anterior chest. C) Tell the client that you will be asking him or her to breathe as quickly and deeply as possible. D) Place the diaphragm on the client's posterior chest wall.

D) Place the diaphragm on the client's posterior chest wall.

26. While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment? A) When I say so, please exhale forcefully and hold the breath. B) Say the letter 'e' and keep saying it until I tell you to stop. C) Breathe in as deeply as you can and hold your breath until I say. D) Please say the number 'ninety-nine' for me.

D) Please say the number 'ninety-nine' for me.

29. A nurse has taught a group of older adults about the high incidence and prevalence of macular degeneration. What health promotion and prevention activity should the nurse encourage these clients to perform? A) Obtain a home version of the Snellen chart and test their vision weekly B) Rinse their eyes with a warmed, normal saline solution three to four times per week C) Maintain a low-sodium diet D) Post an Amsler grid in their home and perform the test on a regular basis

D) Post an Amsler grid in their home and perform the test on a regular basis

6. A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis? A) Vertigo B) Otalgia C) Tinnitus D) Presbycusis

D) Presbycusis

26. The nurse is examining a client's breasts and notes the presence of pronounced dimpling. How should the nurse best respond to this assessment finding? A) Confirm whether the client has breast implants in place. B) Ask the client about any history of mastitis (breast infection). C) Explain to the client that this is a normal, age-related change. D) Promptly refer the client for further medical assessment.

D) Promptly refer the client for further medical assessment.

30. Assessment of a client's breasts reveals tenderness on palpation and diffuse redness. What collaborative problem is most clearly suggested by these data? A) RC: Breast cancer B) RC: Benign breast disease C) RC: Hematoma D) RC: Infection

D) RC: Infection

23. The nurse is performing an assessment of a hospital client at the beginning of a shift. When assessing the client's heart rate, the nurse will most likely palpate what artery? A) Femoral artery B) Aorta C) Ulnar artery D) Radial artery

D) Radial artery

9. The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. Which of the following would the nurse expect to find? A) Orange-peel skin B) Nipple retraction C) Dark pink areola D) Red and scaling on the areola

D) Red and scaling on the areola

12. The results of a client's Rinne test suggest that bone conduction and air conduction are both reduced. Which of the following would be most appropriate? A) Perform a Romberg test. B) Take a swab of the client's tympanic member. C) Repeat the test in 5 to 10 minutes. D) Refer the client for further evaluation.

D) Refer the client for further evaluation.

26. A 2-year-old girl has been brought to the ambulatory clinic by her mother who states, She's put a pea in her ear, and I think she did it 2 days ago because that was the last time we ate them. The nurse's otoscopic examination confirms the presence of this foreign body in the girl's middle ear. How should the nurse best respond to this assessment finding? A) Attempt to remove the pea using sterile forceps. B) Irrigate the ear canal with warm tap water to remove the pea. C) Instruct the mother to watch the girl's ear closely and return for care if it does not fall out in the next few days. D) Refer the girl to her primary care provider for prompt removal of the pea.

D) Refer the girl to her primary care provider for prompt removal of the pea.

19. The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse must assess which lobe anteriorly? A) Left upper lobe B) Left lower lobe C) Right upper lobe D) Right middle lobe

D) Right middle lobe

1. The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. During health promotion, the nurse should focus education on which of the following topics? A) Management of dry skin B) Susceptibility to bruising C) Risks of fungal infections D) Risks of sun exposure

D) Risks of sun exposure

4. An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? A) Squamous cells B) Sweat glands C) Subcutaneous tissue D) Sebum production

D) Sebum production

11. The nurse is preparing to inspect a woman's breasts for retraction and dimpling. Which position would be most appropriate? A) Standing B) Supine C) Semi-Fowlers D) Sitting

D) Sitting

14. The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following should the nurse assess next? A) Lateral aspect of the thorax B) Lung volume C) Hip levels D) Spinal column

D) Spinal column

14. The nurse is collecting data from a client about his nutrition. Which of the following would the nurse document as objective data? A) Client states he is not eating well. B) Client complains of nausea and vomiting. C) Clients experiences urinary frequency. D) Tenting of client's skin observed upon skin pinch.

D) Tenting of client's skin observed upon skin pinch.

27. The nurse is completing a comprehensive nutritional assessment and has assessed and documented the client's triceps skin fold thickness (TSF) using calipers. This assessment finding allows the nurse to determine which of the following? A) The client's ratio of muscle to adipose tissue B) The client's body mass index C) The client's proportion of muscle mass D) The amount of the client's subcutaneous fat stores

D) The amount of the client's subcutaneous fat stores

8. An 18-year-old woman complains because one breast is larger than the other. What additional interview data would suggest a need for referral? A) The client states that she is sexually active. B) The client states that she does not perform breast self-examination. C) The client states that her problem affects her body image. D) The client states that this represents a sudden change in her breast size.

D) The client states that this represents a sudden change in her breast size.

30. A nurse is obtaining subjective data from an adult client who is new to the clinic. The nurse has asked the client, "Where do you usually turn for help in a time of crisis?" What domain is this nurse assessing? A) The client's family relationships B) The client's current level of social and relational stability C) The client's critical thinking and problem-solving abilities D) The client's stress management and coping strategies

D) The client's stress management and coping strategies

17. A client has presented for care because of frequent sinus headaches. During transillumination of the frontal sinuses, a red glow is noted. The nurse should anticipate which of the following? A) The physician will write a prescription for antibiotics. B) The drainage will need to be cultured. C) A repeat procedure will be done in 1 week to compare findings. D) The headaches are most likely not from a sinus infection.

D) The headaches are most likely not from a sinus infection.

30. A nurse is preparing for an assessment by reviewing a new client's electronic health record, which documents the presence of macules on the client's left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions? A) The lesions will be raised and have irregular borders. B) The lesions will be acutely painful. C) The lesions will produce eschar. D) The lesions will not be palpable.

D) The lesions will not be palpable.

26. A small, rural hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met? A) Expand the use of the Nursing Minimum Data Set. B) Eliminate the use of verbal handoffs between nurses. C) Increase interdisciplinary collaboration in the hospital. D) Increase the use of electronic health records (EHRs) in the hospital.

D) The man had an inguinal hernia repair in 2008.

15. During a Weber test, the client reports lateralization of sound to the good ear. How should the nurse interpret this assessment finding? A) The good ear cannot receive sound vibrations. B) There is a dysfunction of the middle ear. C) The poor ear is receiving sound vibrations by air. D) There is a sensorineural hearing impairment.

D) There is a sensorineural hearing impairment.

15. A client has a documented history of hepatomegaly (liver enlargement), and the nurse recognizes the need to perform deep palpation during the physical assessment. The nurse should perform which of the following actions? A) Use one hand and depress the skin 1 centimeter. B) Use the dominant hand to depress the skin one-half to three-quarters of an inch. C) Use both hands to depress the skin one-half of an inch. D) Use both hands to depress the skin 1 to 2 inches.

D) Use both hands to depress the skin 1 to 2 inches.

13. A nurse is comparing the subjective data and objective data obtained from an assessment of a client who is thought to have hepatitis A. This nurse's comparison will achieve what benefit to this client's care? A) Formulation of nursing diagnoses B) Identification of missing data C) Determination of documentation form to use D) Validation of data

D) Validation of data

10. The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health? A) Mental status B) Hearing C) Neurologic status D) Vision

D) Vision

10. The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations? A) Head and neck examination B) Palpation of lymph nodes C) Breast examination D) Vital signs

D) Vital signs

9. A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? A) III B) VI C) VIII D) XII

D) XII