Health Assessment Review/Quiz Questions Exams 1-4

The nurse is completing a head to toe assessment on an aging adult client. Which of the following could the nurse do to conserve client energy? A) Arrange the sequence to allow as few position changes as possible B) Rush through the examination C) Complete the examination in one visit D) Maintain a confident manner

A) Arrange the sequence to allow as few position changes as possible

A nurse is providing a client with information on anal and rectal health. Which of the following should the nurse include in educating the client? Select all that apply A) Avoid straining during defecation B) Eat a high fiber diet C) Avoid lifting extremely heavy items D) Keep anal area clean and dry

A) Avoid straining during defecation B) Eat a high fiber diet C) Avoid lifting extremely heavy items D) Keep anal area clean and dry

After assessing a client's gait, a nurse has the client stand with his eyes closed to perform the Romberg Test in order to assess function of what area of his body? A) Cerebellum B) Temporal Lobe C) Spinal Cord D) Broca's Area

A) Cerebellum

You are caring for a client admitted with C/O dizziness. What questions are appropriate to ask the elicit health history information regarding the client's nuero system? Select all that apply. A) Do you experience weakness? B) Do you experience numbness or tingling? C) Have you encountered any environmental or occupational hazards? D) Have you ever had a stroke or spinal cord injury?

A) Do you experience weakness? B) Do you experience numbness or tingling? C) Have you encountered any environmental or occupational hazards? D) Have you ever had a stroke or spinal cord injury?

After the health history has been obtained and before beginning the physical examination, the nurse should first ask the client to: A) Empty the bladder. B) Completely disrobe. C) Lie on the examination table. D) Walk around the room.

A) Empty the bladder.

According to Erikson, the middle adult's developmental stage is generativity vs stagnation. The following tasks would be expected of a person at this stage except: A) Establishing a career & vocation B) Accepting & adjusting to physical changes C) Coping with an empty nest D) Developing hobby & leisure activities

A) Establishing a career & vocation

Which of the following are coordination and skilled movement assessments used to test cerebellar function? Select all that apply. A) Finger-to-finger test B) Stereognosis C) Patting the thighs D) Finger-to-nose test

A) Finger-to-finger test C) Patting the thighs D) Finger-to-nose test

A client tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A) flexion B) abduction C) adduction D) extension

A) Flexion

The nurse is checking the range of motion in a client's knee and knows that the knee is capable of which movements? A) Flexion and extension B) Supination and pronation C) Inversion and Eversion D) Circumduction

A) Flexion and extension

A client has been in the hospital for 3 days. The nurse performs a bedside assessment in the morning. In the afternoon the client comes back to the floor after an operation. Which type of assessment would the nurse want to perform? A) Focused assessment B) Complete Head to Toe Assessment C) Functional Assessment D) Bedside Assessment

A) Focused assessment

Which of the following is true regarding the re-assessment of a hospitalized client? A) It is performed whenever the nurse sees changes in the client B) It is done to give a baseline so that changes can be detected early C) It is a complete head to toe acute care assessment D) Performed once, preferably in the early part of the day

A) It is performed whenever the nurse sees changes in the client

The nurse is assessing a client who may have hearing loss. Which of these statements is true concerning air conduction? A) It is the normal pathway for hearing. B) It is caused by the vibrations of bones in the skull. C) The amplitude of sound determines the pitch that is heard. D) A loss of air conduction is called a conductive hearing loss.

A) It is the normal pathway for hearing.

A nurse is performing an assessment on a client admitted for alcohol abuse using the CAGE questionnaire. She correctly notes that all of the following are true about the CAGE questionnaire except: A) It takes 30 minutes to complete B) It has 4 straightforward yes/no questions C) It tests for lifetime alcohol abuse D) It stands for: Cut down, Annoyed, Guilty and Eye-opener

A) It takes 30 minutes to complete

A client's wife tells the nurse that she is concerned because she noticed her husband has been having difficulty hearing normal conversation. The nurse suspects the client may have cranial nerve VIII damage. What tests would be appropriate for the nurse to use to confirm suspicions of decreased hearing acuity? Select all that apply. A) Whispered Voice Test B) Weber Test C) Rinne Test D) Romberg Test

A) Whispered Voice Test B) Weber Test C) Rinne Test

You are caring for an 80 year old client. His daughter expresses concerns about him as his wife recently passed away. You are reviewing developmental tasks appropriate for his age according to Erikson. A correct assessment is that the client should be: A: Adjusting to the death of spouse, family members & friends B: Setting up & managing a household C: Learning to cooperate in a marriage of lifelong relationship D: Making friends & establishing a social group

A: Adjusting to the death of spouse, family members & friends

Which of the following is a component of the general survey relating to physical appearance? A:Age B: Gait C: Mood D: Speech

A: Age

The nurse is asking the client for subjective data before performing a cardiac and great vessel assessment. Which of the following should the nurse ask? Select all that apply A. Do you ever have any dyspnea? B. Have you noticed any edema? C. Do you have any history of respiratory infections? D. Have you noticed any skin pigmentation changes? E. Have you had any chest pain?

A. Do you ever have any dyspnea? B. Have you noticed any edema? E. Have you had any chest pain?

The nurse works at a clinic where routine, universal screening for intimate partner violence is done. How often should the nurse screen the women coming into the office? A. Every health care encounter B. Once a year C. Only if the nurse is suspicious there may be abuse occurring D. Twice a year

A. Every health care encounter

The nurse is assessing a client's neck ROM. The nurse would correctly expect the client to be able to perform which movements with the neck? A. Flexion, hyperextension, rotation and lateral bending B. Rotation, supination, inversion, flexion C. Lateral bending, abduction, adduction, forward flexion D. Eversion, pronation, external rotation, hyperextension

A. Flexion, hyperextension, rotation, and lateral bending

Under the requirements of HIPAA (The Health Insurance Portability and Accountability Act), client information may be shared among health care providers: A. If the team member is directly involved in the client's care B. If the team member is a family member of the client C. Without the client consent D. If the team members work on the same unit

A. If the team member is directly involved in the client's care

Which of the following subjective data would the nurse want to collect for the client when performing a Head, Face and Neck Exam? (Select all that apply) A. If they have unusually frequent or severe headaches B. If they have any dizziness C. If they have any neck pain D. If they have any chest pain E. If they have any history of neck injury or surgery

A. If they have unusually frequent or severe headaches B. If they have any dizziness C. If they have any neck pain E. If they have any history of neck injury or surgery

The nurse is assessing the clients posterior chest and hears vesicular breath sounds. Which of the following is the best description of vesicular breath sounds? A. Inspiration is louder and longer than expiration. B. Expiration is louder and longer than inspiration C. Inspiration and expiration are about equal in loudness and time D. A high-pitched, short, crackling, popping sound heard during inspiration.

A. Inspiration is louder and longer than expiration.

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: A. Intermittent claudication B. Sore muscles C. Muscle cramps D. Venous insufficiency

A. Intermittent claudication

During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways? A. Listening to at least one full respiration in each location. B. Listening as the patient inhales and then going to the next site during exhalation. C. Instructing the patient to breathe in and out rapidly while listening to the breath sounds D. If the patient is modest, listening to sounds over his or her clothes or hospital gown

A. Listening to at least one full respiration in each location.

The 8 critical characteristics of a symptom includes: A. Location, character, severity, and timing B. Setting, aggravating factors, and reliability of the informant C. Associated factors, client perception, and gender D. Location, setting, associated factors and family history

A. Location, character, severity, and timing

The nurse is palpating a client's temporomandibular joint (TMJ) which is located just below the temporal artery and anterior to the tragus. Which of the following would be a normal finding? A. Nontender to palpation B. Crepitus C. The jaw locking D. Painful palpation

A. Nontender to palpation

The nurse is assessing a patient's lungs by using the percussion technique. Which sound would the nurse expect to hear over healthy lung tissue? A. Resonance B. Dullness C. Crackles D. Wheezes

A. Resonance

Which of the following is an appropriate position to have the patient assume when auscultating for extra heart sounds or murmurs? A. Roll toward the left side B. Roll toward the right side C. Trendelenburg position D. Prone position

A. Roll toward the left side

The nurse is auscultating heart sounds at the base, over the aortic and pulmonic valves. Which normal heart sounds would the nurse expect to hear louder over these valves? A. S2 B. S1 C. S3 D. S4

A. S2

Which of the following are health effects of violence experienced by older adults that have been abused or neglected? (Select all that apply) A. STIs (Sexually transmitted infections) B. Fluctuations in blood pressure and pulse C. Infections progressing to sepsis D. Cardiac complications due to stress E. The ability to perform ADL's independently

A. STIs (Sexually transmitted infections) B. Fluctuations in blood pressure and pulse C. Infections progressing to sepsis D. Cardiac complications due to stress

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison. A. Side-to-side B. Top-to-bottom C. Posterior-to-anterior D. Interspace-by-interspace

A. Side-to-side

The nurse is assessing a client's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation by displaying the breast against the chest wall? A. Supine with the arms raised over her head B. Sitting with the arms relaxed at her sides C. Supine with the arms relaxed at her sides D. Sitting with the arms flexed and fingertips touching her shoulders

A. Supine with the arms raised over her head

Which of the following are functions of the respiratory system? (Select all that apply) A. Supplying oxygen to the body for energy production. B. Removing carbon dioxide as a waste product. C. Wound repair D. Maintaining acid-base balance E. Maintenance of heat exchange F. Identification

A. Supplying oxygen to the body for energy production. B. Removing carbon dioxide as a waste product. D. Maintaining acid-base balance E. Maintenance of heat exchange

The nurse is assessing a client's abdomen. She places the diaphragm of the stethoscope in the area where bowel sounds are prominent which is: A. The RLQ of the abdomen B. The RUQ of the abdomen C. The LUQ of the abdomen D. The LLQ of the abdomen

A. The RLQ of the abdomen

Which of the following would be considered subjective data? A. The patient states that he has clear discharge coming out of his ears. B. You note that the patient's ears are equal size and shape. C. The patient is unable to hear the words on the Whispered Voice Test. D. The patient's ear drum is a pearl gray color.

A. The patient states that he has clear discharge coming out of his ears.

When assessing the teeth and gums, which of the following would be a normal finding? A. The teeth are white and the gums are coral pink B. The gums are bleeding C. The adult client has 22 total teeth D. The upper and lower jaw are not aligned

A. The teeth are white and the gums are coral pink

The nurse is assessing the client's trachea. Which of the following would be a normal finding? A. The trachea rising to midline when the client swallows B. The trachea deviating to the left when the client swallows C. The trachea deviating to the right when the client swallows D. The trachea not moving when the client swallows

A. The trachea rising to midline when the client swallows

The interview is considered a contract between you and your client. The terms of the contract include: (Select all that apply) A. Time and place of the interview B. Self introduction and explanation of role C. Purpose of interview D. Estimated time for the interview E. Participation expectations

A. Time and place of the interview B. Self introduction and explanation of role C. Purpose of interview D. Estimated time for the interview E. Participation expectations

The function of the trachea and bronchi is to: A. Transport gases between the environment and the lung parenchyma B. Condense inspired air for better gas exchange C. Moisturize air for optimum respiration D. Increase air turbulence and velocity for maximum gas transport

A. Transport gases between the environment and the lung parenchyma

The definition of critical thinking is the process of purposeful thinking and reflective reasoning where practitioners examine ideas, assumptions, principles, conclusions, beliefs, and actions in the context of nursing practice. A. True B. False

A. True

Stridor is a high pitched, inspiratory crowing sound commonly associated with: A. Upper airway obstruction B. Atelectasis C. Congestive heart failure D. Pneumothroax

A. Upper airway obstruction

During a client examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? A. Using gentle pressure, palpate with both hands to compare the two sides. B. Using strong pressure, palpate with both hands to compare the two sides. C. Gently pinch each node between one's thumb and forefinger and move down the neck muscle. D. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

A. Using gentle pressure, palpate with both hands to compare the two sides.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? A. Wheezes B. Bronchial sounds C. Bronchophony D. Crackles

A. Wheezes

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: A. consider this a normal finding. B. refer the individual for further evaluation. C. document this as an asymmetric light reflex. D. perform the confrontation test to validate the findings.

A. consider this a normal finding

Which of the following is the best way to document a client's appearance? A: Tense posture; clothing is clean; wearing light cotton tee shirt, shorts, and no shoes or coat (outdoor temperature in the low 40s). B: Expresses feelings accurately. C: Tearful response to diagnosis of potentially disabling disease. D: Speech clear at moderate rate; laughter during discussion of recent suicides in immediate family.

A: Tense posture; clothing is clean; wearing light cotton tee shirt, shorts, and no shoes or coat (outdoor temperature in the low 40s).

True or False: Pain is whatever the person experiencing it, says it is. A: True B: False

A: True

True or false? (a or b) The expression of pain varies among cultures

A: True

A Muslim woman has been hospitalized. To provide culturally sensitive care, when making staff assignments the nurse should: (Select All That Apply). A: Assign a female care assistant. B: Assign a male care assistant C: Not be concerned about who should be assigned to provide care to this woman. D: Inform the care assistant of the client's need to wear her veil when other visitors enter the room.

A: Assign a female care assistant. D: Inform the care assistant of the client's need to wear her veil when other visitors enter the room.

You are caring for a 38 year old Hispanic client. In order to demonstrate understanding of step two of cultural competence, you should: A: Examine the client within the context of his/her cultural health & illness practices B: Learn to speak the client's language C: Examine the client quickly D: Allow the client to prepare and bring in their own meals

A: Examine the client within the context of his/her cultural health & illness practices

Which of the following are factors that can interfere with auscultation? (Select all that apply) A: Extra room noise B: Client shivering C: The room being too quiet D: Listening on the body, not over clothes E: Nurse bumping the tubing

A: Extra room noise B: Client shivering E: Nurse bumping the tubing

You are caring for a client who is in liver failure. She has been crying and wants you to call the chaplain. You understand that a chaplain can be consulted (referral): Select all that apply A: If a client received a new diagnosis of a terminal illness B: If a client has issues about current faith or beliefs C: If a client is extremely worried, angry or upset D: If a client/significant other requests to see a chaplain

A: If a client received a new diagnosis of a terminal illness B: If a client has issues about current faith or beliefs C: If a client is extremely worried, angry or upset D: If a client/significant other requests

The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: A: Is used to listen for high-pitched sounds. B: Is used to listen for low-pitched sounds. C: Is used to listen for vascular sounds such as bruits or hums D: Is used if placed lightly on the skin

A: Is used to listen for high-pitched sounds.

Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a client? A: Palpation B: Inspection C: Percussion D: Auscultation

A: Palpation

A client comes into the clinic with complaints of nausea. She also states that she has lost her appetite for food. What other information can you elicit to perform a nutritional assessment? (Select all that apply) A: What are your normal eating habits? B: Any vomiting, constipation or diarrhea? C: Notice any changes in taste, smell, chewing or swallowing? D: Any recent trauma or infection?

A: What are your normal eating habits? B: Any vomiting, constipation or diarrhea? C: Notice any changes in taste, smell, chewing or swallowing? D: Any recent trauma or infection?

The nurse is performing an assessment on the client. Which of the following would help the nurse to be successful in the assessment? A: Exposing the entire body at the beginning of the assessment B: Hurrying through the assessment C: Informing the client of your intentions before touching them D: Having the room cold for client comfort

C: Informing the client of your intentions before touching them

Which of the following is NOT an effect of poorly controlled chronic pain? A: Depression B: Family Distress C: Pain relieved by movement D: Reduced quality of life

C: Pain relieved by movement

The nurse is using percussion as an assessment technique on the client. Which of the following best describes how percussion is performed? A:Close careful scrutiny of the client that involves concentrated watching B:Using the stethoscope to listen to sounds produced by the client's body C: Tapping the clients' skin with short, sharp strokes to assess underlying structures D:Lightly pressing on the client's skin to detect surface characteristics

C: Tapping the clients' skin with short, sharp strokes to assess underlying structures

The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? A: The client cannot understand the nurse B: The client is uncomfortable with the nurse C: The client is treating the nurse with respect D: The client is purposefully disrespecting the nurse

C: The client is treating the nurse with respect

The nurse understands that all of the following are components of a mental status assessment except? A: Known illness or health problem B: Current medications known to affect mood or cognition C: Cultural background D: Personal history; current stress, social habits, sleep habits, and drug and alcohol use

C: cultural background

An elderly woman is brought to the emergency department after being found lying on the kitchen floor for 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination? A) Smooth mucous membranes and lips B) Dry mucous membranes and cracked lips C) Pale mucous membranes D) White patches on the mucous membranes

B) Dry mucous membranes and cracked lips

After the health history has been obtained and before beginning the physical examination, the nurse should first ask the client to: A) Sit in a chair B) Empty the bladder C) Walk around the room D) Completely disrobe

B) Empty the bladder

F.A.S.T. is an acronym used as a mnemonic to help detect and enhance responsiveness to stroke victim needs. The nurse recognizes that a correct interpretation of the acronym is: A) S.T.O.P., S=Stop stroke, T=Time to rest, O=Opt out, P=Poke to test B) F=Face Drooping, A=Arm Weakness, S=Speech Difficulty, T=Time to call 911 C) F=Feet drooping, A=Arm Weakness, S=Speech Difficulty, T=Time to stroke D) F=Feel the face, A=Arm yourself, S=Stop, T=Time to rest

B) F=Face Drooping, A=Arm Weakness, S=Speech Difficulty, T=Time to call 911

The nurse is palpating the sinus areas. If the findings are normal, then the client should report which sensation? A) No sensation B) Firm pressure C) Pain during palpation D) Pain sensation behind eyes

B) Firm pressure

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is: A. The largest quadrant of the breast. B. The location of most breast tumors. C. Where most of the suspensory ligaments attach. D. More prone to injury and calcifications than other locations in the breast.

B. The location of the most breast tumors

The nurse is performing the Diagnostic Positions test (Six Cardinal Fields of Gaze) to check the extraocular eye muscles. The nurse knows that a healthy finding would be: A. Each eye moves in opposite directions from each other B. There is parallel tracking of the object with both eyes. C. A rapid eye blink is expected. D. The light reflex of the eyes is located in the same position in each eye.

B. There is parallel tracking of the object with both eyes.

When observing the left tympanic membrane of a patient with an otoscope, the examiner notices the cone of light (light reflex) is at 7 o'clock. The examiner suspects: A. Perforation from a ruptured membrane. B. This is a normal tympanic membrane. C. Abnormal wax build-up D. A fungal infection

B. This is a normal tympanic membrane.

When assessing a patient the nurse is unable to palpate the left dorsalis pedis pulse. What should the nurse do first? A. Document the finding B. Use the doppler to assess the pulse C. Call the physician and tell them the patient has no pulse D. Start assessing the next patient

B. Use the doppler to assess the pulse

Function of the Optic Nerve (CN II): A. Diagnostic positions test B. Visual acuity, visual fields, looking in the eyes with an ophthalmoscope C. Whispered word test D. Testing ROM and strength of the neck, shoulder and head muscles.

B. Visual acuity, visual fields, looking in the eyes with an opthalmoscope

The nurse is teaching her client about skin self-examination. The client asks how often she should perform this assessment on herself. The nurse answers: A. You should perform weekly skin checks B. You should perform monthly skin checks C. You should perform skin checks once a year D. You should perform skin checks only if you notice a new lesion

B. You should perform monthly skin checks

The nurse is preparing to perform an abdominal assessment. Which of the following would help to enhance relaxation of the client's abdominal wall during the examination? A. a cool environment B. positioning the client with the knees bent C. having the client place arms above the head D. examining painful areas first

B. positioning the client with the knees bent

The nurse is counting an adult client's respirations. Which of the following rates would be considered within normal range? A: 24 respirations/minute B: 16 respirations/minute C: 8 respirations/minute D: 32 respirations/minute

B: 16 respirations/minute

The nurse is assessing a client's pulse. Which of the following scores would be considered a normal finding? A: 1+ B: 2+ C: 3+ D: 0

B: 2+

Mrs. Casey is a 39 year old client with a herniated disk and neuropathic pain. Which is a primary characteristic of neuropathic pain? A: An abnormal degree of pain interpretation. B: An abnormal processing of the pain sensation. C: An abnormal transmission of pain signals. D: An abnormal modulation of pain signals.

B: An abnormal processing of the pain sensation.

Which of the following basic functions should the nurse test first in an assessment of mental status? A: Behavior B: Consciousness C: Judgment D: Language

B: Consciousness

If the origin of a client's pain was the muscles and joints, which pain source would you expect? A: Visceral pain B: Deep somatic pain C: Cutaneous pain D: Referred pain

B: Deep Somatic Pain

The nurse is assessing a client's fingernails and notes clubbing. Clubbing is best described by which of the following: A) Curved nails with a convex profile and ridges across the nails. B) Nail bases that are firm and slightly tender. C) Nail bases that feel spongy with an angle of the nail base of 180 degrees or greater. D) Nail bases that feel spongy with an angle of the nail base of 150 degrees.

C) Nail bases that feel spongy with an angle of the nail base of 180 degrees or greater.

The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The client: A) Demonstrates ability to hear normal conversation. B) Sticks tongue out midline without tremors or deviation. C) Follow an object with both eyes without nystagmus or strabismus. D) Moves the head and shoulders against resistance with equal strength.

D) Moves the head and shoulders against resistance with equal strength.

As a mandatory reporter of elder abuse, which of these must be present before a nurse notifies the authorities? A) Statements from the victim B) Statements from witnesses C) Proof of abuse and/or neglect D) Suspicion of elder abuse and/or neglect

D) Suspicion of elder abuse and/or neglect

A nurse is asked to perform an assessment of a client's functional ability prior to discharge. The nurse would be correct in using any of the following instruments to perform an assessment of the client's activities of daily living (ADLs) except: A) The Barthel Index B) The Katz Index C) Functional Independence Measure (FIM) D) The Lawton Instrument

D) The Lawton Instrument

During the admission assessment, the nurse asks the client several questions. The client states, "I am in good health." The nurse correctly documents this as: A) The client's biographical statement B) The client's current health history C) The client's review of systems D) The client's health perception

D) The client's health perception

The nurse is performing an assessment of a male client. Which of these statements is true about the testes? A) The lymphatics of the testes drain into the abdominal lymph nodes. B) The vas deferens is located along the inferior portion of each testis. C) The right testis is lower than the left because the right spermatic cord is longer. D) The cremaster muscle contracts in response to cold and draws the testicles closer to the body.

D) The cremaster muscle contracts in response to cold and draws the testicles closer to the body.

A new graduate nurse asks a more experienced nurse why the initial assessment is done in the early part of the day. The nurse would respond: A) To get your charting done before the physician rounds B) To assess a client following procedures C) To have a more accurate assessment D) To get a baseline for your client so that changes can be detected early

D) To get a baseline for your client so that changes can be detected early

A nurse is performing an assessment on a client admitted with slurred speech. She suspects this client may be experiencing symptoms of aphasia which is: A) the impaired ability to recognize or identify objects despite intact sensory function. B) the impaired ability to carry out motor activities despite intact motor function. C) a disturbance in executive functioning (planning, organizing, sequencing, abstracting). D) a language disturbance in speaking, writing, or understanding.

D) a language disturbance in speaking, writing, or understanding.

Although a full mental status examination may not be required for every client, the health care provider must address the four main components of a mental status exam during a health history and physical examination which are: A) mood, affect, consciousness, and orientation. B) language, orientation, attention, and abstract reasoning. C) memory, attention, thought content, and perceptions. D) appearance, behavior, cognition, and thought processes.

D) appearance, behavior, cognition, and thought processes

The nurse is assessing an older adult's instrumental activities of daily living. Which of the following activities should be included in the assessment? A) shopping. B) meal preparation. C) self-grooming activities. D) both A & B.

D) both A & B.

The nurse is assessing an older adult Client's functional ability. A correct description of functional ability is That it is: A) the measure of the expected changes of aging that one is experiencing. B) referring to the individual's motivation to live independently. C) referring to the level of cognition present in an older person. D) referring to one's ability to perform activities necessary to live in modern society.

D) referring to one's ability to perform activities necessary to live in modern society.

You are assigned to obtain a nutrition assessment on a client. You understand that the easiest method for obtaining information about dietary intake is by using: A) a food diary B) direct observation C) the food frequency questionnaire D) the 24-hour recall

D) the 24-hour recall

Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X (Vagus)? A)Observe the patient's ability to articulate specific words. B)Observe the patient's ability to move the shoulders against resistance. C)Have the patient stick out the tongue and observe for tremors or pulling to one side. D)Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.

D)Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.

The nurse is teaching a client about health promotion of the gastrointestinal system. Which of the following statements would indicate a need for further teaching? A. "I should try to drink at least 8 glasses of water daily." B. "I should try to avoid having high fatty foods in my diet." C. "I plan to exercise more so I can maintain a healthy weight." D. "The amount of alcohol I have should not affect my health if I dilute it with water."

D. "The amount of alcohol I have should . not affect my health if I dilute it with water."

The nurse is caring for a client who reports having abdominal pain. After inspecting the client's abdomen, the nurse would be correct in performing what assessment technique? A. Deep palpation B. Percussion C. Light Palpation D. Auscultation

D. Auscultation

Promoting Client Safety is: A. A key responsibility of the nurse B. Eventually becomes a reflex C. Not a concern of the nurse D. Both A & B are correct

D. Both A & B are correct

The nurse is performing an assessment on a client. Which of the following should the nurse ask to obtain subject data related to the client's gastrointestinal system? A. Have you experienced any changes in bowel habits? B. What medications are you taking? C. Do you have any headaches? D. Both A and B

D. Both A and B

The nurse is providing discharge instructions to a female client. Which of these statements by the client indicates understanding of abnormal assessment findings? A. "I should report sudden nipple retraction" B. "I should report my left breast being larger than the right breast" C. "I should report orange-peel skin discoloration" D. Both A and C

D. Both A and C

A nurse is performing an assessment on a client who reports abdominal pain. Which of the following actions should the nurse implement to promote relaxation of the client's abdomen during the assessment? A. Position the client supine, with the knees bent. B. Examine the painful areas first. C. Distract the client. D. Both a and c

D. Both a and c

The nurse is assessing the pupils of a client with a pen light. Which finding would be considered normal? A. Both eyes cross when exposed to the light. B. The patient's pupils are fixed and dilated in response to light. C. Both pupils dilate in response to light. D. Both pupils constrict in response to light.

D. Both pupils constrict in response to light.

The nurse is aware that one change that may occur in the gastrointestinal system of an aging client is: A. Increased salivation B. Increased liver size C. Increased esophageal emptying D. Decreased gastric acid secretion

D. Decreased gastric acid secretion

When recording data during an interview, the nurse should: A. Document everything post interview B. Record their judgment about what the client said C. Use the computer screen as a barrier between them and the client D. Document as soon as possible

D. Document as soon as possible

The nurse is teaching a client about risk factors for breast cancer. Which of the following is a known risk factor for breast cancer? A. Physical activity B. Low cholesterol diet C. Breastfeeding an infant for more than 6 months D. Menstruation before age 12 or menopause after age 50

D. Menstruation before age 12 or menopause after age 50

The nurse is teaching a client about risk factors for breast cancer. She correctly includes which of the following risk factors? A. Breastfeeding an infant for more than 6 months. B. A low cholesterol diet. C. Physical activity. D. Menstruation before age 12 or menopause after age 55.

D. Menstruation before age 12 or menopause after age 55.

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the apex of the heart are: A. Tricuspid and aortic B. Aortic and pulmonic C. Mitral and pulmonic D. Mitral and Tricuspid

D. Mitral and Tricuspid

When auscultating over a patient's femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits: A. Are often associated with venous disease. B. Occur in the presence of lymphadenopathy. C. In the femoral arteries are caused by hypermetabolic states. D. Occur with turbulent blood flow, indicating partial occlusion.

D. Occur with turbulent blood flow, indicating partial occlusion.

The nurse is preparing to perform ROM on a client who is paralyzed from the waist down. Which type of ROM would be most appropriate to perform on this patient's upper extremities (UE) and lower extremities (LE)? A. Active ROM LE, Passive ROM UE B. Passive ROM for all extremities C. Active ROM for all extremities D. Passive ROM LE, Active ROM UE

D. Passive ROM LE, Active ROM UE

Which of the following adventitious breath sounds can be described as coarse and low pitched with the grating quality of two pieces of leather being rubbed together? A. Wheezing B. Stridor C. Crackles D. Pleural friction rub

D. Pleural friction rub

The nurse is assessing the client's pupillary response to light. The nurse moves the penlight in from the side of the client's face into the right eye. Both the right and left pupil constrict. How would these reflexes be described? A. Right eye consensual response, left eye direct response B. Right eye medial response, left eye lateral response C. Right eye dilation response, left eye constricting response D. Right eye direct response, left eye consensual response

D. Right eye direct response, left eye consensual response

Which of the following behaviors demonstrated by an individual may be indicative of hearing loss? a. Not looking at the examiner when being questioned. b. frequently asking for the question to be repeated. c. talking in a high-pitched voice. d. speaking slowly with well articulated consonants

b. frequently asking for the question to be repeated.

The nurse is assessing a client who admits to being physically abused by her spouse. The client says, "I wish I would have agreed with my husband, because then I wouldn't have been hit." What is the nurse's best response? a. "Changing your reaction to your spouse will likely change his actions against you." b."Try not to blame yourself. You will know better for next time." c. "Your husband has to want to change. Let's focus on you for now." d. "It is not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again."

d. "It is not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again."

Your patient is exhibiting rapid shallow breathing, with a respiratory rate > 24 respirations per minute. Which of the following conditions are they experiencing? A. hypoxemia B. tachypnea C. fremitus D. resonance

B. Tachypnea

Test used for Cranial Nerves: III (Oculomotor), IV (Trochlear) and VI (Abducens): A. Diagnostic positions test B. Visual acuity, visual fields, looking in the eyes with an ophthalmoscope C. Whispered word test D. Testing ROM and strength of the neck, shoulder and head muscles.

A. Diagnostic Positions Test

The nurse is assessing the client's position sense by moving the client's fingers and toes in the up, down, and neutral position. The client is able to identify which position the nurse is moving the limbs. The test is called: A) Graphesthesia B) Extinction C) Point location D) Kinesthesia

D) Kinesthesia

Which statement is true regarding the arterial system? A. Arteries are large-diameter vessels. B. The arterial system is a high-pressure system. C. The walls of arteries are thinner than those of the veins. D. Arteries carry deoxygenated blood back to the heart

B. The arterial system is high pressure system.

A palpable vibration increased with lobar pneumonia is also known as: A. Rhonchi B. Resonance C. Fremitus D. Crackles

C. Fremitus

The two sinuses that can be directly palpated are? A. Frontal and Sphenoid B. Maxillary and Ethmoid C. Frontal and Maxillary D. Ethmoid and Sphenoid

C. Frontal and Maxillary

Which of the following terms is used to describe a decreased level of oxygen (O2) in the blood? A. Anemia B. Hypercapnia C. Hypoxemia D. Emphysema

C. Hypoxemia

Which of the following chest configurations is an exaggerated posterior curvature of the thoracic spine that is associated with aging and physical fitness? A. Scoliosis B. Barrel Chest C. Kyphosis D. Pectus Excavatum

C. Kyphosis

Which of the following correctly expresses the relationship to the lobes of the lungs and their anatomic position? A. Upper lobes-lateral chest B. Upper lobes-posterior chest C. Lower lobes-posterior chest D. Lower lobes-anterior chest

C. Lower lobes-posterior chest

The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland. A. Stensen's B. Sublingual C. Parotid D. Submandibullar

C. Parotid

The nurse is performing an ear examination of an 80-year-old client. Which of these would be considered a normal finding for the aging adult? A) A high-tone frequency loss B) Increased elasticity of the pinna C) A thin, translucent membrane D) A shiny, pink tympanic membrane

A) A high-tone frequency loss

When assessing the hypoglossal nerve (CN XII), the nurse looks at and tests: A) Movement and strength of the tongue B) Full, sustained eye opening C) Symmetry of facial features D) The uvula rising to the midline when a person says "ah"

A) Movement and strength of the tongue

What should the nurse assess before entering the client's room on morning rounds? A) Posted conditions, such as isolation precautions B) The client's input and output chart from the previous shift C) The client's general appearance D) The presence of any visitors in the room

A) Posted conditions, such as isolation precautions

A nurse receiving report on a client admitted with symptoms of a stroke asks when the client's symptoms began. She knows this information is important in order to: Select all that apply. A) Reduce long term brain damage B) Reduce disability C) Provide appropriate treatment D) Save the person's life

A) Reduce long term brain damage B) Reduce disability C) Provide appropriate treatment D) Save the person's life

You are discussing the characteristics of culture with a colleague. You correctly note that culture is which of the following? Select all that apply. A) Shared B) Apparent C) Autonomous D) Learned

A) Shared D) Learned

Your client's daughter expresses concerns about her safety. She notes that her 74 year old mother has had a couple of dents in her car recently. All of the following would be sufficient reason to encourage the client to stop driving except: A) She Takes insulin to control type 2 diabetes mellitus B) she Almost crashes, with frequent close calls C) she Has trouble seeing or following traffic signals D) she Has difficulty checking over her shoulder when backing up or changing lanes

A) She Takes insulin to control type 2 diabetes mellitus

A nurse is performing an assessment of her client's functional ability prior to discharge. She correctly uses the Functional Independence Measure (FIM) instrument to assess all of the following except: A) The client's ability to manage his finances B) The client's ability to put on his shirt C) The client's ability to get into the chair D) the client's ability to wipe himself after toileting

A) The client's ability to manage his finances

A client is admitted with complaints of lower back pain. The nurse understands that the most reliable indicator of the client's pain is: A) The client's self report B) The pain assessment tool: PQRST C) Nonverbal Cues D) The nurse's assessment

A) The client's self report

The nurse is examining an older female client. Which of the following are expected changes that would be noted? Select all that apply A) The vagina is narrow and has lost its elasticity B) The labia & clitoris decrease in size C) Thinning pubic hair D) Decreased sexual drive

A) The vagina is narrow and has lost its elasticity B) The labia & clitoris decrease in size C) Thinning pubic hair

During the history, a client tells the nurse that "it feels like the room is spinning around me." The nurse would document this as: A) Vertigo B) Syncope C) Dizziness D) Seizure activity

A) Vertigo

A nurse is conducting a complete neurological exam on a client who reports difficulty with speech. What other questions would be important for the nurse to ask the client? Select all that apply. A) When did you first notice this symptom? B) How long did the symptoms last? C) Can you describe the symptoms? D) Any problems forming words?

A) When did you first notice this symptom? B) How long did the symptoms last? C) Can you describe the symptoms? D) Any problems forming words?

A nurse is performing an abdominal assessment. The nurse correctly observes the following assessment findings when inspecting a client's abdomen. Select all that apply. A. Contour and symmetry B. Appearance of umbilicus C. Skin color D. Demeanour

A. Contour and symmetry B. Appearance of umbilicus C. Skin color D. Demeanour

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: A) auricle. B) concha. C) outer meatus. D)mastoid process.

A) auricle

To perform an accurate assessment of respirations, the examiner should: A) count for 30 seconds and multiply by two B) count for 15 seconds while keeping fingers on the pulse and then multiply by four. C) assess respirations for a full 2 minutes if an abnormality is suspected. D) inform the person of the procedure and count for 1 minute.

A) count for 30 seconds and multiply by two

During an assessment of a 20-year-old client with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: A) dehydration. B) irritation by gastric juices. C) a normal oral assessment. D) side effects from nausea medication.

A) dehydration.

The wife of a 65-year-old client tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe. A) frontal B) parietal C) occipital D) temporal

A) frontal

The nurse is examining an older male client. Which of the following is not an expected change that should be noted? A) loss of libido B) decreased pubic hair C) decreased penis size D) slowed time for erection

A) loss of libido

The salivary gland that is the largest and located in the cheek in front of the ear is the _____ gland. A) parotid B) Stensen's C) sublingual D) submandibular

A) parotid

When documenting intimate partner violence and elder abuse, the nurse should include: A) photographic documentation of injuries. B) a summary of the abused patient's statements. C) verbatim documentation of every statement made. D) a general description of injuries in the progress notes.

A) photographic documentation of injuries.

The nurse is doing an assessment on a 21-year-old client and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? A)"Are you aware of having any allergies?" B) "Do you have an elevated temperature?" C) "Have you had any symptoms of a cold?" D)"Have you been having frequent nosebleeds?"

A)"Are you aware of having any allergies?"

The nurse is educating a 55-year-old client on breast self-examination (BSE.) Which of these statements by the client indicates understanding of the information provided? "The best time for postmenopausal women to perform BSEs is____________" A. "On the same day every month." B. "Daily, when I shower or bathe." C. "One week after my menstrual period." D. "Annually with my annual gynecologic examination."

A. "On the same day every month."

How should the nurse document mild, slight pitting edema on the ankles of a heart failure patient? A. 1+ B. 2+ C. 3+ D. 4+

A. 1+

The nurse is educating the client about risk factors for cardiovascular disease. Which of the following risk factors for cardiovascular disease are modifiable? Select all that apply. A. Abnormal lipids B. Smoking C. Gender D. Hypertension E. Diabetes F. Family history

A. Abnormal lipids B. Smoking D. Hypertension E. Diabetes

During an assessment, the nurse notices that the client's umbilicus is enlarged and everted. The nurse recognizes this as: A. Abnormal: May be an umbilical hernia B. A normal result of aging C. Likely caused by constipation D. A rare occurrence

A. Abnormal: May be an umbilical hernia

During an annual physical examination, a 43-year-old client states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: A. BSEs may detect lumps that appear between mammograms. B. BSEs are unnecessary until the age of 50 years. C. She is correct—mammography is a good replacement for BSE. D. She does not need to perform BSEs as long as a physician checks her breasts annually.

A. BSEs may detect lumps that appear between mammograms.

Which of the following are components of the complete health history? (Select all that apply) A. Biographical Data B. Reason for seeking care C. Family history D. Review of systems E. Past history or history of present illness F. Functional assessment or ability to perform activities of daily living (ADLs)

A. Biographical Data B. Reason for seeking care C. Family history D. Review of systems E. Past history or history of present illness F. Functional assessment or ability to perform activities of daily living (ADLs)

What is the definition of Holistic Health? A. Body, mind and spirit part of a whole within the environment. B. Body, mind and spirit assessed as separate parts C. Absence of Disease D. Disease Prevention

A. Body, mind and spirit part of a whole within the environment

A client is admitted with a new skin lesion. Using the ABCDEF method, the nurse knows that one of the signs of melanoma would be: A. Border irregularity B. Symmetry C. Border regularity D. Diameter less than 6 mm

A. Border irregularity

The nurse is describing how to perform a testicular self-examination to a client. Which of these statements is most accurate? A) "A good time to examine your testicles is just before you take a shower." B) "If you notice an enlarged testicle or a painless lump, call your health care provider." C) "The testicle is pear-shaped and immovable. It feels firm and has a lumpy consistency." D) "Perform a testicular exam at least once a week to detect the early stages of testicular cancer."

B) "If you notice an enlarged testicle or a painless lump, call your health care provider."

A nurse is preparing to assess a client. She understands the key to successful inspection requires all of the following except: A) Good lighting B) A stethoscope C) Using one's eyes, ears, nose D) comparing body sides for symmetry

B) A stethoscope

During an examination of a 62 year old male, the nurse notices an immobile, tender nodule. A correct assessment of this finding is that this nodule is: A) Normal B) Abnormal

B) Abnormal

A female client comes in to the clinic complaining of perianal itching. Which of the following would NOT be appropriate to assist the client in preparing for a perianal examination? A) Instruct the client to inform you of any pain or discomfort during the exam. B) Assume that the client has had a vaginal exam before and has no questions. C) Ask the client if she would like a family member, friend or chaperone present. D) Have the client empty her bladder.

B) Assume that the client has had a vaginal exam before and has no questions.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? A) Acne B) Basal cell carcinoma C) Malignant melanoma D) Squamous cell carcinoma

B) Basal cell carcinoma

The nurse is examining a male client. The client appears apprehensive. Which of the following actions can the nurse employ to reduce the client's anxiety? A) Use a soft, stroking touch B) Be confident and relaxed C) Talk to the client about his sexual practices D) Perform the examination quickly

B) Be confident and relaxed

You are caring for a 72 year old client who suffered a stroke. Her 44 year old daughter comes to visit with her 3 young grandchildren. The daughter tells you she is feeling "overwhelmed" as she has to work, care for her parents and her own children. The nurse suspects she may be experiencing: A) Realistic ideation B) Caregiver burnout C) Pessimisim D) Moral relativism

B) Caregiver burnout

A client presents to the ED in acute respiratory distress. How should the nurse proceed with gathering the health history? A) Collect all the information regardless of client condition B) Collect a mini-database and then complete the assessment once the distress is resolved C) Do not collect any information at this time D) Allow rest periods when needed

B) Collect a mini-database and then complete the assessment once the distress is resolved

The nurse is assessing a client's visual acuity using The Snellen Chart. The client's vision is 20/20. This indicates that there is normal function of which cranial nerve? A) Cranial Nerve IV B) Cranial Nerve II C) Cranial Nerve VII D) Cranial Nerve V

B) Cranial Nerve II

Which of the following are expected changes that can be seen in the older adult due to the loss of neurons in the brain and spinal cord limitation? Select all that apply. A) Improvement in fine coordination and agility. B) Decreased muscle strength and agility. C) Decreased reaction time. D) Progressive decrease in cerebral blood flow.

B) Decreased muscle strength and agility. C) Decreased reaction time. D) Progressive decrease in cerebral blood flow.

What is an advantage for using the SBAR during staff communication? A) Provides a complete client health history B) Improves verbal communication and reduces medical errors C) Focuses on a comprehensive physical examination D) Avoids making recommendations

B) Improves verbal communication and reduces medical errors

During a neurological assessment, the nurse finds the following: asymmetry when the client smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air from one side only when the nurse presses against the puffed cheeks. This would indicate dysfunction of which of these cranial nerves? A) Motor component of IV B) Motor component of VII C) Motor and sensory components of XI D) Motor component of X and sensory component of VII

B) Motor component of VII

A graduate nurse asks a more experienced nurse when she should complete a neuro assessment during the course of her shift. An APPROPRIATE response would be: A) Neuro assessments should not be performed while assessing other body systems. B) Neuro assessments can be performed covertly. C) Neuro assessments should only be performed on admission. D) Neuro assessments should only be performed when a client complains of a headache.

B) Neuro assessments can be performed covertly.

What should the nurse assess before entering the client's room on morning rounds? A) Presence of any visitors in the room B) Posted conditions, such as isolation precautions C) The client's input and output chart from the previous shift D) The client's general appearance

B) Posted conditions, such as isolation precautions

Which of these statements is true regarding the recording of data from the history and physical examination? A) Use long, descriptive sentences to document findings. B) Record the data as soon as possible after the interview and physical examination. C) If the information is not documented, then it can be assumed that it was done as a standard of care. D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the client.

B) Record the data as soon as possible after the interview and physical examination.

A 60 year old client expresses concerns about his sexual drive. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life can be attributed to: A) Decreased sperm production. B) Side effects of medications. C) Increased sperm production. D) Decreased pleasure from sexual intercourse.

B) Side effects of medications.

As a mandatory reporter of elder abuse, which must be present before a nurse should notify the authorities? A) Statements from witnesses B) Suspicion of elder abuse and/or neglect C) Proof of abuse and/or neglect D) Statements from the victim

B) Suspicion of elder abuse and/or neglect

Which of the following is a true statement regarding the bedside assessment of the hospitalized client? A) Hospitalized clients require a complete head to toe screening exam every 24 hours B) The bedside assessment is a specialized assessment done at least every 12 hour shift C) The bedside assessment is the complete examination done with the first client encounter D) The bedside assessment only focuses on one body system

B) The bedside assessment is a specialized assessment done at least every 12 hour shift

A nurse is caring for a client whose daughter reports having "behavioral" problems. The nurse knows that the client's change in personality, behavior, emotions, and intellectual function is related to which area of the brain? A) Wernicke's area B) The frontal lobe C) Broca's area D) The temporal lobe

B) The frontal lobe

The nurse is assessing a client who may have suffered a stroke. Which of these statements it true concerning the areas of the brain? A) The cerebellum is the center for speech and emotions. B) The hypothalamus controls temperature and regulates sleep. C) The basal ganglia are responsible for controlling voluntary movements. D) Motor pathways of the spinal cord and brainstem synapse in the thalamus.

B) The hypothalamus controls temperature and regulates sleep.

A clinical manifestation common in an individual with chronic obstructive pulmonary disease (COPD) is: A. Periodic breathing patterns B. Pursed lip breathing C. Unequal chest expansion D. Hyperventilation

B. Pursed lip breathing

A nurse is performing an assessment on an uncircumcised male client. She retracts the foreskin and remembers to return the skin to its original position. This action is performed to prevent which of the following from occurring? A) An erection B) Tissue loss C) Increased circulation D) Hair growth

B) Tissue loss

A nurse is performing an assessment on an uncircumcised male client. She retracts the foreskin and remembers to return the skin to its original position. This action is performed to prevent which of the following from occurring? Select all that apply A) An erection B) Tissue loss C) Decreased circulation D) Amputation

B) Tissue loss C) Decreased circulation D) Amputation

In performing a whispered words test to assess hearing, which of these actions would the nurse do? A) Shield the lips so that the sound is muffled. B) Whisper a set of random numbers and letters and ask the patient to repeat them. C) Ask the patient to place his finger in his ear to occlude outside noise. D)Stand about 4 feet away to ensure that the patient can really hear at this distance.

B) Whisper a set of random numbers and letters and ask the patient to repeat them.

A client comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _____ and proceeds with the examination by ____. A) XI; palpating the anterior and posterior triangles B) XI; asking the CLIENT to shrug her shoulders against resistance C) XII; percussing the sternomastoid and submandibular neck muscles D) XII; assessing for a positive Romberg sign

B) XI; asking the CLIENT to shrug her shoulders against resistance

The nurse is preparing to perform a functional assessment of an older client who is confused. Which of the following approaches is the most appropriate for the nurse to employ? A) observe the client's ability to perform the tasks. B) ask the client's wife how he does when performing tasks. C) refer the client for a psychiatric assessment D) ask the client's physician for information on the client's abilities.

B) ask the client's wife how he does when performing tasks.

When completing a physical assessment of all body systems on an older adult with mobility problems, the sequence should: A) begin with the physical examination followed by the health history. B) be arranged to minimize the number of position changes for the client and the examiner. C) start with the most invasive assessments. D) be from head to toe to prevent missing any important assessments.

B) be arranged to minimize the number of position changes for the client and the examiner.

After completing an assessment of a 60 year-old male client with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): A) annual proctoscopy. B) colonoscopy every 10 years. C) fecal test for blood every 6 months. D) digital rectal examinations every 2 years.

B) colonoscopy every 10 years.

The primary purpose of the ciliated mucous membrane in the nose is to: A) warm the inhaled air. B) filter out dust and bacteria. C) filter coarse particles from inhaled air. D) facilitate movement of air through the nares.

B) filter out dust and bacteria.

An 85-year-old client comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: A) long bones tend to shorten with age. B) of the shortening of the vertebral column. C) there is a significant loss of subcutaneous fat. D) there is a thickening of the intervertebral disks.

B) of the shortening of the vertebral column.

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: A) light pink with a slight bulge. B) pearly gray and slightly concave. C) pulled in at the base of the cone of light. D)whitish with a small fleck of light in the superior portion.

B) pearly gray and slightly concave.

A client states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse suspects that the client is experiencing: A) dysuria B) stress incontinence C) hematuria D) urge incontinence

B) stress incontinence

During a breast health assessment, the client states that she has noticed pain in her left breast. An appropriate response to this by the nurse would be: A. "Don't worry about the pain; breast cancer is not painful." B. "I would like some more information about the pain in your left breast." C. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." D. "Breast pain is almost always the result of benign breast disease."

B. "I would like some more information about the pain in your left breast."

During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. The nurse understands that before reporting this finding as "absent bowel sounds" it is important to listen for at least _____ in each quadrant. A. 1 minute. B. 5 minutes. C. 10 minutes. D. 2 minutes.

B. 5 minutes

The nurse is performing a neurological assessment on a 60 year old client who suffered a stroke and is experiencing left-sided weakness. She asks the client to stick her tongue out and move it from side to side. The nurse notes the client's tongue deviates to the left side and suspects damage to which cranial nerve? A. Cranial Nerve IX B. Cranial Nerve XII C. Cranial Nerve VIII D. Cranial Nerve V

B. Cranial Nerve XII

The nurse is palpating the temporomandibular joint (TMJ) which is located just below the temporal artery and anterior to the tragus. Which of the following would be considered an abnormal finding? A. No tenderness to palpation B. Crepitus noted C. The joint moves freely with no limitation D. There is no locking of the jaw

B. Crepitus is noted

The nurse is performing percussion by tapping on a client's abdomen in the left upper quadrant (spleen) and right upper quadrant (liver). Which of the following would be an expected assessment finding in these two areas of the GI system? A. Resonance B. Dullness C. Tympany D. Hyperresonance

B. Dullness

True or false: Open ended questions are used for specific information, short one or two word answers, just the facts, neutral interaction, and have minimal rapport building A. True B. False

B. False

The nurse is assessing a client's neck ROM (Range of Motion). The nurse would correctly expect the client to be able to perform which movements with the neck? A. Eversion, pronation, external rotation, hyperextension B. Flexion, hyperextension, rotation and lateral bending C. Rotation, supination, inversion, flexion D. Lateral bending, adduction, abduction, forward flexion

B. Flexion, hyperextension, rotation and lateral bending

A client comes to the clinic with what he calls a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. Which of the following statements is true about breast cancer? A. Breast masses in men are difficult to detect because of minimal breast tissue. B. Gynecomastia is a benign growth of the breast tissue. C. Breast cancer is more likely to occur in men than women. D. Gynecomastia is an enlarged cancerous nodule located in the breast tissue.

B. Gynecomastia is a benign growth of the breast tissue.

An emergency database is: A. Concerns mainly one problem or body system B. Is an urgent, rapid collection of crucial information and often is compiled currently with lifesaving measures C. Used to follow up on a past problem D. Includes a complete health history and a full physical examination

B. Is an urgent, rapid collection of crucial information and often is compiled currently with lifesaving measures

Which of the following does not define a health assessment? A. Data collection using all of your senses B. Last step of the nursing process C. Requires careful observation including watching, listening, feeling, touching and smelling D. Collecting data related to a person's health

B. Last step of the nursing process

Freshly oxygenated blood enters the heart through the ___, and is pumped out to the body through the ____. A. Right atrium; aorta B. Left atrium; aorta C. Right ventricle; pulmonary arteries D. Left ventricle; pulmonary arteries

B. Left atrium; aorta

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: A. palpate the artery in the upper one third of the neck. B. listen with the bell of the stethoscope to assess for bruits. C. palpate both arteries simultaneously to compare amplitude. D. instruct patient to take slow deep breaths during auscultation.

B. Listen with the bell of the stethoscope to assess for bruits

The nurse is preparing to examine a client who reports right lower abdominal pain. The nurse's priority would be to: A. Palpate the tender area first. B. Palpate the tender area last. C. Avoid palpating the tender area. D. Notify the physician.

B. Palpate the tender area last

An analgesic medication has been prescribed for a client with headaches. The client tells the clinic nurse that he would like to take an herbal substance to help treat his headaches. The nurse should take which action? A: Tell the client that if he takes the herbal substance, he will need to drink plenty of fluids to hydrate B: Encourage the client to discuss the use of an herbal substance with the health care provider (HCP) C: Tell the client that herbal substances are not safe and should never be used D: Advise the client to read labels of herbal therapies closely

B: Encourage the client to discuss the use of an herbal substance with the health care provider (HCP)

Upon receiving the patient's lab results, the nurse notes the patient has an increased level of carbon dioxide in the blood. Which of the following conditions would the patient be experiencing? A. Resonance B. Hypercapnia C. Fremitus D. Tachypnea

B: Hypercapnia

When performing a physical assessment, the technique the nurse will always use first is: A: Palpation B: Inspection C: Percussion D: Auscultation

B: Inspection

What must the nurse assess first when providing culturally competent health care to an Asian American client? A: The tradition of the Asian American culture and the health care practices related to health and wellness B: The nurse's heritage-based cultural values, beliefs, attitudes, and practices C: Any differences between the nurse's culture and the Asian American culture D: The attitudes of Asian American cultures to the health care system in the U.S.

B: The nurse's heritage-based cultural values, beliefs, attitudes, and practices

The nurse notices a colleague is preparing to check the blood pressure of a client who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to: A: Yield a falsely low blood pressure. B: Yield a falsely high blood pressure. C: Be the same, regardless of cuff size. D: Vary as a result of the technique of the person performing the assessment.

B: Yield a falsely high blood pressure.

The nurse is assessing the ear of an adult client. How should the nurse perform the examination? A. Pull the pinna down and insert scope B. Insert the scope straight into the ear C. Pull the pinna up and back and insert the scope D. Tilt the scope to the angle of the ear

C. Pull the pinna up and back and insert the scope

If a client has a drinking problem, which statement by the nurse is most appropriate? A) "If you continue to drink, you might develop serious health problems. It is up to you to find help and the way to quit." B) "I want you to record how much you drink over the next 2 to 3 months. This will help you to determine if you have a drinking problem." C) "I believe that you have an alcohol problem and strongly recommend that you quit drinking. I am willing to help." D) "Your alcohol consumption is not that bad. You only need to cut down on the amount by drinking only on the weekend."

C) "I believe that you have an alcohol problem and strongly recommend that you quit drinking. I am willing to help."

A nurse is explaining to a colleague how to avoid interview traps when assessing a client. Which of the following statements by the colleague indicates the need for further education?" A) "I should keep the introduction short/formal." B) "I should ask follow-up questions." C) "I should interrupt the client if he/she talks too much." D) "I should use a trained interpreter when necessary."

C) "I should interrupt the client if he/she talks too much."

During the interview, a client reveals to the nurse that she has been having a large amount of vaginal discharge and itching. She is worried that it may be a sexually transmitted infection. An appropriate response to this would be: A) "Oh, don't worry. Some cyclic vaginal discharge is normal." B) "Have you been engaging in unprotected sexual intercourse?" C) "I'd like some information about the discharge. What color is it?" D) "Have you had any urinary incontinence associated with the discharge?"

C) "I'd like some information about the discharge. What color is it?"

During the assessment of the biceps reflexes, the nurse finds that a client's responses are normal bilaterally. The nurse would be correct in documenting this finding as ____ +. A) 3+ B) 1+ C) 2+ D) 4+

C) 2+

The nurse is assessing an 80-year-old client. Which of these findings would be expected for this client? A) Hypertrophy of the gums B) An increased production of saliva C) A decreased ability to identify odors D) Finer and less prominent nasal hair

C) A decreased ability to identify odors

During a clinical rotation at the hospital you and another student are discussing a client you cared for that day on the elevator. As a student, your role should involve which of the following? Select all that apply: A) Sharing your computer password with another student B) Sharing client information with family and friends C) Asking questions if unsure D) Limiting patient specific information that is discussed in public areas of the hospital

C) Asking questions if unsure D) Limiting patient specific information that is discussed in public areas of the hospital

Which of the following would NOT be appropriate to assist a female client in preparing for a vaginal examination? A) Have the client empty her bladder. B) Ask the client if she would like a family member, friend or chaperone present. C) Assume that the client has had a vaginal exam before and has no questions. D) Instruct the client to inform you of any pain or discomfort during the exam.

C) Assume that the client has had a vaginal exam before and has no questions.

A female client tells the nurse that she has been very unsteady and has had difficulty maintaining her balance. The nurse suspects this could be due to dysfunction of which area of the brain? A) Thalamus B) Brainstem C) Cerebellum D) Extrapyramidal tract

C) Cerebellum

A client tells the nurse he is having numbness on the left side of his face. The nurse asks him to close his eyes and touches a cotton ball to his forehead, chin, and both cheeks.The nurse is testing the function of which cranial nerve? A) Cranial Nerve III B) Cranial Nerve IV C) Cranial Nerve V D) Cranial Nerve VII

C) Cranial Nerve V

The nurse is performing an oral assessment and asks the client to stick out his tongue and say "ahh." She notes that his uvula deviates to one side. She suspects there may be damage to which cranial nerve? A) Cranial Nerve IX B) Cranial Nerve XII C) Cranial Nerve X D) Cranial Nerve VII

C) Cranial Nerve X

A client was admitted to the ED with slurred speech. The nurse notes that this could be due to dysfunction of what cranial nerve(s)? A) Cranial Nerve I B) Cranial Nerve V C) Cranial Nerves IX and X D) Cranial Nerve III

C) Cranial Nerves IX and X

A 92-year-old client has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? A) Epistaxis B) Rhinorrhea C) Dysphagia D) Xerostomia

C) Dysphagia

The nurse is inspecting a female client's perianal area. Which of the following assessment findings, if noted, would be considered abnormal? A) Smooth and even colored sacrococcygeal area B) Dark pink colored labia minora C) Excoriation, inflammation or swelling D) Moist, hairless anus

C) Excoriation, inflammation or swelling

The Glasgow Coma Scale (GCS) is used to measure all of the following functions except: A) Motor Response B) Verbal Response C) Limb Ataxia D) Eye opening

C) Limb Ataxia

The nurse is charting on a client's eye assessment and notes PERRLA. What does this stand for? A. Pupils Equal, Rigid, React to Light, and Accessible B. Pupils Even, Right, React to Light, and Accommodation C. Pupils Equal, Round, React to Light and Accommodation D. Pupils Even, Rigid, Restrict from Light, and Accommodation

C. Pupils Equal, Round, React to Light and Accommodation

A nurse is assessing a client recently diagnosed with Parkinson's Disease. What abnormal body movements are typically associated with the disease? A) Myoclonus B) Fasciculations C) Resting tremors D) Tics

C) Resting tremors

The nurse is calling the health care provider about a client's changing condition. Which of the following would be included in the SBAR communication? A) Situation, background, all vitals, and review of orders B) Summary, better plan, accurate diagnosis, and rights C) Situation, background, assessment, and recommendation D) Subjective information, background, assessment, and revisions needed

C) Situation, background, assessment, and recommendation

A female client calls out to the nurse stating, "I see spiders on my arm." The nurse suspects the client is displaying symptoms of delirium. Which tool should the nurse use when assessing this client? A) The Glasgow Coma Scale B) The Neurologic Recheck Examination C) The Confusion Assessment Method (CAM) D) The Complete Neurologic Examination

C) The Confusion Assessment Method (CAM)

Which of the following statements it true regarding the olfactory nerve (CN 1)? A)The Olfactory Nerve is tested by having the client shrug their shoulder. B) The Olfactory Nerve is tested by having the client say "light, tight, dynamite." C) The Olfactory Nerve is tested by having the client smell a familiar substance like coffee, lemon or vanilla. D) The Olfactory Nerve is tested by having the client stick the tongue out.

C) The Olfactory Nerve is tested by having the client smell a familiar substance like coffee, lemon or vanilla.

Fill in the blank: A nurse in a rehabilitation unit is performing the Get Up and Go Test on his client prior to discharge. The client's wife asks what this test is used to assess and how it is performed. A correct response would be the test is used to assess ______ by observing ________. A) The client's swallowing status; the client eating a meal. B) The client's mood; the client interacting with others. C) The client's fall risk; the client's gait balance and sitting balance. D) The client's toileting; the client's ability to pull his pants up and down.

C) The client's fall risk; the client's gait balance and sitting balance.

The nurse is examining a client's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? A) Sticky honey-colored cerumen is a sign of infection. B) The presence of cerumen is indicative of poor hygiene. C) The purpose of cerumen is to protect and lubricate the ear. D) Cerumen is necessary for transmitting sound through the auditory canal.

C) The purpose of cerumen is to protect and lubricate the ear.

An 18-year-old is at the clinic for "a sore throat lasting 6 days." The nurse is aware that which of these findings would be consistent with an acute infection? A) Tonsils 1+/1-4+ and pink, same color as oral mucosa B) Tonsils 2+/1-4+ with small plugs of white debris C) Tonsils 3+/1-4+ with large white spots D) Tonsils 3+/1-4+ with pale coloring

C) Tonsils 3+/1-4+ with large white spots

A client is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: A) flexion B) abduction C) adduction D) extension

C) adduction

A client has been shown to have sensorineural hearing loss. During the assessment, it would be important for the nurse to: A) speak loudly so he can hear the questions. B) assess for middle ear infection as a possible cause. C) ask the patient what medications he is currently taking. D) look for the source of the obstruction in the external ear.

C) ask the patient what medications he is currently taking.

A client with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the client that the middle ear functions to: A) maintain balance. B) interpret sounds as they enter the ear. C) conduct vibrations of sounds to the inner ear. D) increase amplitude of sound for the inner ear to function.

C) conduct vibrations of sounds to the inner ear.

The nurse suspects that a client has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the client to: A) dorsiflex the foot B) plantarflex the foot C) hold both hands back to back while flexing the wrists for 60 seconds D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds

C) hold both hands back to back while flexing the wrists for 60 seconds

The nurse is assessing a client in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? A)"We will need to get a biopsy and see what the cause is." B)"This is an overgrowth of hair and will go away in a few days." C)"This is a fungal infection caused by all the antibiotics you've received." D)"This is probably caused by the same bacteria you had in your lungs."

C)"This is a fungal infection caused by all the antibiotics you've received."

The nurse is teaching the patient about health promotion of the cardiovascular system. Which of the following statements would indicate a need for further teaching? A. "I would like some information about ways to help me quit smoking." B. "I should try to cut down on the amount of saturated fat I eat in my diet." C. "Even though my dad had a heart attack, I don't need to get screened for heart issues earlier than anyone else." D. "I should try to start an aerobic exercise program."

C. "Even though my dad had a heart attack, I don't need to get screened for heart issues earlier than anyone else."

A nurse is performing an assessment on a client. Which of the following statements demonstrates her understanding of the rationale for correct sequencing for an abdominal assessment? A. "It is important to sequence the exam to prevent distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation." B. "It is important to sequence the exam to determine areas of tenderness before using percussion and palpation." C. "It is important to sequence the exam to avoid distorting the client's bowel sounds." D. "It is important to sequence the exam to allow the client more time to relax and be more comfortable with the physical examination."

C. "It is important to sequence the exam to avoid distorting the client's bowel sounds."

The nurse is educating a client on breast self-examination (BSE). Which of these statements by the client indicates understanding of the proper BSE technique? A. "The best time to perform the BSE is in the middle of my menstrual cycle." B. "A woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue." C. "The best time to perform the BSE is 4 to 7 days after the first day of my menstrual cycle." D. "I do not need to perform a BSE until after my baby is born."

C. "The best time to perform the BSE is 4 to 7 days after the first day of my menstrual cycle."

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: A. Mitral and tricuspid B. Tricuspid and aortic C. Aortic and pulmonic D. Mitral and pulmonic

C. Aortic and pulmonic

When assessing an African American patient, the nurse knows that the best way to assess for cyanosis is to: A. Assess the sclera, hard palate, mucous membranes, and skin B. Assess sclera, junction of the hard & soft palates, & palms. C. Assess conjunctivae, oral mucosa, & nail beds D. Assess nail beds, lips, & face

C. Assess conjunctivae, oral mucosa, & nail beds

During an examination of a client, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? A. Breasts should always be symmetric. B. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. C. Asymmetry is not unusual, but the nurse should verify that this change is not new. D. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth.

C. Asymmetry is not unusual, but the nurse should verify that this change is not new.

The nurse is caring for a client who reports having abdominal pain. After inspecting the client's abdomen, the nurse would be correct in performing what assessment technique? A. Deep palpation B. Percussion C. Auscultation D. Light palpation

C. Auscultation

Which of the following pulses should the nurse assess bilaterally, but separate or one at a time? A.Ulnar B. Posterior tibial C. Carotid D. Radial

C. Carotid

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? A. Absent or decreased breath sounds B. Productive cough with thin, frothy sputum C. Chest pain that is worse on deep inspiration and dyspnea D. Diffuse infiltrates with areas of dullness on percussion

C. Chest pain that is worse on deep inspiration and dyspnea

A client database consists of all of the following except: A. Subjective data B. Objective data C. Client Safety D. Laboratory & other diagnostic test results

C. Client Safety

When assessing a client's lungs, the nurse recalls that the left lung: A. is shorter than the right lung because of the underlying stomach B. is divided by the horizontal fissure C. Consists of two lobes D. primarily consist of an upper lobe on the posterior chest

C. Consists of two lobes

During an assessment of a 20-year-old client with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: A. Normal oral assessment B. Side effects from nausea medication. C. Dehydration D. Irritation by gastric juices

C. Dehydration

All of the following are interviewing traps or non-therapeutic communication except: A. Using avoidance language B. Leading/biased questions C. Empathy D. False reassurance

C. Empathy

When assessing the pupillary light reflex, the nurse should use which technique? A. Shine a penlight from directly in front of the patient and inspect for pupillary constriction. B. Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction. C. Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. D. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose.

C. Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction.

When assessing the pupillary light reflex, the nurse should use which technique? A. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction B. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose. C. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. D. Shine a penlight from directly in front of the patient, and inspect for pupillary dilation.

C. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.

A client's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. A.Low gurgling; bell B. Loud, whooshing, blowing; diaphragm C. Soft, whooshing, pulsatile; bell D. High-pitched tinkling; diaphragm

C. Soft, whooshing, pulsatile; bell

During the physical examination, the nurse notices that the client has an inverted left nipple. Which statement regarding this is most accurate? A. Normal nipple inversion is usually bilateral. B. Unilateral inversion of a nipple is always a serious sign. C. The nurse should determine whether the inversion is a recent change. D. Nipple inversion is not significant unless accompanied by an underlying palpable mass.

C. The nurse should determine whether the inversion is a recent change.

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? A. To measure the rate of lymphatic drainage B. To evaluate the adequacy of capillary patency before venous blood draws C. To evaluate the adequacy of collateral circulation before cannulating the radial artery D. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

C. To evaluate the adequacy of collateral circulation before cannulating the radial artery

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? A. To measure the rate of lymphatic drainage B. To evaluate the adequacy of capillary patency before venous blood draws C. To evaluate the adequacy of collateral circulation before cannulating the radial artery D. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

C. To evaluate the adequacy of collateral circulation before cannulating the radial artery

The nurse is palpating a client's breasts during a seated examination. She notes the client has large pendulous breasts. What is the most appropriate course of action for the nurse to take? A. Have a physician perform the assessment B. Have another nurse continue the assessment C. Use the bimanual technique to perform the assessment D. Refer the client for a breast scan

C. Use the bimanual technique to perform the assessment

The Acoustic (Vestibulocochlear) nerve (CN VIII) Test: A. Diagnostic positions test B. Visual acuity, visual fields, looking in the eyes with an ophthalmoscope C. Whispered word test D. Testing ROM and strength of the neck, shoulder and head muscles.

C. Whispered word test

In using the ophthalmoscope to assess a client's eyes, the nurse notices a red glow in the pupils. On the basis of this finding, the nurse would: A. suspect that there is an opacity in the lens or cornea. B. check the light source of the ophthalmoscope to verify that it is functioning. C. consider this a normal reflection of the ophthalmoscope light off the inner retina. D. continue with the ophthalmoscopic examination and refer the patient for further evaluation.

C. consider this a normal reflection of the ophthalmoscope light off the inner retina.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: A. at 30 feet the patient can read the entire chart B. the patient can read from 30 feet what a person with normal vision can read from 20 feet C. the patient can read at 20 feet what a person with normal vision can read at 30 feet D. the patient can read the chart from 20 feet in the left eye and 30 feet in the right eye

C. the patient can read at 20 feet what a person with normal vision can read at 30 feet

The nurse is auscultating a patient's lungs and hears discontinuous, high-pitched, short, popping sounds heard during inspiration, and not cleared by coughing. These are described as: A. Bradypnea B. Rhonchi C. Crackles D. Wheezing

C: Crackles

Which is the best nursing intervention regarding complementary and alternative medicine? A: Advising the client about "good" versus "bad" therapies B: Discouraging the client from using any alternative therapies C: Educating the client about therapies that he or she is using or is interested in using D: Identifying herbal remedies that the client should request from the health care provider (HCP)

C: Educating the client about therapies that he or is using or is interested in using.

You are assessing the orientation of an 85-year-old man. Which of the following indicates that he is oriented to person, place, time, and situation? The client: A: States he is in the hospital, knows the day of the week, does not remember your name. B: Knows the name of the city he is in, does not know the correct time of day, knows his own name. C: He knows his own name, states he is in a hospital (knows what hospital), knows the date, and states he had a heart attack. D: Names the hospital and city it is in, does not know the month or day of the week, knows his own name and your name.

C: He knows his own name, states he is in a hospital (knows what hospital), knows the date, and states he had a heart attack.

You have been approached by a client's spouse who is concerned about his "excessive drinking." You know that all of the following are appropriate interventions except: A: Advise & assist as needed. B: Recommend that they cut down. C: Inform the spouse that the client will be "okay." D: Referral to a counselor.

C: Inform the spouse that the client will be "okay."

At the beginning of rounds, when the nurse enters the room, what should the nurse do first? A) Check the infusion pump settings for accuracy B) Check the intravenous infusion site for redness or swelling C) Offer the client something to drink D) Make eye contact with the client and introduce himself or herself as the client's nurse

D) Make eye contact with the client and introduce himself or herself as the client's nurse

The nurse is assessing the support system an older client has before she is discharged. She correctly identifies the following as examples of the client's informal source of support: A) The local senior center B) Her Medicare check C) Meals on Wheels meal delivery service D) Her neighbor, who visits with her daily

D) Her neighbor, who visits with her daily

All of the following is required equipment you would use for a complete head to toe assessment except: A) Tuning fork B) Platform scale with height attachment C) Stethoscope with bell and diaphragm end pieces D) Hoyer lift

D) Hoyer lift

The FIRST assessment technique that the professional nurse should use when assessing a client is: A) Auscultation B) Palpation C) Percussion D) Inspection

D) Inspection

A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" A correct response would be: A) "It depends. Do you smoke?" B) "A Pap test needs to be performed annually until you are 65 years of age." C) "If you have two consecutive normal Pap tests, then you can wait 5 years between tests." D) "After age 30, if you have three consecutive normal Pap tests, then you may be screened every 3 years."

D) "After age 30, if you have three consecutive normal Pap tests, then you may be screened every 3 years."

The nurse is giving report to the next shift and is using the situation, background, assessment, recommendation (SBAR) framework for communication. Which of these statements reflects the Background portion of the report? A) "I'm worried that his gastrointestinal bleeding is getting worse." B) "We need an order for oxygen." C) "My name is Ms. Smith, and I'm giving the report on Mrs. X in room 1104." D) "He is 4 days postoperative, and his incision is open to air."

D) "He is 4 days postoperative, and his incision is open to air."

The nurse is teaching a male client the best way to perform a testicular self-examination. Which of these statements best describes the correct information? A) "The testicle is pear-shaped and immovable. It feels firm and has a lumpy consistency." B) "Perform a testicular exam at least once a week to detect the early stages of testicular cancer." C) "A good time to examine your testicles is just before you take a shower." D) "If you notice an enlarged testicle or a painless lump, call your health care provider."

D) "If you notice an enlarged testicle or a painless lump, call your health care provider."

The nurse is taking the history of a client who may have a perforated eardrum. What would be an important question in this situation? A) "Do you ever notice ringing or crackling in your ears?" B) "When was the last time you had your hearing checked?" C) "Have you ever been told you have any type of hearing loss?" D) "Was there any relationship between the ear pain and the discharge you mentioned?"

D) "Was there any relationship between the ear pain and the discharge you mentioned?"

A 75 year old client with an enlarged prostate is concerned because he has trouble sleeping. He states, "I have to pee about 6 or 7 times a night and it just drips." A correct response would be: A) "You probably have a bladder infection. We'll need to give you antibiotics." B) This is a natural part of the aging process." C) "This is the way the kidney removes bacteria from the body." D) "You may want to cut back on drinking fluids about 3 hours before bedtime."

D) "You may want to cut back on drinking fluids about 3 hours before bedtime."

When assessing muscle strength, the nurse observes that a client has complete range of motion against gravity with full resistance. What Grade should the nurse record using a "0 to 5" point scale? A) 2 B) 3 C) 4 D) 5

D) 5

The nurse is performing a perianal assessment of a female client and notes copious, foul-smelling vaginal discharge. A correct assessment of this finding is that this is: A) A Pilonidal cyst B) Carcinoma C) Poor hygiene D) A vaginal infection

D) A vaginal infection

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor? A) Increased vascularity of the skin in the elderly B) Increased numbers of sweat and sebaceous glands in the elderly C) An increase in elastin and a decrease in subcutaneous fat in the elderly D) An increased loss of elastin and a decrease in subcutaneous fat in the elderly

D) An increased loss of elastin and a decrease in subcutaneous fat in the elderly

The nurse is aware that intimate partner violence (IPV) screening should occur with which situation? A) When a history of abuse in the family is known B) When IPV is suspected C) When a woman has an unexplained injury D) As a routine part of each health care encounter

D) As a routine part of each health care encounter

In which of the following ways does the electronic health record (EHR) increase client safety? It: A) Decreases transcription and prescribing errors B) Notifies providers of medication interactions C) Means the provider must be physically present on the floor to write orders D) Both A & B

D) Both A & B

A nurse suspects that her client may have suffered a stroke. Which tools can the nurse use to confirm her suspicions? A) R.A.C.E B) NIH Scale C) F.A.S.T D) Both B and C

D) Both B and C

A female client has just been diagnosed with Human papillomavirus (HPV) and genital warts. The nurse should counsel her to receive regular examinations because this virus places her at a higher risk for which disease process? A) Bladder Infection B) Uterine Prolapse C) Ovarian Cysts D) Cervical Cancer

D) Cervical Cancer

A female client is in the clinic with weakness in her left arm and leg that she has noticed for the past week. Which type of neurologic examination would be MOST APPROPRIATE for the client? A) Glasgow Coma Scale B) Neurologic Recheck Examination C) Neurologic Screening Examination D) Complete Neurologic Examination

D) Complete Neurologic Examination

The nurse is using the diagnostic positions test to asses her client's extraocular eye movements. She notes parallel tracking of both eyes. She would be correct in documenting normal findings for which cranial nerve(s)? A) Cranial Nerve VII B) Cranial Nerve I C) Cranial Nerve II D) Cranial Nerves III, IV & VI

D) Cranial Nerves III, IV & VI

The nurse is assessing a client who has a hearing impairment. How should the nurse communicate with this client? A) Use a low tone and speak slowly. B) Use a normal tone of voice and speak slowly. C) Speak loudly with a normal rate. D) Face the client and speak slowly.

D) Face the client and speak slowly.

A nurse is performing a client assessment. Which of these clinical situations, if noted, should the nurse consider to be outside normal limits? A. The client has had one pregnancy. Her breast examination reveals breasts that are soft and slightly sagging. B. The client has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. C. The client has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is somewhat engorged. She states that the examination was slightly painful. D. The client has had two pregnancies. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.

D. The client has had two pregnancies. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.

The purpose of health history is to collect subjective data, which is: A. Verifiable by another person B. What you observe through measurement, inspection, palpation, percussion, and auscultation C. The reason for seeking care D. What the person says about himself or herself

D. What the person says about himself or herself

Spinal accessory Nerve (CN XI) Test: A. Diagnostic positions test B. Visual acuity, visual fields, looking in the eyes with an ophthalmoscope C. Whispered word test D. Testing ROM and strength of the neck, shoulder and head muscles.

D. testing ROM and strength of the neck, shoulder, and head muscles

A client is admitted with a drinking problem. Which statement by the nurse would be most appropriate? A: "Your alcohol consumption is not that bad. You only need to cut down on the amount by drinking only on the weekend." B: "I want you to record how much you drink over the next 2 to 3 months. This will help you to determine if you have a drinking problem." C: "If you continue to drink, you might develop serious health problems. It is up to you to find help and the way to quit." D: "I believe that you have an alcohol problem and strongly recommend that you quit drinking. I am willing to help."

D: "I believe that you have an alcohol problem and strongly recommend that you quit drinking. I am willing to help."

When assessing the quality of a client's pain, the nurse should ask which question? A: "When did the pain start?" B: "How bad is it?" C: "Where does it radiate?" D: "What does your pain feel like?"

D: "What does your pain feel like?"

Which of the following clients is at the highest risk for nutritional deficits? A: A 5-month-old infant who is only being breastfed B: A 2-year-old toddler who is in the 50th percentile C: An 13-year-old female who is 5'3" and weighs 110 lbs and thinks she's "fat" D: A 65-year-old female who is on a fixed income and is taking five medications

D: A 65-year-old female who is on a fixed income and is taking five medications

While completing a pain assessment, the client tells you that her shoulder pain started 2 days ago after moving heavy boxes. Which type of pain is she describing? A: Chronic pain B: Referred pain C: Nociceptive pain D: Acute pain

D: Acute pain

The nurse is assessing a 43 year old client who is 5'4" and weighs 274 pounds. His blood pressure is 180/74 (hypertension) and he is complaining of back pain. What other risk factor should this client be concerned with considering his history? A: Type II Diabetes Mellitus B: Coronary Artery Disease C: Colon Cancer D: All the above

D: All of the above

While mentoring a colleague in the clinical setting he asks what questions would be appropriate to help in evaluating a client's spiritual health. A correct response would be, ask the client: A: Are you in need of religious/spiritual or emotional support? B: Tell me what life means to you. C: Is this illness causing any major life changes for you or a loved one? D: All the above

D: All the above

The nurse is assessing a client's pain. The nurse knows that the most reliable indicator of pain would be the: A: client's vital signs. B: physical examination. C: results of a computerized axial tomography scan. D: client's subjective report

D: Client's subjective report

What is an integral factor in responding adequately to the health care needs of a 41-year-old African American woman? A: Racial awareness. B: Political correctness. C: Ethnocentrism. D: Cultural competence.

D: Cultural competence

Which of these is a necessary tool for building cultural competence? A: Cultural Competency Assessment Tool B: Health Risk Assessment Tool C: Ethnic Identity Tool D: Heritage Assessment Tool

D: Heritage Assessment Tool

The nurse is about to take a client's oral temperature. When would the nurse need to choose an alternate route such as axillary, tympanic or rectal? A:If the client was getting ready to eat breakfast B: If the client was being taken for a procedure C: If the client had been laying in bed for 15 minutes D: If the client had just taken a drink of a cold beverage

D: If the client had just taken a drink of a cold beverage

You are performing an admission assessment on a 23 year old college student. You are reviewing developmental tasks appropriate for her age according to Erikson. A correct assessment is that the client should be: A: Reviewing & redirecting career goals B: Attaining desired career performance C: Arranging safe & satisfactory living quarters D: Making friends & establishing a social group

D: Making friends & establishing a social group

The nurse notices the client is grimacing, guarding her abdomen, and crying. She documents this as which type of pain behavior? A: Verbal pain behaviors B: Cutaneous pain C:Visceral pain D: Nonverbal pain behaviors

D: Nonverbal pain behaviors

The nurse is caring for a client in the ED who has been a client many times before in the ED. In fact, this is the client's second overdose in one month. The nurse says, "Here we go again. I don't know why we bother with this guy, because he will be back out there as soon as he is discharged". The nurse: A: is not being professional and cannot give unbiased care. B: is obligated to provide care. C: is not obligated to provide care. D: must find a way to come to terms with the way he or she feels about these types of issues and work on ways to deal with them.

D: must find a way to come to terms with the way he or she feels about these types of issues and work on ways to deal with them.