Health Promotion and Disease Prevention (MODULE 2)

A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding?

Accommodation Rationale: Accommodation is adaptation of the eye for near vision. Movement of the ciliary muscles increases the curvature of the lens. To observe accommodation, the examiner notes convergence (motion toward) of the axes of the eyeballs and pupillary constriction. Myopia is nearsightedness. Hyperopia is farsightedness. Photophobia is abnormal sensitivity to light, especially of the eyes.

A nurse is reviewing the healthcare record of a client who has just undergone an examination of the internal genitalia. Which of the following documented findings indicates an abnormality?

Clear secretions with a foul odor are noted on the cervix. Rationale: Normally the cervix is pink, midline, and about 1 inch in diameter. Depending on the day of the menstrual cycle, secretions may be clear and thin or thick, opaque, and stringy. Secretions should always be odorless and nonirritating. Secretions with a foul odor are associated with infection.

A nurse is preparing to assist the physician in performing an internal gynecological examination of a client. In which of the following positions does the nurse place the client for this examination?

Lithotomy Rationale: An internal gynecological examination is performed with the client in the lithotomy position. In this position, the client is supine, with the feet in stirrups, the knees apart, and the buttocks at the end of the examining table. The client is draped so that only the vulva is exposed. In the prone position, the client would be lying on her stomach. The Sims position, a left side-lying position, is most often used in administering an enema.

A nurse performing an eye examination uses an ophthalmoscope to best visualize which of the following areas?

Optic disc Rationale: The ophthalmoscope enlarges the examiner's view of the eye so that the media (anterior chamber, lens, vitreous humor) and the ocular fundus (the internal surface of the retina) can be examined. The optic disc is located on the internal surface of the retina. The iris, conjunctiva, and cornea can be examined without the use of an ophthalmoscope.

A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat words that are:

Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested Rationale: In performing the voice test, the nurse tests one ear at a time while masking hearing in the other ear to prevent transmission around the head. The nurse shields his or her lips so that the client cannot compensate for hearing loss (consciously or unconsciously) by lip-reading or using the "good" ear. The nurse stands 1 to 2 feet from the client's ear, exhales, and slowly whispers some two-syllable words. A client with normal hearing repeats each word correctly.

A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing:

Intermittent claudication Rationale: Leg pain characteristic of peripheral artery disease is known as intermittent claudication. Usually the client can walk only a certain distance before cramping, burning, muscle discomfort, or pain forces him or her to stop; the pain subsides after rest. When the client resumes walking, he or she can walk the same distance before the pain returns. The pain is reproducible. As the disease progresses, the client walks shorter and shorter distances before pain recurs. Ultimately pain may even occur while the client is at rest. Therefore the other options are incorrect.

A nurse performing a physical examination is assessing the client for costovertebral angle tenderness. When the nurse percusses the area, the client complains of sharp pain. The nurse interprets this finding as most indicative of:

Kidney inflammation Rationale: When assessing for costovertebral angle tenderness, the nurse is checking for kidney tenderness. Sharp pain that occurs on percussion of the costovertebral angle indicates inflammation of the kidney or paranephric area. To assess the kidney, the nurse places one hand over the 12th rib, at the costovertebral angle, on the back. The nurse then thumps that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver, or spleen enlargement are not associated with the costovertebral angle.

A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. The nurse interprets this to mean that the client:

Can read at a distance of 20 feet what a client with normal vision can read at 80 feet Rationale: When recording the results of visual acuity testing with the use of the Snellen chart, the nurse would use the numeric fraction noted at the end of the last line on the chart read successfully by the client. The top number (numerator) indicates the distance the client is standing from the chart; the denominator is the distance at which a normal eye could have read that particular line. Therefore a reading of 20/80 means that the client can read at a distance of 20 feet what a client with normal vision can read at 80 feet.. Legal blindness is defined as the best corrected vision in the better eye of 20/200 or worse. Normal visual acuity is 20/20.

Performing an abdominal assessment, a nurse notes tenderness while lightly palpating a client's right lower quadrant. The nurse determines that this finding is most likely associated with which of the following anatomic structures?

Appendix Rationale: The appendix is located in the right lower quadrant. The spleen is a soft mass of lymphatic tissue located on the posterolateral wall of the abdominal cavity, immediately under the diaphragm. The pancreas is a soft lobular gland located behind the stomach. The liver fills most of the right upper quadrant and extends over to the left midclavicular line.

On assessing a client's skin, the nurse notes the presence of several large red-blue and purple areas on the client's body that do not blanch when pressure is applied. The nurse documents this finding as:

Ecchymosis Rationale: Ecchymosis refers to a large patch of capillary bleeding into the tissues (bruise). The color of such an area changes from red-blue or purple to green, yellow, and brown before the area disappears. Pressure on the area will not cause it to blanch. Psoriasis is noted as scaly erythematous patches with silvery scales on top that usually occur on the scalp, the outsides of elbows and knees, the low back, and the anogenital area. Bilateral edema or edema that is generalized over the entire body is known as anasarca. This finding is indicative of a central problem such as congestive heart failure or kidney failure. Petechiae are tiny purple or red spots that appear on the skin as a result of tiny hemorrhages within the dermal and subdermal areas.

An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse concludes that:

The client has a normal cardiac output Rationale: In the normal resting adult, the heart pumps between 4 and 6 L of blood per minute throughout the body. This cardiac output equals the volume of blood in each systole (called stroke volume) multiplied by the number of beats per minute. Therefore a cardiac output of 5 L/min is a normal cardiac output. The other options are incorrect interpretations.

The nurse, performing an abdominal examination, inspects the client's abdomen. Which assessment technique does the nurse perform next?

Auscultation Rationale: The assessment techniques used for a physical examination are inspection, palpation, percussion, and auscultation. These techniques are performed one at a time and normally in this order. The exception to this order is an abdominal examination: During the abdominal examination, auscultation is performed after inspection and before palpation and percussion, because palpation and percussion can increase peristalsis, which would yield a false interpretation of bowel sounds.

A nurse in the emergency department is performing a musculoskeletal assessment of a client. The presence of which of the following conditions would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

Neck trauma Rationale: A nurse performing a musculoskeletal assessment would not test ROM in a client who has sustained neck trauma, which may have resulted in a cervical fracture. If a cervical fracture is present, further movement of the neck could result in spinal cord injury. ROM testing does not need to be avoided if the client is experiencing a headache, sinus infection, or muscle spasms.

A nurse teaches a client about healthy dietary measures and explains the MyPlate food plan. The nurse determines that the client understands the information if the client says how many of his grains should be whole grains?

One-half Rationale: According to the MyPlate food plan, at least half of grains eaten daily should be whole grains. While it is acceptable to make more than half of your grains whole grains, MyPlate does not require it.

A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?

Right lower quadrant Rationale: When auscultating bowel sounds, the nurse uses the diaphragm endpiece, because bowel sounds are relatively high pitched. The nurse holds the stethoscope lightly against the skin, because pushing too hard could stimulate more bowel sounds. The nurse begins auscultating in the right lower quadrant at the ileocecal valve, because bowel sounds are normally always present there. The nurse then listens for bowel sounds in the other quadrants.

A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data?

A 1 × 2-inch scar is present on the lower right portion of the abdomen. Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client's last menstrual period, and the reported use of medication for headaches are all subjective data.

A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as:

Abnormal bronchophony Rationale: The quality of voice resonance can be performed by testing for the presence of bronchophony, egophony, and whispered pectoriloquy. In bronchophony, the nurse asks the client to repeat the word "ninety-nine" as the nurse listens to the client's chest with a stethoscope. Normal voice transmission is soft, muffled, and indistinct. The nurse normally hears sound through the stethoscope but cannot distinguish exactly what is being said. A pathologic condition that increases lung density enhances the transmission of voice sounds; in such a case, the nurse will hear "ninety-nine" clearly. Vesicular breath sounds are heard over peripheral lung fields where air flows through smaller bronchioles and alveoli. In egophony, the client's chest is auscultated while the client phonates a long "ee-ee-ee-ee" sound. Normally the nurse hears "eeeeee" through the stethoscope. In whispered pectoriloquy, the client is asked to whisper a phrase such as "one-two-three" as the nurse listens to the chest. The normal response is a muffled, almost inaudible sound.

A 16-year-old girl visits the women's health clinic to obtain information about birth control because she is sexually active and wants to avoid pregnancy. The nurse who is interviewing the client should first:

Assess the client's knowledge of available birth control methods Rationale: Learning occurs more readily when new information complements existing knowledge. Therefore it is important for the nurse to assess the client's level of knowledge of the subject matter. Although the use of written material assists in the learning process, this would not be the first nursing intervention. Telling the client that because of her age and lifestyle birth control pills would be the easiest method of contraception provides advice from the nurse's perspective and does not allow the client the opportunity to make her own decision. Telling the client that birth control methods cannot be discussed unless the client's boyfriend is present is incorrect and nontherapeutic.

A nurse is preparing to perform a skin examination with the use of a Wood light. In preparing for this diagnostic test, the nurse should:

Darken the room Rationale: A handheld long-wavelength ultraviolet (black) light, or Wood light, is sometimes used during physical examination of the skin. Areas of blue-green or red fluorescence are associated with certain skin conditions. Hypopigmented skin appears more prominent when it is viewed under black light, greatly facilitating the evaluation of pigment changes in fair-skinned clients. Examination of the skin is always carried out in a darkened room. The test is noninvasive, and the nurse should reassure the client that no discomfort is associated with a Wood light examination.

A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting:

Data related to the respiratory system Rationale: An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals.

A nurse performing a neurological assessment is inspecting the client's eyelids for ptosis. The nurse checks the client for:

Drooping Rationale: Ptosis, a drooping of the eyelids, can occur as a result of disorders such as myasthenia gravis, dysfunction of cranial nerve III, and Bell palsy. Pupil dilation and constriction are checked with the use of a flashlight. Ocular movements are checked by leading the client's eyes through the six cardinal positions of gaze.

At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she states that:

Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down Rationale: BSE is performed monthly and should be carried out after the menstrual period, on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. A woman who is not having menstrual periods should select a specific day of the month and perform BSE on that day each month. BSE is not the only way to detect early breast cancer. Women should get regular physical examinations and mammograms as prescribed. The woman is taught to inspect the breasts while standing in front of a mirror, to palpate the breasts while in the shower (because soap and water assist in palpation), and, finally, to perform palpation while lying supine.

A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign?

Percussing at the location of the median nerve Rationale: The Tinel sign is elicited with direct percussion in the location of the median nerve at the wrist. The test produces no symptoms in the normal hand. In the presence of carpal tunnel syndrome, percussion of the median nerve produces burning and tingling along its distribution (Tinel sign). Asking the client to hold the hands back to back while flexing the wrist 90 degrees is the Phalen test, another test for the presence of carpal tunnel syndrome. Testing the strength of each joint and checking for repetitive movements in the joints involve the assessment of muscle strength and range of motion.

A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells the client that this test measures:

Peripheral vision Rationale: The confrontation test is a gross measure of peripheral vision. It compares the client's peripheral vision with the nurse's, assuming that the nurse's vision is normal. The nurse positions himself or herself at eye level with the client, about 2 feet away, then directs the client to cover one eye with an opaque card and look straight at the nurse with the other eye. The nurse covers the eye opposite the client's covered one. The nurse then holds a pencil or flicking finger as the target, midline between the nurse and the client, and slowly advances it from the periphery in several directions. The nurse asks the client to say "now" as the target is first seen. This should occur just as the nurse sees the object. Near vision is tested with a handheld vision screener that contains various sizes of print. Color vision is tested with the use of the Ishihara test, which comprises a series of cards bearing a pattern of dots printed against a background of many colored dots. Distant vision is tested with the use of a Snellen chart.

A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by:

Placing a tape measure around the widest point of the lower leg Rationale: The nurse uses a nonstretchable tape measure to measure the calf at its widest point, taking care to measure the opposite leg in exactly the same place, the same number of centimeters down from the patella or other landmark. The descriptions in the incorrect options would not provide an accurate measurement of calf circumference.

A nurse conducting a peripheral vascular assessment performs the Allen test. The nurse understands that this test is used to determine the patency of the:

Radial and ulnar arteries Rationale: The nurse would perform the Allen test to determine the patency of the radial and ulnar arteries. The nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While the nurse is applying pressure, the client is asked to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used to obtain a blood specimen.

A nurse is gathering supplies to perform a physical assessment of a client. Which necessary item does the nurse select to perform the Weber test?

Rationale: Tuning fork tests measure hearing by way of air conduction or by bone conduction, in which sound vibrates through the cranial bones to the inner ear. The Weber test is a tuning fork test that is performed when the client reports hearing better with one ear than with the other. In the Weber test, a vibrating tuning fork is placed in the midline of the client's skull and the client is asked whether the tone sounds the same in both ears or better in one. The client should hear the tone by bone conduction through the skull, and it should sound equally loud in both ears. The otoscope, reflex hammer, and stethoscope may be used when performing the physical exam but are not needed to perform the Weber test.

A nurse is examining the peripheral vision of a client using the confrontation test. To carry out this procedure, the nurse:

Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field Rationale: The confrontation test is a gross measure of peripheral vision. It compares the client's peripheral vision with the examiner's vision under the assumption that the examiner's vision is normal. The examiner positions himself or herself at eye level with the client, about 2 feet away. The examiner directs the client to cover one eye with an opaque card and look straight at the examiner with the other. The examiner covers his or her own eye opposite the client's covered one. Next the examiner holds a pencil or flicking finger as a target midline between himself or herself and the client and slowly advances it from the periphery in several directions. The examiner asks the client to say "now" as the target is first seen. This sighting should occur just as the examiner sees the object for the first time. Asking the client to discriminate numbers on a chart composed of colored dots and darkening the room and asking the client to identify colored blocks and shapes that appear in the visual field are both components of testing for color vision.

A nurse is preparing to screen a client's vision with the use of a Snellen chart. The nurse:

Tests the right eye, then tests the left eye, and finally tests both eyes together Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot with the chart at the client's eye level. The client is positioned on a mark exactly 20 feet from the chart. The client uses an opaque card to shield one eye at a time during the test; after each eye is tested, both eyes are assessed together. The client is asked to read through the chart to the smallest line of letters he or she can discern. The client is encouraged to read the next smallest line as well. Therefore the other options are incorrect.

A nurse is preparing to listen to a client's breath sounds. The nurse should:

Use the diaphragm of the stethoscope, holding it firmly against the client's chest Rationale: The nurse asks the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client is asked to breathe through the mouth a little more deeply than usual but is told to stop if he or she begins to feel dizzy. The nurse uses the flat diaphragm endpiece of the stethoscope, holding it firmly on the chest wall, and listens for at least one full respiration in each location, moving from side to side to compare sounds.

A 35-year-old female client asks the clinic nurse when she should begin to have yearly mammograms. What does the nurse tell the client?

Yearly mammograms are recommended starting at age 40. Rationale: The American Cancer Society recommends yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Clinical breast exam should be done about every 3 years for women in their twenties and thirties and every year for women 40 and older. Women should know how their breasts normally look and feel and report any breast change promptly to the healthcare provider. Breast self-exam should be done monthly starting when a woman is in her twenties. The American Cancer Society also recommends that some women, because of their family history, a genetic tendency, or certain other factors, be screened with magnetic resonance imaging in addition to mammograms.

A nurse is providing instructions to a client who is scheduled to undergo a Papanicolaou (Pap) test in one week. Which statement does the nurse make to the client?

"Avoid intercourse for 24 hours before the scheduled examination." Rationale: The Pap test is used to screen for cervical cancer. It is not performed during menses or if a heavy infectious discharge is present. The woman is instructed not to douche, have intercourse, or insert anything into the vagina in the 24 hours before the test. Telling the client to use tampons, douche before the exam, or obtain a sample of the discharge for inspection is incorrect.

A nurse is describing the procedure for testicular self-examination (TSE) to a male client. Which statement should the nurse make to the client?

"If you notice an enlarged testicle or a lump, you need to notify the physician." Rationale: During a shower or bath is the best time to examine the testes, because warm temperatures make the testes hang lower in the scrotum. The testes should feel round and smooth, without lumps. Self-examination should be performed monthly. The physician is to be notified immediately if any abnormalities are found.

During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client?

"I need some more information about the discharge. What color is it?" Rationale: If the client says that she has had some vaginal drainage, the nurse should obtain additional data about the discharge. The nurse would ask about the character and color of the discharge, when the discharge began, any factors associated with the discharge, medications being taken, and self-care behaviors. Normal discharge is sparse, clear, or cloudy and is always nonirritating. Unprotected sexual intercourse suggests that the discharge is associated with a STI and would cause more concern on the part of the client. Telling the client not to worry is a nontherapeutic communication technique. Asking about her last gynecological checkup may be an appropriate question but is not related to the subject of the question.

A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the client's pulse is normal. Which of the following notations would the nurse make in the client's record to document the force of the client's pulse?

2+ Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+, bounding pulse; 3+, increased pulse; 2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the client's pulse as 2+.

A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. The nurse, inspecting the ears for cerumen impaction, checks for:

A yellowish or brownish waxy material in the external auditory canal Rationale: Cerumen (ear wax) is a yellowish or brownish waxy secretion produced by vestigial apocrine sweat glands in the external ear canal. It becomes impacted because of the narrow tortuous canal or as a result of poor cleaning methods. Cerumen may partially obscure the eardrum or totally occlude the ear canal. Even when the canal is 90% to 95% blocked, hearing is normal, but when the last 5% to 10% becomes occluded (e.g., when cerumen expands after the client swims or showers), the client experiences sudden hearing loss and a feeling of fullness in the ear. Redness and swelling of the tympanic membrane, edema in the external auditory canal, and an external auditory canal that is longer than normal are not descriptions of cerumen.

A nurse performing a genital examination of a male client notes that the skin of the penis and scrotum is wrinkled. On the basis of this finding, the nurse:

Documents the normal finding Rationale: The penile skin is normally wrinkled and hairless, without lesions. The dorsal vein may also be apparent on inspection of the penis. Scrotal skin also has a wrinkled appearance (rugae). Asymmetry is normal, with the left half of the scrotum usually lower than the right. Wrinkled skin on the penis and scrotum is a normal finding; therefore the nurse would document the finding. The other options are incorrect.

A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection?

Ask health history questions while performing the examination and initiating emergency measures Rationale: If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client's immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment.

A nurse performing a neurological assessment is preparing to assess the optic nerve. The nurse performs this examination by:

Assessing visual acuity Rationale: The optic nerve is assessed through the testing of visual acuity and visual fields by means of confrontation. Ptosis, a drooping of the eyelid, can be assessed by means of inspection of the eyelids. Testing of the abducens, oculomotor, and trochlear nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and assessing extraocular movements through the cardinal positions of gaze.

A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expects to note if the bladder is full?

Dull sounds Rationale: Normally a bladder is not percussible until it contains 150 mL of urine. If the bladder is full, dullness is heard over the symphysis pubis. Hyperresonance is present with gaseous distention of the abdomen. Bowel sounds are auscultated, not percussed.

A nurse performing an abdominal assessment is preparing to auscultate for bowel sounds. The nurse:

Begins in the right lower quadrant Rationale: To auscultate for bowel sounds, the nurse uses the diaphragm endpiece, because bowel sounds are relatively high pitched. The stethoscope is held lightly against the skin, because pushing too hard can stimulate more bowel sounds. The nurse begins in the right lower quadrant of the abdomen at the ileocecal valve, because bowel sounds are always present there normally. The nurse should listen for 5 minutes before deciding that bowel sounds are absent.

During a physical assessment, the client tells the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing:

Dysphagia Rationale: Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia is a loss of appetite. Eructation is belching. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid.

A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope at the:

Fifth left interspace at the midclavicular line Rationale: The mitral valve is located in the area of the fifth left interspace, at the midclavicular line. The pulmonic valve is located in the area of the second left interspace. The aortic valve is located in the area of the second right interspace. The tricuspid valve is located in the area of the left lower sternal border.

A nurse is palpating a client's sinus areas. Which of the following sensations does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?

Firm pressure Rationale: The client would normally feel a firm pressure as the nurse palpates his or her sinuses. Pain experienced during palpation of the sinuses is an indication of acute sinusitis. Headaches that vary in intensity with position changes or when secretions drain indicate acute sinusitis. An acute headache should not occur with palpation of the sinuses.

A nurse reviewing the healthcare record of a client notes documentation of grade 4 muscle strength. The nurse understands that this indicates:

Full ROM against gravity with some resistance Rationale: Muscle strength is graded on a scale of 0 to 5. A grade of 5 indicates normal strength and is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and full ROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity. Grade 2 indicates poor strength and full ROM with gravity eliminated (passive motion). Grade 1 indicates trace strength and slight contraction. Grade 0 indicates zero strength and no contraction.

A nurse is assessing a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the nurse obtain data on from the client?

Hypertension Rationale: Risk factors for CAD may be categorized as modifiable and unmodifiable. Unmodifiable risk factors include age, sex, ethnicity, genetic predisposition, and family history of heart disease. Modifiable risk factors include increased concentrations of serum lipids, hypertension, cigarette smoking, obesity, and level of physical activity. Contributing modifiable risk factors include diabetes mellitus and a stressful lifestyle.

A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as:

Nystagmus Rationale: Nystagmus is a fine oscillating movement, most notable around the iris. The nurse checks for nystagmus when assessing a client for ocular muscle weakness. Mild nystagmus at extreme lateral gaze is normal; nystagmus at any other position is not. Ptosis is a drooping of the eyelid. Scleral icterus is a yellowing of the sclera, extending up to the cornea, that indicates jaundice. Exophthalmos, a noticeable protrusion of the eyeball, is a characteristic sign of hyperthyroidism.

A nurse is assisting the physician in performing transillumination of a client's scrotum. The nurse prepares for this procedure by:

Obtaining a flashlight and darkening the room Rationale: Transillumination of the testes is a painless procedure that is performed when swelling or a lump is noted on palpation. After the room is darkened, a strong flashlight is shined from behind the scrotal contents. Normal scrotal contents do not appear on transillumination. Instructing the client to drink fluids or to take deep breaths and bear down is not necessary.

A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be?

Rustling Rationale: Vesicular breath sounds are rustling and sound like wind blowing through trees. Bronchial (tracheal) breath sounds are harsh, hollow, tubular sounds.

A nurse reviewing the medical record of a client with the diagnosis of heart failure notes documentation indicating that the client has deep pitting edema, that the indentation remains for a short time, and that the leg looks swollen. How does the nurse document this finding?

3+ edema Rationale: Edema, the accumulation of fluid in the intercellular spaces, is not normally present. To check for edema, the nurse presses his or her thumbs firmly against the ankle malleolus or the tibia. Normally the skin surface stays smooth. If the pressure leaves a dent in the skin, "pitting" edema is present. Its presence is graded on the following 4-point scale: 1+ denotes mild pitting and slight indentation but no perceptible swelling of the leg, 2+ indicates moderate pitting in which the indentation subsides rapidly, 3+ indicates deep pitting in which the indentation remains for a short time and the leg looks swollen, and 4+ denotes very deep pitting in which the indentation lasts a long time and the leg is very swollen.

A nurse sees documentation in the client's record indicating that the physician has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds are:

Abnormal sounds that should not be heard in the lungs Rationale: Adventitious breath sounds are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused when moving air collides with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds.

A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding as:

Anasarca Rationale: Bilateral edema, or edema that is generalized over the entire body, is known as anasarca. This finding is indicative of a central problem such as congestive heart failure or kidney failure. It does not indicate increased vascularity of skin tissue. Ecchymosis is a large patch of capillary bleeding into the tissues (bruise).

A nurse reviewing a client's record notes documentation that the client has melena. How does the nurse detect the presence of melena?

By checking the client's stool for blood Rationale: Melena is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.

A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?

Coffee Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse tests the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a nonnoxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. A tuning fork is used to assess the function of cranial nerve VIII (acoustic nerve). A wisp of cotton is used to assess the sensory function of cranial nerve V (trigeminal nerve). An ophthalmoscope is used to assess the internal structures of the eye.

A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing?

Cranial nerve XII Rationale: To test cranial nerve XII (hypoglossal nerve), the examiner inspects symmetry and movement of the tongue. The nurse looks for a forward thrust in the midline as the client sticks out the tongue. The examiner tests the motor function of cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve) by depressing the client's tongue with a tongue blade and noting the pharyngeal movement as the client says "ah." Motor function of these nerves is also tested by touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Eliciting a response from cranial nerve V (trigeminal nerve) tests the muscles of mastication.

A female client is seen in the clinic for a gynecological examination. The nurse begins collecting subjective data. Which of the following topics does the nurse ask the client about first?

Her menstrual history Rationale: The nurse should begin collecting subjective data by asking the client about her menstrual history, because this information is usually nonthreatening to the client. Questions about sexual history, obstetrical history, and the presence of vaginal discharge would be asked, but this information may be perceived by the client as more sensitive and the questions more threatening.

A nurse performing a musculoskeletal assessment of a client with suspected carpal tunnel syndrome plans to perform the Phalen test. The nurse should ask the client to:

Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds Rationale: In the Phalen test, the nurse asks the client to hold the hands back to back while flexing the wrists 90 degrees. Dorsiflexing or plantarflexing the foot and hyperextending the fingers are not associated with testing for carpal tunnel syndrome. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.

While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which of the following findings does the nurse expect to note when auscultating the client's bowel sounds?

Hyperactive bowel sounds Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hypoactive bowel sounds are low pitched. Hypoactive sounds (or an absence of sounds) follow abdominal surgery or occur with inflammation of the peritoneum.

A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips:

Lateral to the extensor tendon of the big toe Rationale: The dorsalis pedis pulse is palpated lateral to and parallel with the extensor tendon of the big toe. The popliteal pulse is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. The femoral artery is located below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines.

A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client?

Left lateral Rationale: A female client is placed in the left lateral position for a rectal examination. If the examiner is examining the genitalia as well as the rectum, the woman is placed in the lithotomy position. A male client is placed in the left lateral or standing position. It would be difficult to perform a rectal examination on a client in the supine position.

A nurse is preparing to listen to the breath sounds of a client. The nurse should:

Listen for at least one full respiration in each location on the chest Rationale: To best listen to breath sounds, the nurse asks the client to sit, leaning slightly forward, with the arms resting comfortably across the lap. The client is instructed to breathe through the mouth, a little deeper than usual, but to stop if he or she feels dizzy. The flat diaphragm endpiece of the stethoscope is held firmly against the client's chest wall. The nurse listens for at least one full respiration in each location on the chest. Side-to-side comparison is most important in the assessment of breath sounds.

A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which of the following findings does the nurse expect to note if cholecystitis is present?

Murphy sign Rationale: The Murphy sign is an indicator of gallbladder disease. The client is asked to inhale while the examiner's fingers are hooked under the liver border, at the bottom of the rib cage. Inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed. The Homan sign is pain in the calf area on sharp dorsiflexion of the client's foot. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen. Rebound tenderness is a reliable sign of peritoneal irritation. The McBurney sign is a reaction of the client indicating severe pain and extreme tenderness when the McBurney point (midway between the umbilicus and the anterior iliac crest in the right lower quadrant of the abdomen) is palpated. Such a reaction indicates appendicitis.

A nurse performing a neurological assessment of an adult client asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?

Olfactory Rationale: The olfactory nerve is tested by determining the sense of smell in clients who report loss of smell, those with head trauma, those with abnormal mental status, and those in whom the presence of an intracranial lesion is suspected. The optic nerve is assessed by testing visual acuity and visual fields. The abducens nerve is usually assessed with the oculomotor and trochlear nerves; testing involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and testing extraocular movements through the cardinal positions of gaze. The hypoglossal nerve is assessed through inspection of the tongue.

A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination:

One week after menstruation begins Rationale: BSE should be performed after the menstrual period, on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. The pregnant woman or menopausal woman who is not having menstrual periods is taught to select a specific day to examine the breasts every month. Therefore the other options are incorrect.

A nurse reviewing a client's healthcare record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the nurse determine that the client has?

Osteoarthritis Rationale: Osteoarthritis is characterized by hard, nontender nodules of 2 to 3 mm or larger. These osteophytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes. In this disorder, when these nodes occur on the proximal interphalangeal joints they are called Bouchard nodes. Heberden nodes are not associated with scoliosis, rotator cuff lesions, or carpal tunnel syndrome.

A nurse is preparing to check the breath sounds of a client. Over which anatomic area does the nurse place the stethoscope when auscultating for bronchial breath sounds?

Rationale: Bronchial (tracheal) breath sounds are located over the trachea and larynx. Bronchovesicular breath sounds are located over major bronchi. Vesicular breath sounds are located over the peripheral lung fields. The upper sternal area is where main bronchi are located. Breath sounds are normally not heard over the cricoid cartilage.

A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct?

Setting the room temperature at a comfortable level Rationale: When preparing the physical environment for an interview with a client, the nurse sets the room temperature at a comfortable level. The nurse also provides privacy and sufficient lighting and removes distracting objects or equipment and noise from the environment. The distance between the client and the nurse should be 4 to 5 feet (twice arm's length). The nurse arranges the seating so that client and nurse are at eye level. Barriers (e.g., facing a client across a desk or table) are avoided.

A nurse conducting an interview with a client collects subjective data. During the interview, the nurse:

Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors Rationale: During an interview, the nurse keeps note-taking to a minimum and tries to focus his or her attention on the client. Any note-taking should be secondary to the dialogue and should not interfere with the client's dialogue. Note-taking during an interview breaks eye contact too often; shifts the nurse's attention away from the client, diminishing his or her sense of importance; interrupts the client's narrative flow; impedes the nurse's observation of the client's nonverbal behaviors; and may be threatening to the client during the discussion of sensitive issues.

A nurse performing a physical assessment of a client gathers both subjective and objective data. Which of the following findings would the nurse document as subjective data?

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

When conducting a physical examination of an adult client, in what order does the nurse perform the various assessment techniques? Number 1 is the first technique performed and number 4 is the last technique performed.

The correct order is: Inspection Palpation Percussion Auscultation Rationale: The assessment techniques used to perform a physical examination are inspection, palpation, percussion, and auscultation. These activities are performed one at a time and in this order. The exception is abdominal assessment, in which the nurse would inspect and then auscultate, because percussion and palpation can cause peristalsis, which could cause the examiner to make a false interpretation of bowel sounds.

A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the nurse places the stethoscope over:

The peripheral lung fields Rationale: Vesicular breath sounds are heard over the peripheral lung fields, where air flows through the smaller bronchioles and alveoli. Bronchovesicular breath sounds are heard over the major bronchi. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Breath sounds are not heard over the xiphoid process.

A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client?

Complete Rationale: A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting such as a pediatric or family practice clinic, an independent or group private practice, a college health service, a women's healthcare agency, a visiting nurse agency, or a community health agency. An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or one body system. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed.

A nurse inspecting a client's throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of:

Cranial nerves IX and X Rationale: The motor function of cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) is tested by depressing the tongue with a tongue blade and noting the pharyngeal movement as the client says "ah." Motor function of these nerves is also tested by touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Eliciting a response from cranial nerve V (trigeminal nerve) tests the muscles of mastication. Eliciting a response from cranial nerve I (olfactory nerve) tests the function of smell. Eliciting a response from cranial nerve II (optic nerve) involves eye examinations. In testing cranial nerve XII (hypoglossal nerve), the examiner inspects symmetry and movement of the tongue.

A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands that the primary purpose of including cultural information in the health assessment is to:

Determine what the client believes has caused the epilepsy Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican-American culture, epilepsy is seen as a reflection of physical imbalance. Although the nurse may obtain data related to family history (hereditary) and formulate nursing diagnoses, these are not the primary reasons for including cultural information in the health assessment. A nurse gathers assessment data but does not confirm a medical diagnosis.

An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?

Exposure to cigarette smoke Rationale: Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include youth (otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. Loud music, the use of power tools, and occupational noise can all cause hearing loss. Hearing loss may occur as a result of an acute loud noise (acoustic trauma) or long-term exposure to loud noise (noise-induced hearing loss).

A nurse conducting a physical assessment of a client plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal:

A problem with balance Rationale: The Romberg test, a balance test, is used to assess cerebellar function. The client stands with his or her feet together and arms at the side. Once he or she is in a stable position, the client is asked to close the eyes and hold the position for about 20 seconds. Normally the client can maintain posture and balance, although slight swaying may occur. Hearing acuity, including distant hearing and the ability to discriminate high- and low-pitched sounds, is assessed with the use of the voice and tuning-fork tests.

A nurse performing a neurological examination is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which of the following actions does the nurse take to test this nerve?

Asking the client to close his or her eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear Rationale: To test the cochlear portion of the acoustic nerve, the nurse has the client close the eyes and indicate when a ticking watch or rustling of the examiner's fingertips is heard as the stimulus is brought closer to the ear. To test the motor component of the trigeminal nerve, the nurse asks the client to clench the teeth and palpates the masseter muscles just above the mandibular angle. To test the sensory component of the trigeminal nerve (cranial nerve V), the nurse has the client identify light and sharp touch on both sides of the face. Asking the client to raise the eyebrows and watching for symmetry is one method of testing the function of the facial nerve (cranial nerve VII).

A client complains that her skin is redder than normal. The nurse assesses the client's skin, documents hyperemia, and explains to the client that this condition is caused by:

Excess blood in the dilated superficial capillaries Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. A reduced amount of bilirubin in the blood, diminished perfusion of the surrounding tissues, and contraction of the underlying blood vessels are all incorrect explanations for hyperemia.

A nurse performing a cranial nerve assessment is testing the function of the oculomotor, trochlear, and abducens nerves. Which of the following parameters does the nurse check to determine the function of these nerves?

Eye movements Rationale: Testing of the oculomotor, trochlear, and abducens nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation, as well as testing of extraocular movements through the cardinal positions of gaze. Inspection of the tongue for symmetry reveals the function of cranial nerve XII (hypoglossal nerve). Assessment of facial symmetry reveals the function of cranial nerve VII (facial nerve). The corneal reflex reflects the function of the sensory afferent in cranial nerve V (trigeminal nerve) and the motor efferent in cranial nerve VII (facial nerve).

During a neurological assessment, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing?

Facial Rationale: Assessment of cranial nerve VII (facial nerve) involves noting mobility and symmetry as the client smiles, frowns, closes the eyes tightly (against the nurse's attempt to open them), lifts the eyebrows, shows the teeth, and puffs out the cheeks. Cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) are tested together. Testing the motor function of these nerves entails depressing the client's tongue with a tongue blade and noting pharyngeal movement as the client says "ah" and touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Testing of the abducens, oculomotor, and trochlear nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and testing extraocular movements through the cardinal positions of gaze.

A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment?

Follow-up Rationale: A follow-up database is compiled to evaluate the status of an identified problem at regular and appropriate intervals. An emergency database calls for rapid collection of the data, often at the same time lifesaving measures are being performed. A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. An episodic database (problem-centered) is compiled for a limited or short-term problem. It is focused mainly on one problem or body system.

A nurse is performing an abdominal assessment on a client. On auscultation of the abdomen the nurse hears a bruit over the abdominal aorta. Which action should the nurse take as a priority on the basis of this finding?

Notify the healthcare provider Rationale: Detection of a bruit over the aorta on assessment of the abdomen could indicate the presence of an aneurysm. The nurse would notify the healthcare provider of the finding and would not palpate or percuss the abdomen because of the risk of rupture. Although the nurse would document the findings, this is not the priority action.

A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork?

On the client's mastoid bone Rationale: In the Rinne test, the base of an activated tuning fork is held first against the mastoid bone, behind the ear, and then in front of the ear canal (0.5 to 2 inches). When the client no longer perceives the sound behind the ear, the fork is moved in front of the ear canal until the client indicates that the sound can no longer be heard. The client reports whether the sound from the tuning fork is louder behind the ear (on the mastoid bone) or in front of the ear canal. In the Weber test, an activated tuning fork is placed on the midline of the skull, the forehead, or the teeth.

Performing an abdominal assessment, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner because:

Palpation and percussion can increase peristalsis Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. The other options identify incorrect reasons for auscultating the abdomen before palpating and percussing it.

A nurse is preparing to test the function of cranial nerve XI. Which of the following actions does the nurse take to test this nerve?

Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size. The nurse checks that these muscles are equal in strength by asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands. Asking the client to stick out the tongue and watching for tremors is the method for assessing the function of cranial nerve XII (hypoglossal nerve). Assessment of pharyngeal function reveals the function of cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve).

A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse take before inserting the otoscope?

Pulling the pinna up and back Rationale: In an adult client, the nurse pulls the pinna up and back to help straighten the S shape of the ear canal. The client's head is tilted slightly away from the examiner, toward the client's opposite shoulder. The nurse holds the pinna gently and firmly until the examination is complete and the otoscope has been removed from the client's ear. The nurse pulls the pinna down when examining an infant or a child younger than 3 years.

A nurse is using an otoscope to examine the ears of a client. Which of the following findings indicates to the nurse that the tympanic membrane is normal?

Rationale: The tympanic membrane is shiny and translucent, with a pearly gray color. The appearance of a yellow clump of material indicates the presence of a piece of cerumen in the external meatus. An excessive amount of cerumen in the external auditory canal appears dark and covers a large part of the canal and tympanic membrane. A hole in the tympanic membrane indicates perforation of the membrane.

A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse determines that:

The skin temperature is normal Rationale: To assess skin temperature, the nurse would first note the temperature of his or her own hands, then use the backs (dorsa) of the hands to palpate the client's skin bilaterally. The skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. The hands and feet may feel slightly cooler in a cool environment. Giving the client additional fluids, removing the blanket, and checking for a fever are all incorrect responses to this finding.

During a neurological assessment, the nurse asks the client to close the jaws tightly, after which the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of the:

Trigeminal nerve Rationale: To test the motor function of cranial nerve V (trigeminal nerve), the nurse assesses the muscles of mastication by palpating the temporal and masseter muscles as the client clenches the teeth. The nurse tries to separate the jaws by pushing down on the client's chin. Normally the nurse cannot separate the jaws. Testing of the trochlear, abducens, and oculomotor nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and assessing extraocular movements through the cardinal positions of gaze.

A nurse preparing to perform an abdominal assessment asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity?

Tympany Rationale: The nurse expects to primarily note tympany when percussing the abdomen. Tympany should predominate because air in the intestines rises to the surface when the client is supine. Dullness occurs over a distended bladder, adipose tissue, fluid, or a mass. Borborygmus (the term used to describe hyperperistalsis) may be noted on auscultation, not percussion. Hyperresonance is present with gaseous distention.

A nurse is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the nurse:

Uses a tuning fork Rationale: Testing of cranial nerve VIII (acoustic nerve) entails checking hearing acuity by assessing the client's ability to hear normal conversation, assessing the client's performance on the whispered voice test, and performing the Weber and Rinne tuning fork tests. Asking the client to puff out the cheeks is used to test the function of cranial nerve VII (facial nerve). Testing of taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve). Checking the client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve).

A nurse performing a skin assessment notes that the client's skin is very dry. The nurse documents this finding as:

Xerosis Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Causes include too-frequent bathing, low humidity, and decreased production of sebum in aging skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin. Seborrhea is one of several common skin conditions in which an overproduction of sebum results in excessive oiliness or dry scales. Actinic keratoses are red-tan scaly plaques that grow over the years, becoming raised and roughened. A silvery-white scale may adhere to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. Actinic keratoses are premalignant and may develop into squamous cell carcinoma.

A nurse reviewing the physical assessment findings in a client's healthcare record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has?

Carpal tunnel syndrome Rationale: The Phalen test is performed to check for the presence of carpal tunnel syndrome. The client is asked to hold the hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen test reproduces the numbness and burning experienced by a client with carpal tunnel syndrome. This test does not reveal the presence of scoliosis, bone deformity, or Heberden nodules, which occur in osteoarthritis.

A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which of the following actions does the nurse take to help ensure the success of the interview? Select all that apply.

Ensuring that the room is private Seeing that distracting objects are removed from the room Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained, that there are no interruptions during the interview, that the room temperature is comfortable, that lighting is sufficient, that ambient noise is reduced, and that distracting objects are removed from the room. The nurse also ensures that the client and nurse are seated comfortably, eye to eye, without a desk or table between them, because a desk or table would act as a barrier. The nurse should maintain a distance of 4 to 5 feet from the client to avoid invading the client's private space, which might create anxiety on the part of the client.

A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that the client has normal:

Ocular movements Rationale: Leading the client's eyes through the six cardinal fields of gaze will elicit any muscle weakness during movement. This test assesses the function of the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Near vision is tested with the use of a handheld vision screener that contains various sizes of print. Central vision is measured with the use of a Snellen chart. Peripheral vision is measured with the confrontation test.

A nurse performing a physical examination is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note?

Gurgling sounds Rationale: Bowel sounds are a result of the movement of air and fluid through the small intestine. Depending on the time elapsed since the client has eaten, a wide range of normal sounds may occur. Bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly between five and 30 times a minute. Bowel sounds are hypoactive (low-pitched) or entirely absent after abdominal surgery or with inflammation of the peritoneum.

A nurse performing a respiratory assessment of a client plans to assess tactile (vocal) fremitus. The nurse performs this assessment by:

Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine" Rationale: Palpation over the lung is used to assess tactile (vocal) fremitus. The nurse begins by palpating over the lung apices in the supraclavicular areas. The nurse compares vibrations from side to side as the client repeats the word "ninety-nine." To palpate for symmetric chest expansion, the nurse places the hands on the anterolateral wall, with the thumbs along the costal margins and pointing toward the xiphoid process. The client is asked to take a deep breath; as he or she does so, the nurse watches his or her thumbs move apart and watches for symmetry. Auscultation of breath sounds over the trachea and larynx is used to assess bronchial breath sounds. Auscultation of breath sounds over the peripheral lung fields is used to assess vesicular breath sounds.

A nurse is preparing to assess the function of a client's spinal accessory nerve. Which of the following actions does the nurse ask the client to take to aid assessment of this nerve?

Shrugging the shoulders against the nurse's resistance Rationale: To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve).

A mother brings her 18-month-old child to the clinic to receive the next scheduled vaccine. The child has previously received the following vaccines: three doses of the hepatitis B vaccine (at birth and 1 and 6 months of age); three doses of the diphtheria/tetanus/acellular pertussis (DTaP) vaccine (at 2, 4, and 6 months of age); four doses of Haemophilus influenzae type b (Hib) conjugate vaccine (at 2, 4, 6, and 12 months of age); three doses of inactivated poliovirus vaccine (IPV) (at 2, 4, and 6 months of age); one dose of measles/mumps/rubella vaccine (MMR) (at 12 months of age); varicella zoster vaccine at 12 months of age; and four doses of pneumococcal vaccine (at 2, 4, 6, and 12 months of age). After reviewing the child's immunization record, which scheduled vaccine does the nurse prepare to administer?

DTaP Rationale: DTaP is administered at 2, 4, and 6 months of age; between 15 and 18 months of age; and between 4 and 6 years of age. Because the child has received only three doses of this vaccine, the DTaP should be administered. Hepatitis B vaccine is administered at birth and at 1 and 6 months of age. Hib is administered at 2, 4, and 6 months of age and between 12 and 15 months. IPV is administered at 2, 4, and 6 months of age and between 4 and 6 years of age. MMR is administered between 12 and 15 months of age and again between 4 and 6 years of age. Varicella zoster vaccine is administered between 12 and 15 months of age. Pneumococcal vaccine is administered at 2, 4, and 6 months of age and at 12 to 15 months of age.

A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment by:

Listening to the carotid artery, using the bell of the stethoscope to assess for bruits Rationale: To assess the carotid artery, the nurse uses the techniques of palpation and auscultation. The nurse palpates each carotid artery medial to the sternomastoid muscle in the neck. The nurse should avoid putting pressure on the carotid sinus higher in the neck because of the risk of excessive vagal stimulation, which could slow the heart rate. The nurse should palpate one artery at a time to avoid compromising arterial blood flow to the brain. The nurse should auscultate each carotid artery for the presence of a bruit. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally a bruit is not present. The nurse should lightly place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath briefly so that tracheal breath sounds do not mask or mimic a carotid artery bruit.