HESI Practice- Saunders

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? 1.The major bronchi 2.The trachea and larynx 3.The peripheral lung fields 4.The lower posterior thorax

1.The major bronchi

The nurse is documenting the findings of a physical examination in a client's record. Which findings should the nurse determine to be objective data? 1.The client experiences migraine headaches. 2.The client has a rash on the chest and arms. 3.The client reports having difficulty urinating. 4.The client reports taking atenolol for blood pressure.

2.The client has a rash on the chest and arms.

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? 1.Near the lateral 12th rib 2.Just under the left clavicle 3.In the fifth intercostal space 4.Posteriorly under the left scapula

2.Just under the left clavicle The apex of the lung is the rounded, uppermost part of the lung. The nurse would place the stethoscope just under the left clavicle. The other options are incorrect locations.

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? 1.Ask the client to puff out the cheeks. 2.Separate the client's jaw by pushing down on the chin. 3.Place a small amount of sugar on the client's tongue and ask him or her to identify the taste. 4.Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

2.Separate the client's jaw by pushing down on the chin.

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 1. After a shower or bath 2.While standing to void 3.After having a bowel movement 4.While lying in bed before arising

1. After a shower or bath

The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area? 1.Left shoulder 2.Right scapula 3.Right shoulder 4.Small of the back

1. Left shoulder The nurse should instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the left breast is to be examined, the pillow would be placed under the left shoulder; therefore, all other options are incorrect.

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? 1.Mitral area 2.Right atrium 3.Right ventricle 4.Pulmonic valve

1. Mitral area The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to the apical pulse. S1 (lub) and S2 (dub) should be distinguished. The pulse should be counted for a full minute. The right atrium, right ventricle, and pulmonic valve areas will not provide clear auscultation of the apical pulse.

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective? 1."This is mostly used in a walk-in clinic or emergency department." 2."This is focused on disease detection and conducted in a health care provider's office." 3."This is conducted on admission in a primary care or long-term care setting." 4."This is conducted as a follow-up examination by a health care provider."

1."This is mostly used in a walk-in clinic or emergency department." A problem-based assessment involves a history and physical examination that is limited to a specific problem or client complaint and is most often used in a walk-in clinic or emergency department. A screening assessment is a limited examination focused on disease detection. A complete assessment includes a complete health history and physical examination and forms a baseline database. It is performed on admission to a primary care or long-term care setting. An episodic or follow-up assessment is done when a client is being followed up for a previously identified or treated problem.

The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions on breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which information should the nurse give to the client? 1."You need to perform BSE on the same day every month." 2."It is not necessary to do BSE because you are postmenopausal." 3."You are not at risk for breast cancer because you are in the postmenopausal phase." 4."Mammograms performed every 20 years are sufficient in the postmenopausal phase."

1."You need to perform BSE on the same day every month." Women who are in the postmenopausal phase are taught to do BSE on the same day of every month. Before menopause, women should do the procedure 7 days after the start of the menstrual cycle when the breasts are less tender. It is important for postmenopausal women to do BSE monthly because they can get breast cancer. Mammograms need to be performed more frequently than every 20 years and per American Cancer Association guidelines.

The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? 1.A tuning fork 2.A stethoscope 3.A tongue blade 4.A reflex hammer

1.A tuning fork

A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child? 1.Assess the child's physical status. 2.Ask the child how the injury occurred. 3.Report the case as suspected child abuse. 4.Observe the interactions between the child and his friends.

1.Assess the child's physical status. The initial intervention is to assess the child's physical status. The child should be initially assessed for injury to the right arm and for bruises, burns, scars, and any other signs of abuse. The nurse would next report the case as suspected child abuse to the appropriate authorities. Option 2 may or may not be appropriate, depending on the situation because the child may be fearful of telling the truth about how the injury occurred. Option 4, although appropriate for some situations, is not appropriate as the initial intervention.

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply. 1.Presence of fasciculations 2.Muscle strength graded 5/5 3.Symmetrical movements bilaterally 4.Increased muscle size on the dominant arm 5.A 1-cm hypertrophy of the right upper arm

2.Muscle strength graded 5/5 3.Symmetrical movements bilaterally 4.Increased muscle size on the dominant arm 5.A 1-cm hypertrophy of the right upper arm Fasciculations are fine muscle twitches that normally are not present. Muscle strength is graded from 0/5 (paralysis) to 5/5 (normal power). Symmetrical muscle movement is a normal finding. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal.

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1.Auscultating lung sounds 2.Obtaining the client's temperature 3.Assessing the strength of peripheral pulses 4.Obtaining information about the client's respirations 5.Performing a musculoskeletal and neurological examination 6.Asking the client about a family history of any illness or disease

1.Auscultating lung sounds 2.Obtaining the client's temperature 4.Obtaining information about the client's respirations A focused assessment focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The clinic nurse should teach the group which point about this procedure? 1.Do the exam on the same day every month. 2.Do the exam 7 days after the start of the menstrual cycle. 3.Examine the left breast with the left hand and vice versa. 4.Use the tips of the fingers to increase the likelihood of feeling lumps.

1.Do the exam on the same day every month.

The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)? 1.Elevate the shoulders. 2.Swallow a sip of water. 3.Open the mouth and say "aah." 4.Vocalize the sounds "la-la," "mi-mi," and "kuh-kuh."

1.Elevate the shoulders.

A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate. The client returns to the primary health care provider's (PHCP's) office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment? 1.Follow-up database 2.Emergency database 3.Complete health database 4.Problem-centered database

1.Follow-up database

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action? 1.Identify an object placed in the client's hand. 2.Identify 3 numbers or letters traced in the client's palm. 3.State whether 1 or 2 pinpricks are felt when the skin is pricked bilaterally in the same place. 4.Identify the smallest distance between 2 detectable pinpricks, made with 2 pins held at various distances.

1.Identify an object placed in the client's hand. Astereognosis is the inability to discern the form or configuration of common objects using the sense of touch. Graphesthesia is the inability to recognize the form of written symbols. The remaining options test for extinction phenomena and 2-point stimulation, respectively.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the primary health care provider (PHCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry? 1.It is painless and safe. 2.It causes only mild discomfort at the site. 3.It requires insertion of only a very small catheter. 4.It has an alarm to signal dangerous drops in oxygen saturation levels.

1.It is painless and safe.

The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment of the client's smoking history? 1.Number of pack-years 2.Desire to quit smoking 3.Brand of cigarettes used 4.Number of past attempts to quit smoking

1.Number of pack-years The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of pack-years, which is the standard method of documenting smoking history. The brand of cigarettes may give a general indication of tar and nicotine levels, but the information is of no immediate clinical use. Desire to quit and number of past attempts to quit smoking may be useful when the nurse develops a smoking cessation plan with the client.

The nurse is caring for a pediatric client who just arrived at the emergency department with an extremity fracture. The nurse uses the 5 "Ps" to assess the extent of the client's injury. What are some of the 5 "Ps"? Select all that apply. 1.Pallor 2.Pain and point of tenderness 3.Paralysis distal to the fracture site 4.Pulses proximal to the fracture site 5.Sensation distal to the fracture site

1.Pallor 2.Pain and point of tenderness 3.Paralysis distal to the fracture site 5.Sensation distal to the fracture site If a child sustains a fracture, the extent of the injury is immediately assessed using the 5 "P's"-pain and point of tenderness, pulses distal (not proximal) to the fracture site, pallor, paresthesia (sensation) distal to the fracture site, and paralysis (movement distal to fracture site).

The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this examination? 1.Pull the pinna up and back before inserting the speculum. 2.Pull the earlobe down and back before inserting the speculum. 3.Tilt the client's head forward and down before inserting the speculum. 4.Use the smallest speculum available to decrease the discomfort of the exam.

1.Pull the pinna up and back before inserting the speculum. The nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back, and the nurse visualizes the external canal while slowly inserting the speculum. The remaining options are incorrect procedures.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1.Rhythmic respirations with periods of apnea 2.Regular rapid and deep, sustained respirations 3.Totally irregular respiration in rhythm and depth 4.Irregular respirations with pauses at the end of inspiration and expiration

1.Rhythmic respirations with periods of apnea Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia.

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. 1.Set the room temperature at a comfortable level. 2.Remove distracting objects from the interviewing area. 3.Place a chair for the client across from the nurse's desk. 4.Ensure comfortable seating at eye level for the client and nurse. 5.Provide seating for the client so that the client faces a strong light. 6.Ensure that the distance between the client and nurse is at least 7 feet (2.1 meters).

1.Set the room temperature at a comfortable level. 2.Remove distracting objects from the interviewing area. 4.Ensure comfortable seating at eye level for the client and nurse. When preparing the physical environment for an interview, the nurse should set the room temperature at a comfortable level. The nurse should provide sufficient lighting for the client and nurse to see each other. The nurse should avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment should be removed from the interview area. The nurse should arrange seating so that the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a desk or table, because this creates a barrier. The distance between the nurse and the client should be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If the nurse places the client any closer, the nurse will be invading the client's private space and may create anxiety in the client. If the nurse places the client farther away, the nurse may be seen as distant and aloof by the client.

The nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The client complains of discomfort at the intravenous (IV) site, and the nurse notes that the site is cool, pale, and swollen and that the solution is infusing slowly. What action should the nurse take first? 1.Stop the IV infusion. 2.Apply ice to the catheter site. 3.Readjust the rate of IV administration. 4.Contact the primary health care provider.

1.Stop the IV infusion. The IV must be stopped immediately because it has infiltrated. The remaining options allow the IV solution to continue to flow and further exacerbate the infiltration rather than intervene to stop it.

The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex? 1.Stroking the foot from the heel to the toe 2.Gently inserting a gloved finger in the rectum 3.Directing a flashlight onto the pupils of the eyes 4.Using a tongue depressor and stimulating the back of the throat

1.Stroking the foot from the heel to the toe

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1.The right eye is tested, followed by the left eye, and then both eyes are tested. 2.Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3.The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. 4.The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

1.The right eye is tested, followed by the left eye, and then both eyes are tested.

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? 1.Waves of loud gurgles auscultated in all 4 quadrants 2.Low-pitched swishing auscultated in 1 or 2 quadrants 3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants 4.Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants

1.Waves of loud gurgles auscultated in all 4 quadrants Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyper-resonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.

The clinic nurse is performing an assessment for a client who is complaining of shortness of breath. The client admits to smoking 1 pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack-years? Fill in the blank. _______ pack-years

10 pack-years The standard method for quantifying the smoking history is to multiply the number of packs smoked per day by the number of years of smoking. The result is then recorded as the number of pack-years. The calculation for the number of pack-years for the client in this question who smokes 1 pack per day for 10 years is 1 pack × 10 years = 10 pack-years.

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area? 1.Sclerae 2.Oral mucosa 3.Sole of the foot 4.Palm of the hand

2.Oral mucosa In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Jaundice would be best noted in the sclerae of the eye. Cyanosis would be best noted in the palms of the hands and soles of the feet.

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? 1.Poor hygiene 2.Difficulty walking 3.Fear of the parents 4.Bald spots on the scalp

2. Difficulty walking Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, or emotional maltreatment. Sexual abuse can involve incest, molestation, exhibitionism, pornography, prostitution, or pedophilia. Many times the findings associated with sexual abuse may not be easily apparent in the child. The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may indicate physical neglect. Fear of the parents and bald spots on the scalp most likely are associated with physical abuse.

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? 1.To examine the testicles while lying down 2.That the best time for the examination is after a shower 3.To gently feel the testicle with one finger to feel for a growth 4.That TSEs should be done at least every 6 months

2. That the best time for the examination is after a shower

The nurse is conducting a health screening clinic and is preparing to test the visual acuity of a client using a Snellen chart. The nurse educates the client about the procedure. Which statement by the client indicates that the teaching has been effective? 1."Stand 10 ft (3 meters) from the chart and cover 1 eye." 2."Stand 20 ft (6 meters) from the chart and cover 1 eye." 3."Stand 30 ft (9 meters) from the chart and read the largest line on the chart." 4."Stand 40 ft (12 meters) from the chart and read the largest line on the chart."

2."Stand 20 ft (6 meters) from the chart and cover 1 eye."

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? 1.Turn the flashlight on directly in front of the eye and watch for a response. 2.Ask the client to follow the flashlight through the 6 cardinal positions of gaze. 3.Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. 4.Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.

2.Ask the client to follow the flashlight through the 6 cardinal positions of gaze. The nurse asks the client to follow the flashlight through the 6 cardinal positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI. Options 1 and 3 relate to pupillary response to light. Also, shining the light directly into the client's eye without asking the client to focus on a distant object is not an appropriate technique. Option 4 assesses accommodation of the eye.

The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test? 1.Tuning fork and audiometer 2.Cloves, peppermint, and soap 3.Flashlight, pupil size chart, and millimeter ruler 4.Safety pin, hot and cold water in test tubes, and cotton wisp

2.Cloves, peppermint, and soap

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/min. On the basis of this finding, which action is most appropriate? 1.Administer oxygen. 2.Document the findings. 3.Notify the primary health care provider. 4.Reassess the respiratory rate in 15 minutes.

2.Document the findings. The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/min. The normal apical heart rate is 90 to 130 beats/min, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? 1.Focus on a close object. 2.Focus on a distant object. 3.Close 1 eye and read letters on a chart. 4.Raise 1 finger when the sound is heard.

2.Focus on a distant object. The nurse tests for accommodation by initially asking the client to focus on a distant object. This process dilates the pupils. The client is then asked to shift the gaze to a near object, such as a finger held about 3 in (7.5 cm) from the nose. A normal response includes pupillary constriction and convergence of the axes of the eyes.

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. 1.Allergy to pollen 2.History of headaches 3.Previous back injury 4.History of hypertension 5.History of diabetes mellitus

2.History of headaches 3.Previous back injury 4.History of hypertension 5.History of diabetes mellitus Previous neurological problems such as headache or back injury place the client at greater risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment for allergies is a routine part of the health history, regardless of the nature of the client's problem.

The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse should next ask the client to take which action? 1.Identify 3 objects placed in the hand, 1 at a time. 2.Identify 3 numbers or letters traced in the client's palm. 3.Identify the smallest distance between 2 skin pricks after pricking the skin with 2 pins at varying distances. 4.State whether 1 or 2 skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client's skin.

2.Identify 3 numbers or letters traced in the client's palm.

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1.Provide the client with materials on legal blindness. 2.Instruct the client that he or she may need glasses when driving. 3.Inform the client of where he or she can purchase a white cane with a red tip. 4.Inform the client that it is best to sit near the back of the room when attending lectures.

2.Instruct the client that he or she may need glasses when driving. Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client should be instructed to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness.

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? 1.Flashlight 2.Snellen chart 3.Reflex hammer 4.Ophthalmoscope

2.Snellen chart Cranial nerve II (the optic nerve) is responsible for visual acuity. This may be tested by using a Snellen chart to assess distant vision. Another item that may be used to evaluate the optic nerve function is a Rosenbaum card to evaluate near vision. This is a hand-held card used to test visual acuity. The nurse records the smallest line seen as well as the distance that the card is held from the client.

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1.Test the corneal reflexes. 2.Test the 6 cardinal positions of gaze. 3.Test visual acuity, using a Snellen eye chart. 4.Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

2.Test the 6 cardinal positions of gaze.

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply. 1.Sclerae 2.Tongue 3.Nail beds 4.Elbows and heels 5.Mucous membranes

2.Tongue 3.Nail beds 5.Mucous membranes Skin color may be more difficult to assess in the client with dark skin. The best areas to use to detect pallor and cyanosis include the tongue, nail beds, and mucous membranes. The sclerae are most useful in evaluating jaundice. Elbows and heels are not appropriate areas to assess for skin color changes.

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test? 1."I will tell you when I see the colored dots." 2."I will tell you when I see the flash of bright light." 3."I will tell you when the small object is in my visual field." 4."I will tell you when the blocks and shapes are in my visual field."

3."I will tell you when the small object is in my visual field."

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? 1.An involuntary rhythmic, rapid, twitching of the eyeballs 2.A dorsiflexion of the great toe with fanning of the other toes 3.A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 4.A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique? 1."I will ask the client to raise the legs up to the waist and then to lower the legs slowly." 2."I will ask the client to raise the legs and to try to lower them against pressure from my hand." 3."I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." 4."I will ask the client to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward."

3."I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward."

The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction? 1."TSE is performed once a month." 2."TSE should be performed on the same day each month." 3."It is best to do TSE first thing in the morning before a bath or shower." 4."The scrotum is held in 1 hand and the testicle is rolled between the thumb and forefinger of the other hand."

3."It is best to do TSE first thing in the morning before a bath or shower." TSE is performed once a month and should be done on the same day of each month, as an aid to help the client remember to perform the exam. The scrotum is held in 1 hand and the testicle is rolled between the thumb and forefinger of the other hand. It is best to perform the exam during or after (not before) a warm shower or bath when the scrotum is most relaxed.

The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client? 1."You have normal vision." 2."You have some degree of blindness." 3."You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)." 4."You can read at a distance of 30 ft (9 meters) what a person with normal vision can read at 20 ft (6 meters)."

3."You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)."

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1.Lub-dub sounds 2.Scratchy, leathery heart noise 3.A blowing or swooshing noise 4.Abrupt, high-pitched snapping noise

3.A blowing or swooshing noise A heart murmur is an abnormal heart sound and is described as a faint or loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are normal and represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound.

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1.A defect in the cochlea 2.A defect in cranial nerve VIII 3.A physical obstruction to the transmission of sound waves 4.A defect in the sensory fibers that lead to the cerebral cortex

3.A physical obstruction to the transmission of sound waves A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve? 1.Coffee beans 2.A tuning fork 3.A wisp of cotton 4.An ophthalmoscope

3.A wisp of cotton

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve? 1.Ask the client to clench the teeth. 2.Ask the client to read the letters in a line on a Snellen chart. 3.Ask the client to shrug the shoulders against the nurse's resistance. 4.Ask the client to close the eyes, occlude 1 nostril, and identify a specific odor such as coffee.

3.Ask the client to shrug the shoulders against the nurse's resistance.

The nurse would perform which action to assess for a pulse deficit? 1.Count the carotid pulsations for 1 full minute. 2.Measure the blood pressure in both the arm and leg. 3.Auscultate the apical heartbeat while palpating the radial artery. 4.Place the diaphragm of the stethoscope directly over the skin at the mitral area.

3.Auscultate the apical heartbeat while palpating the radial artery. A pulse deficit is the difference between the apical and peripheral pulses and could indicate a dysrhythmia. If an irregularity in the pulse is noted, the nurse should check for a pulse deficit. To check for a pulse deficit the nurse would auscultate the apical heart rate and rhythm while palpating a peripheral artery and assess for a difference in the rates. A difference in the rates indicates a pulse deficit. Therefore, options 1, 2, and 4 are incorrect sites.

The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data? 1.Pedal pulses are present. 2.Temperature is 99.6º F (37.6º C). 3.Client reports difficulty sleeping at night. 4.Client has an apical pulse rate of 56 beats/min.

3.Client reports difficulty sleeping at night.

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? 1.Complaints of ringing in the ear 2.An excessive amount of cerumen in the ear canal 3.Intolerance for sound levels that do not bother other people 4.Complaints of dizziness and sensations of being "off balance"

3.Intolerance for sound levels that do not bother other people Hyperacusis is a change in hearing for a client and the intolerance for sound levels that do not bother other people. Ringing in the ears is known as tinnitus. An excessive amount of cerumen in the ear canal is not associated with hyperacusis. Complaints of dizziness and sensations of being "off balance" are known as vertigo.

The nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment technique should the nurse perform next? 1.Palpate the abdomen for size. 2.Palpate the liver at the right rib margin. 3.Listen to bowel sounds in all 4 quadrants. 4.Percuss the right lower abdominal quadrant.

3.Listen to bowel sounds in all 4 quadrants. The appropriate sequence for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection to ensure that the motility of the bowel and bowel sounds are not altered by percussion or palpation. Therefore, after inspecting the skin on the abdomen, the nurse should listen for bowel sounds.

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for? 1.A yellow tinge to the skin 2.Bluish discoloration of the skin 3.Loss of normal red tones in the skin 4.An ashen-gray appearance to the skin

3.Loss of normal red tones in the skin In dark-skinned clients, pallor results in the loss of normal red tones in the skin. The brown-skinned client may have yellow-tinged skin when pallor is present. Bluish discoloration of the skin most often is associated with cyanosis. In the black-skinned client, pallor produces an ashen-gray color.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? 1.Have 1 of the client's family members interpret. 2.Have the Spanish-speaking triage receptionist interpret. 3.Page an interpreter from the hospital's interpreter services. 4.Obtain a Spanish-English dictionary and attempt to triage the client.

3.Page an interpreter from the hospital's interpreter services. The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive? 1.Absent bowel sounds 2.Client complaints of wound pain 3.Pain with dorsiflexion of the foot 4.Crackles on auscultation of the lungs

3.Pain with dorsiflexion of the foot To elicit Homans' sign, the nurse would dorsiflex the client's foot and assess for pain in the calf area. The presence of pain may indicate a positive Homans' sign. Wound pain and absent bowel sounds are unrelated findings. Crackles on auscultation of the lungs may indicate a respiratory complication.

A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? 1.Palpating over the lung apices in the supraclavicular area 2.Asking the client to repeat the word ninety-nine during palpation 3.Palpating over the breast tissue to assess and compare vibrations from 1 side to the other 4.Comparing vibrations from 1 side to the other as the client repeats the word ninety-nine

3.Palpating over the breast tissue to assess and compare vibrations from 1 side to the other When assessing for tactile fremitus, the nurse should begin palpating over the lung apices in the supraclavicular area. The nurse should compare vibrations from 1 side to the other as the client repeats the word ninety-nine. The nurse should avoid palpating over female breast tissue because breast tissue usually blocks the sound.

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? 1.Focus only on the physical examination. 2.Obtain all information from family members. 3.Plan short sessions with the client to obtain data. 4.Use the primary health care provider's medical history.

3.Plan short sessions with the client to obtain data.

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? 1.Ataxia 2.Nystagmus 3.Pronator drift 4.Hyperreflexia

3.Pronator drift Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. Hyperreflexia is an excessive reflex action.

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the primary health care provider (PHCP)? 1.Absence of a bruit 2.Concave, midline umbilicus 3.Pulsation between the umbilicus and the pubis 4.Bowel sound frequency of 15 sounds per minute

3.Pulsation between the umbilicus and the pubis The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and should be reported to the PHCP. Bruits normally are not present. The umbilicus should be in the midline with a concave appearance. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute.

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client? 1.A wider than normal ear canal 2.A pearly gray tympanic membrane 3.Redness and swelling in the ear canal 4.An excessive amount of cerumen lodged in the ear canal

3.Redness and swelling in the ear canal External otitis is a painful condition caused when irritating or infective agents come into contact with the skin of the external ear. Affected skin becomes red, swollen, and tender to touch or movement. Swelling of the ear canal narrows the canal and can lead to temporary hearing loss from obstruction. The tympanic membrane is not usually affected in external otitis. Cerumen does not cause external otitis; however, external otitis can result if the person uses a sharp or small object that traumatized the external ear when trying to remove the cerumen.

After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds? 1.Waves of loud gurgles auscultated in all 4 quadrants 2.Low-pitched swishing auscultated in 1 or 2 quadrants 3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants 4.Very high-pitched loud rushes auscultated especially in 1 or 2 quadrants

3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants

When assessing a client's liver during an assessment, the nurse should palpate which abdominal quadrant? 1.Left upper quadrant 2.Left lower quadrant 3.Right upper quadrant 4.Right lower quadrant

3.Right upper quadrant

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination? 1.Modified left lateral recumbent position 2.Supine with the head and feet flat 3.Supine with the head raised slightly and the knees slightly flexed 4.Semi-Fowler's position with the head raised 45 degrees and the knees flat

3.Supine with the head raised slightly and the knees slightly flexed During the abdominal examination, the client lies supine (flat on the back) with the head raised slightly and the knees slightly flexed. This position relaxes the abdominal muscles. The modified left lateral recumbent position is a side-lying position and would not adequately expose the abdomen for examination. Placing the head and feet flat would result in the abdominal muscles being taut. The abdomen cannot be accurately assessed if the head is raised 45 degrees.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff? 1.One half of the distance between the antecubital fossa and the shoulder 2.One third of the distance between the antecubital fossa and the shoulder 3.Two thirds of the distance between the antecubital fossa and the shoulder 4.One quarter of the distance between the antecubital fossa and the shoulder

3.Two thirds of the distance between the antecubital fossa and the shoulder The size of the blood pressure cuff is important. Cuffs that are too small will cause falsely elevated values, and those that are too large will cause inaccurate low values. The cuff should be positioned to cover two thirds of the distance between the antecubital fossa and the shoulder. It is also important for the nurse to remember that placing the stethoscope too firmly on the antecubital fossa causes error in auscultation and that sounds are difficult to hear in children because of low frequency and amplitude. Therefore, a pediatric stethoscope bell is often helpful.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1.Stridor 2.Crackles 3.Wheezes 4.Diminished

3.Wheezes Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway.

The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen chart. After the client's vision is tested with a Snellen chart, the results of testing are documented as 20/40. Which statement by the new RN indicates that the teaching has been effective? 1."The client's vision is normal, but the client may require reading glasses." 2."The client is legally blind, and glasses or contact lenses will not be helpful." 3."The client can read at a distance of 40 ft (12 meters) what a person with normal vision can read at 20 ft (6 meters)." 4."The client can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters)."

4."The client can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters)." Vision that is 20/20 is normal; that is, the client is able to read at 20 ft (6 meters) what a person with normal vision can read at 20 ft (6 meters). A client with a visual acuity of 20/40 can read at a distance of only 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters).

A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6º F (37º C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first? 1."Do you exercise regularly?" 2."Are you considering trying to lose weight?" 3."Is there a history of diabetes mellitus in your family?" 4."When was the last time you had your blood pressure checked?"

4."When was the last time you had your blood pressure checked?"

The nurse is making an initial home visit to a client who was recently discharged from the hospital after treatment for a myocardial infarction. The nurse should use which type of database initially to obtain information from the client? 1.An episodic database 2.A follow-up database 3.An emergency database 4.A complete health database

4.A complete health database A complete health database is the framework for a complete health history and full physical examination. The information thus obtained describes the current and past health state and forms a baseline against which all future changes can be measured. The complete health database is used in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, women's health care agency, visiting nurse agency, or community health agency. An episodic database is used for a limited or short-term problem. It focuses mainly on 1 problem or 1 body system. A follow-up database evaluates an identified problem at regular and appropriate intervals. An emergency database is used for rapid collection of the data, often compiled concurrently with lifesaving measures.

The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action? 1.Ask a second nurse to be present during the interview. 2.Defer both the health history and the neurological examination. 3.Defer the health history and proceed with the neurological examination. 4.Ask the client to give permission for a family member to stay during the interview.

4.Ask the client to give permission for a family member to stay during the interview. The health history and physical assessment for a client with a neurological problem are very similar to those for any other client, with perhaps a more intense neurological examination. If the client is confused or agitated or has difficulty hearing or speaking, the nurse should ask the client to give permission for a family member or significant other to stay with him or her during the history taking to ensure accurate data. Deferring the health history and/or neurological examination will not obtain the assessment data. Having a second nurse present is of no benefit.

The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time? 1.At ovulation time 2.7 to 10 days after menses 3.Just before menses begins 4.At a specific day of the month and on that same day every month thereafter

4.At a specific day of the month and on that same day every month thereafter If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the same day every month. Options that recommend scheduling related to menses are inappropriate because the client who had a hysterectomy would not be menstruating. It is best not to perform the BSE at ovulation time because of the hormonal changes that occur.

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? 1.Tapping the Achilles tendon using the reflex hammer 2.Gently pricking the client's skin on the dorsum of the foot in 2 places 3.Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument 4.Holding the sides of the client's great toe and, while moving it, asking what position it is in

4.Holding the sides of the client's great toe and, while moving it, asking what position it is in A method of testing for proprioception is to hold the sides of the client's great toe and, while moving it, asking the client what position it is in. Tapping the Achilles tendon with a reflex hammer describes gastrocnemius muscle contraction. Pricking the skin on the dorsum of the foot in 2 different places describes 2-point discrimination. The plantar reflex is tested when the sole of the foot is stroked with a blunt instrument.

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? 1.At the onset of menstruation 2.Every month during ovulation 3.Weekly at the same time of day 4. One week after menstruation begins

4.One week after menstruation begins

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? 1.Over the second intercostal space at the left sternal border 2.Over the fourth intercostal space at the right sternal border 3.Over the second intercostal space at the right sternal border 4.Over the fifth intercostal space in the left midclavicular line

4.Over the fifth intercostal space in the left midclavicular line The first heart sound (S1) is heard loudest at the lower left sternal border or the apex of the heart. The apex is located at the fifth intercostal space in the left midclavicular line. Therefore, the locations in the remaining options are incorrect.

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? 1.Assess for drainage from the wound. 2.Assess for redness around the wound edges. 3.Palpate for swelling around the wound edges. 4.Palpate for increased skin temperature around the wound edges.

4.Palpate for increased skin temperature around the wound edges. Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by palpating for increased skin temperature. Redness around the wound edges may be difficult to note in the dark-skinned client. Swelling and drainage from the wound are not specific indicators of erythema

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? 1.Wheezes 2.Rhonchi 3.Crackles 4.Pleural friction rub

4.Pleural friction rub A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating. The sounds are localized over an area of inflammation on the pleura and may be heard in both the inspiratory and the expiratory phases of the respiratory cycle. Wheezes are musical noises heard on inspiration, expiration, or both and are the result of narrowed airway passages. Rhonchi are usually heard on expiration when there is an excessive production of mucus that accumulates in the air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together and indicate fluid in the alveoli.

The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if 1 of the students states that which action should be performed? 1.Perform the exam after a cold shower. 2.Expect the exam to be slightly painful. 3.Perform the self-examination every other month. 4.Roll the testicle between the thumb and forefinger.

4.Roll the testicle between the thumb and forefinger.

A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the nurse include in the client's focused assessment? 1.Ability to drive a car 2.The normal everyday routine in the home 3.Ability to do light or heavy housework and to pay bills 4.Self-care needs such as toileting, feeding, and ambulating

4.Self-care needs such as toileting, feeding, and ambulating

The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action? 1.Whisper a statement while the client blocks both ears. 2.Quietly whisper a statement and test both ears at the same time. 3.Whisper a statement with the examiner's back to the client. 4.Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal.

4.Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal. To perform a voice test, the examiner stands 1 to 2 ft (30 to 60 cm) away from the client and asks the client to block 1 external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. The client is not asked to block both ears, and the examiner should face the client during the test.

A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used. 1.Asks the client to cover 1 eye 2.Examiner covers eye opposite to the eye covered by the client 3.Asks the client to report when object is first noted 4.Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client 5.The examiner brings in an object gradually from periphery

4.Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client 1.Asks the client to cover 1 eye 2.Examiner covers eye opposite to the eye covered by the client 5.The examiner brings in an object gradually from periphery 3.Asks the client to report when object is first noted

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test? 1.The client is asked to discriminate numbers from a chart composed of colored dots. 2.The room is darkened, and the client is asked to identify colored blocks and shapes when they appear in the visual field. 3.The examiner and client cover their right eyes and stare at each other's left eyes, and a small object is brought into the visual field. 4.The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.

4.The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status? 1.The client's ability to ambulate 2.The intactness of the tympanic membrane 3.The intactness of the retinal structure of the eye 4.The functional status of the vestibular apparatus in the inner ear

4.The functional status of the vestibular apparatus in the inner ear The Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The Romberg test also assesses intactness of the cerebellum and proprioception. Options 1, 2, and 3 are incorrect and unrelated to this test.