N3035 - Health Assessment Final

During the assessment of a client with a heart murmur, the nurse places the palm of their hand on the client's precordium and feels a moderate vibration. The nurse would document this finding as which of the following? Thrill Bruit Within normal limits Fremitus

Thrill

The nurse refers an elderly client for further evaluation after assessing moderate edema, warm skin, and pigmentation around the ankles. What does the nurse suspect? Venous insufficiency Stasis ulceration Arterial occlusion Dependent edema

Venous insufficiency

The nurse is assessing a client for possible oral cancer. Which of the following areas should the nurse closely inspect? Hard palate Buccal mucosa Along the gum line Ventral surface of the tongue

Ventral surface of the tongue

The nurse is caring for a client who a chronic neurologic condition that decreases the client's peristalsis. The nurse implements a care plan and interventions based on what potential complication? Constipation Fluid volume excess Fluid volume deficit Diarrhea

Constipation

The nurse is completing a physical assessment on a client with an injury to the cerebellum. Which are would be a primary focus for this client's assessment? Vital signs Coordination Cardiac output Respiratory status

Coordination

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

"Are you allergic to any medications?"

A 60-year-old client is being evaluated for age-related hearing loss. Which of the following questions would the nurse ask to obtain the most useful information regarding the hearing loss? "Are you experiencing any pain in your ears?" "Have you noticed an increase in soft cerumen from your ears?" "Do you notice any drainage from your ears?" "Are you having difficulty hearing high-frequency sounds?"

"Are you having difficulty hearing high-frequency sounds?"

The nurse is using COLDSPA to assess a client's history of chest pain. Which question best addresses "A" in the assessment model? "In your experience, what kinds of activities tend to cause your chest pain?" "Do you have any other symptoms with your chest pain, such as nausea?" "Would you describe your chest pain as being acute, or is it chronic?" "Does your pain radiate to another location?"

"Do you have any other symptoms with your chest pain, such as nausea?"

A client expresses concerns over having black stools. The fecal occult test (guaiac) is negative. Which response by the nurse is most appropriate? "You should schedule a colonoscopy immediately." "Sometimes stress can alter stool color." "Do you take iron supplements?" "This is probably a false negative. We should rerun the test."

"Do you take iron supplements?"

A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. Which interview question is most likely to identify a risk factor for oral cancer? "Are you prone to getting canker sores?" "Do you use chewing or smoking tobacco?" "Do you brush and floss daily?" "How often do you visit the dentist in a year?"

"Do you use chewing or smoking tobacco?"

During the interview of a client, the client states to the nurse, "I am just so overwhelmed with everything in my life right now. I think it would be better for everyone if I just wasn't around anymore." What statement by the nurse would be most appropriate? "Everyone gets overwhelmed at times. I'm sure things will get better." "Have you been thinking about killing yourself?" "You should try looking at the bright side of things." "I'm sure things aren't that bad. Have you tried medications for your depression?"

"Have you been thinking about killing yourself?"

During a skin assessment, an adult client asks the nurse, "Why do you need to know about sunburns I had as a kid?" Which of the following is the best response by the nurse? "Having bad sunburns as a child puts you at risk for skin cancer later in life." "Repeated sunburns in childhood may explain the presence of some of your moles." "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." "This is one of the assessments we use to determine how well you took care of your skin when you were young."

"Having bad sunburns as a child puts you at risk for skin cancer later in life."

The nurse is preparing to assess the abstract reasoning of a client who has a diagnosis of early stage Alzheimer disease. Which of the following questions would be most appropriate for the nurse to ask? "When did you get your first job?" "Can you tell me what you have eaten in the last 24 hours?" "Can you draw the face of a clock for me?" "How are an apple and orange the same?"

"How are an apple and orange the same?"

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

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

A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. Which of the following statements, if made by the client, would indicate a need for further teaching? "I need to tell you that I am having my menstrual period." "I will void into the specimen bottle you gave me." "I will be sure that no stool is included in my urine sample." "I will keep the toilet paper in the specimen."

"I will keep the toilet paper in the specimen."

The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following? 4+ 2+ 1+ 3+

2+

The physician has ordered point-of-care (POC) testing on a client admitted with diabetes mellitus and a possible urinary tract infection. The nurse understands that all of the following can be examined using POC except: Presence of glucose in the urine Presence of protein in the urine 24-hour clearance of blood urea nitrogen Specific gravity of the urine

24-hour clearance of blood urea nitrogen

The nurse is assessing a client's deep tendon reflexes (DTRs). When striking the patellar tendon with the reflex hammer, the nurse notes a brisk reaction of the lower extremity. The nurse would document this finding as which of the following? 3+ 4+ 5+ 2+

3+

The nurse has completed the review of systems component of the client's health history. Which finding should the nurse document under the review of systems? "High school diploma plus 2 years of college" "Lungs clear to auscultation bilaterally" "Caregiver reliable source of information" "Menstruation began at age 13"

"Menstruation began at age 13"

The nurse is using COLDSPA to assess a client's history of back pain. Which statement by the client best addresses "S" in the assessment model? "My pain is a 7 out of 10." "The pain started two weeks ago." "The pain never completely goes away." "I am so tired of hurting."

"My pain is a 7 out of 10."

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

"Please say the number 'ninety-nine' for me."

A client tells the clinic nurse that he feels distended and "full of gas" frequently after meals. Which of the following questions by the nurse would elicit the most helpful information? "How many cups of coffee do you drink a day?" "Do you eat enough lean meat during the week?" "Tell me how often you eat vegetables like broccoli and cauliflower." "Do you eat a lot of cheese and pasta?"

"Tell me how often you eat vegetables like broccoli and cauliflower."

An older client is concerned about new seborrheic keratoses appearing on the skin. How should the nurse respond to this client's concern? "These areas need to be cleansed daily and and treated with a topical antibiotic ointment." "It means you have skin cancer and need to have them removed." "These are considered a normal age-related change in the skin." "I will report these to the health care provider so that medication can be prescribed."

"These are considered a normal age-related change in the skin."

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

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

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

"What makes it worse?"

A client has been admitted to the hospital for a surgical procedure, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as biased? "How would you describe your feelings about getting older?" "How often do your adult children typically visit you?" "You know you should quit smoking because it affects others, right?" "Your husband's death must have been very difficult for you."

"You know you should quit smoking because it affects others, right?"

While examining the muscle tone of a client, the nurse finds only a slight flicker of contraction. The nurse would document this finding on the strength table as which of the following? 3 5 0 1

1

The nurse is caring for several clients on the medical-surgical unit. Which of the following clients would the nurse recognize as having the greatest risk for developing a urinary tract infection (UTI)? A 40-year-old male client on bedrest who uses the urinal every 4 hoursCor A 60-year-old postmenopausal female admitted with diabetic ketoacidosis A 23-year-old female client admitted with appendicitis An 18-year-old female client with a previous history of a sexually transmitted infection using oral contraceptives

A 60-year-old postmenopausal female admitted with diabetic ketoacidosis

The unit nurse is reviewing the physician orders for each of her clients. For which of the following clients would the nurse question the physician's order for an indwelling catheter (which client does not need a catheter)? A client being transferred to surgery for a bowel resection An incontinent client with an open wound on the coccyx (tailbone) A client on hospice who has recently become incontinent of urine and stool A client admitted for 23 hour observation with bathroom privileges

A client admitted for 23 hour observation with bathroom privileges

When auscultating a client's breath sounds, the nurse notes a high, harsh sound with short inspiration and long expiration over the trachea. The nurse understands these sounds to be which of the following? Bronchovesicular breath sounds Vesicular breath sounds Bronchial breath sounds Adventitious breath sounds

Bronchial breath sounds

The nurse is assessing a client for possible meningitis. The nurse flexes the client's neck and head towards the client's chest. The nurse is performing which of the following? Bulge test Phalen's test Brudzinski's sign Kernig's sign

Brudzinski's sign

The nurse is performing a neurological examination on a client. The nurse notes that the sides of the mouth are symmetric when the client smiles. The nurse would document this finding as which of the following? Cranial nerve VI (abducens) is intact Cranial nerve X (vagus) is intact Cranial nerve VII (facial) is intact Cranial nerve V (trigeminal) is intact

Cranial nerve VII (facial) is intact

A client is admitted with complaints of abdominal pain for the past two weeks. A physical examination does not reveal the cause of the pain. Which of the following indirect visualization studies would the nurse anticipate prepping the client for? Colonoscopy Abdominal CT scan Wireless capsule endoscopy Esophagogastroduodenoscopy (EGD)

Abdominal CT scan

Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following? Acute illness Psoriasis Vitamin B deficiency Prolonged oxygen deficiency

Acute illness

During the assessment of a client with a chest tube, the nurse notes crepitus around the insertion site. The nurse recognizes which of the following as the cause of the crepitus? Fluid or pus in the lungs Infection at the insertion site Consolidation of the lung Air leaking into the subcutaneous tissues

Air leaking into the subcutaneous tissues

The nurse is auscultating the lung sounds of a client with asthma and notes sibilant wheezes during expiration. The nurse understands the cause of the wheezes to be which of the following? Air passing through constricted passages Inflamed parietal and visceral pleura rubbing together Air suddenly opening small air passages coated with exudate Air passing through secretions in the bronchi and trachea

Air passing through constricted passages

During the examination of the client's mouth, the nurse notes a decrease in tongue strength. The nurse interprets this finding as a problem with which of the following? Cranial nerve VI (abducens) Cranial nerve XII (hypoglossal) Cranial nerve IX (glossopharyngeal) Cranial nerve V (trigeminal)

Cranial nerve XII (hypoglossal)

The nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which of the following findings would most likely lead the nurse to this suspicion? Diastasis recti Cullen's sign Tenderness on palpation Positive Murphy's sign

Cullen's sign

A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following should the nurse do next? Recheck in 5 minutes after elevating the arm. Refer the client for medical follow-up. Reassess after applying warm compresses. Document this finding as normal.

Document this finding as normal.

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

Dorsal hand surface

The nurse is assessing the external eye structures of an elderly client. Which of the following age-related findings would the nurse anticipate observing? Tophi Exophthalmos Arcus senilis Episcleritis

Arcus senilis

During the assessment of an elderly client's peripheral vascular status, the nurse notes the following: cramping leg pain when walking; cool, pale feet; circular ulcer on the right great toe; no edema. Based on these findings, the nurse suspects which of the following conditions? Venous insufficiency Musculoskeletal weakness Arterial insufficiency Neurologic impairment

Arterial insufficiency

The nurse is assessing the client's eyes and vision. When performing the confrontation test for peripheral vision, which of the following would the nurse ask after covering one of the client's eyes? Ask the client to look directly at a light with the uncovered eye. Ask the client to focus straight ahead, and look for movement in the uncovered eye. Ask the client to close the uncovered eye and then open it quickly. Ask the client to state when they can see the nurse's finger enter their visual field.

Ask the client to state when they can see the nurse's finger enter their visual field.

During the examination of an 8-year-old child's ears, the nurse notes white spots on the tympanic membrane. No redness or drainage is noted. Which of the following actions by the nurse would be most appropriate? Assess the child for further symptoms of an acute ear infection Assess the child for previous head trauma Ask the mother whether the child has had numerous ear infections Determine whether impacted cerumen is present

Ask the mother whether the child has had numerous ear infections

A client tells the clinic nurse that she has sought care because she has been experiencing excessive watering in her right eye. Which of the following assessments should the nurse perform next? Perform the eye positions test Test pupillary reaction to light Ask the client if they have a history of glaucoma Assess the nasolacrimal duct

Assess the nasolacrimal duct

The nurse is preparing to discharge a male client following outpatient surgery. The client tells the nurse he is unable to void while lying supine. What can the nurse do to facilitate his voiding? Ask his wife to assist with the urinal. Assist him to a standing position. Provide him with a glass of water. Tell him he has to void before being discharged.

Assist him to a standing position.

A male construction worker asks the nurse if the mole on his arm is skin cancer. Using the mnemonic device ABCDE, which finding by the nurse would suggest skin cancer? Asymmetric, irregular borders Diameter of 2 mm Solid, dark brown color Flat with waxy, crusty scales

Asymmetric, irregular borders

The emergency department nurse is assessing a client who was hit by a car while on his bike. The nurse notes the client has irregular respirations of varying depth and rate followed by periods of apnea. The nurse would document the respirations as which of the following? Kussmaul respirations Hyperventilation Biot's respirations Cheyne-Stokes respirations

Biot's respirations

A nurse is caring for a client who is being treated for bladder infection. The client complains to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition? Polyuria Oliguria Dysuria Anuria

Dysuria

The nurse is preparing to obtain information about a client's mental and psychological status. Which of the following actions would the nurse take first? Question the patient about their usual lifestyle and behaviors. Perform a neurologic examination to determine any deficits. Check the client's level of consciousness for any changes. Explain the purpose of the exam and the types of questions that will be asked.

Explain the purpose of the exam and the types of questions that will be asked.

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

Explain the purpose of the interview.

While obtaining the health history of an elderly client, the client complains that his food "just doesn't smell right anymore". The nurse would make sure to assess which cranial nerve during the physical assessment? CN IV (trochlear) CN VI (abducens) CN I (olfactory) CN X (vagus)

CN I (olfactory)

The nurse is beginning the initial assessment of a 92-year-old client admitted from the long-term care facility. The client does not seem to be responding to the nurse's questions or following her movements. What is the appropriate next action by the nurse? Document "unable to assess client". Skip the subjective data collection and proceed to the physical assessment. Defer the assessment until the client is more responsive. Check the client's vision and hearing before proceeding with the assessment.

Check the client's vision and hearing before proceeding with the assessment.

A client comes to the clinic complaining of a sore throat. After assessing the throat, the nurse documents the tonsils as 3+. The nurse explains to the client that "3+ tonsils" are which of the following? Extend to the midline, touching each other Barely visible on inspection Visible beyond the anterior pillars Extend ¾ midway to midline, nearly touching the uvula

Extend ¾ midway to midline, nearly touching the uvula

The nurse is caring for an African American client admitted to the unit for cirrhosis of the liver. Which of the following areas would the nurse inspect to determine if the client has jaundice? Ears Face Eyes Legs

Eyes

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

Circulatory

The nurse is prepping the client for abdominal surgery. Which type of enema would the nurse anticipate administering? Medicated Cleansing Anthelmintic Oil retention

Cleansing

The nurse is assessing the client's temporomandibular joint (TMJ). Which of the following findings by the nurse would be documented as normal? Popping and grating sounds Swelling around the joint space Clicking when the mouth opens Tenderness on palpation

Clicking when the mouth opens

The nurse asks a client to recall five words after 5, 10, and 30 minutes. Which of the following is the nurse assessing? Client's memory of new information Client's thought process and perceptions Client's recent memory Client's concentration

Client's memory of new information

The nurse is providing care for elderly clients in a long-term care facility. Which of the following would the nurse not anticipate as a change in urinary elimination due to aging? Increased urination at night Degenerative conditions affecting voluntary control Urine retention and stasis Decreased frequency of urination

Decreased frequency of urination

While inspecting the lower extremities of a client, the nurse observes an ulcer. What would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply. Deep Leg edema Client reports severe pain Circular in shape Irregular border

Deep Client reports severe pain Circular in shape

A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma? Purple-blueCo Deep red Light brown or tan Pale gray

Deep red

The hospitalized client complains of pain in the right calf. The nurse notices red streaks along the leg and it is warm and swollen. The nurse would anticipate which of the following diagnoses? Deep vein thrombosis Venous insufficiency Arterial insufficiency Systemic infection

Deep vein thrombosis

The nurse is inspecting the abdomen of a client with liver disease. Which of the following assessments would reflect this diagnosis? Grey-Turner's sign Dilated veins Pale blue abdomen Scaphoid abdomen

Dilated veins

Assessment of a client's skin reveals an individual and distinct 2-mm lesion on the client's back. The nurse would document the configuration as which of the following? Annular Confluent Linear Discrete

Discrete

When performing the cover test on a client, the nurse notes that the covered eye has turned in towards the nose during the examination. The nurse would document this finding as which of the following? Exotropia Presbyopia Esotropia Myopia

Esotropia

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

Establishing a trusting relationship

To alleviate a client's anxiety during a comprehensive assessment, the nurse should do which of the following? Remain in the exam room while the client changes into a gown Explain each procedure being performed and the reason for the procedure Begin with intrusive procedures first to get them completed quickly Ask the client to sign a consent for the physical exam

Explain each procedure being performed and the reason for the procedure

The nurse is auscultating the apical pulse on a healthy adult client. Which of the follow would indicate correct placement of the stethoscope by the nurse? Third intercostal space, left sternal border Second intercostal space, right sternal border Second intercostal space, left sternal border Fifth intercostal space, left midclavicular line

Fifth intercostal space, left midclavicular line

The nurse is caring for a client with eczema and extremely dry skin. The nurse notes deep linear cracks to the client's heels. The nurse would document the assessment findings as which of the following? Scar Ulcer Erosion Fissure

Fissure

The nurse is performing a neurological check on a client with a head injury from a motor vehicle accident four hours ago. The nurse suspects the client has developed increased intracranial pressure. Which of the following would lead the nurse to suspect this diagnosis? Fixed and dilated pupils Exotropia Esotropia Pinpoint pupils

Fixed and dilated pupils

A client is admitted to the clinic with concerns about a possible urinary tract infection (UTI). Which of the following signs and symptoms would not be associated with a lower UTI? Flank pain Dysuria Frequency Urgency

Flank pain

A client tells the nurse that she is having a hard time bringing her hand to her mouth during meals. To assess the client's range of motion in the elbow, the nurse would have the client demonstrate which of the following? Flexion Circumduction Abduction Internal rotation

Flexion

The nurse notes decorticate posturing in a client following a traumatic brain injury. Which of the following assessments by the nurse would be consistent with this posturing? Flexion of the elbows Extended elbows and pronated wrists Dorsiflexion of the feet Externally rotated thighs

Flexion of the elbows

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

Focused assessment

The nurse is performing hourly assessments of the client's level of consciousness. During the assessment, the client remains unresponsive after multiple attempts of the nurse calling their name. Which of the following would the nurse perform next? Call the rapid response team Rub the client's sternum with the knuckles. Press down on one of the client's nail beds. Gently shake the client's shoulders.

Gently shake the client's shoulders.

When assessing the client's sensation, the nurse draws a number on the client's palm and asks him to identify it. Which of the following tests is the nurse performing? Graphesthesia Stereognosis Extinction Tactile discrimination

Graphesthesia

The nurse is planning a bowel training program for a client with a spinal cord injury. Which of the following expected outcome would the nurse include in the care plan? Have a formed stool at least once every 4 days Use enemas once daily to increase the number of bowel movements Have a soft, formed stool at regular intervals without a laxative Continue the occasional use of laxatives to produce formed stool

Have a soft, formed stool at regular intervals without a laxative

During an abdominal assessment, the nurse notes a bulge down the center of the client's abdomen as she is lying supine and raising her head. The nurse suspects this finding is due to which of the following? Hernia Cancerous mass Small bowel obstruction Aortic aneurysm

Hernia

As part of a mental status assessment, the nurse asks the client how they would respond if they found a wallet lying on the sidewalk. This will allow the nurse to assess which domain of mental status? Constructional ability Concentration Abstract reasoning Judgment

Judgment

During a neurologic examination of a client, the nurse holds alternating hot and cold packs to the client's lower extremities. The client reports that they can barely feel the packs on the skin and states, "I'm having a hard time telling if it's hot or cold". The nurse correctly documents this findings as which of the following? Hyperesthesia Hypalgesia Hypesthesia Anesthesia

Hypesthesia

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse? Vitamin deficiency Hypoxia A normal finding Infection of the nailbed

Hypoxia

The nurse is performing an otoscopic examination of a healthy client's left tympanic membrane. At which location would the nurse anticipate seeing the cone of light? In the upper left quadrant In the 7 o'clock position In the 5 o'clock position In the center of the membrane

In the 7 o'clock position

A nursing student is preparing to perform an abdominal assessment on a client. The student performs the assessment correctly when they demonstrate the techniques in which order? Percuss, inspect, auscultate, palpate Inspect, auscultate, percuss, palpate Auscultate, inspect, palpate, percuss Palpate, percuss, inspect, auscultate

Inspect, auscultate, percuss, palpate

The nurse asks a client to bring his hands together behind his lower back with his elbows flexed. Which range of motion movement is the nurse assessing? Abduction Internal rotation Adduction External rotation

Internal rotation

The nurse is assessing a client admitted with exacerbation of his congestive heart failure (CHF). Which of the following would be consistent with this diagnosis? Jugular venous distention with the client sitting up Increased cardiac output Jugular veins visible with the client positioned supine Increased urination during the day

Jugular venous distention with the client sitting up

The nurse is inspecting the oral cavity of a client. Which of the following findings would the nurse report for immediate medical follow-up? Leukoplakia Thrush Canker sore Gingivitis

Leukoplakia

The nurse is preparing to assess a client's ileostomy. Which of the following would the nurse anticipate to find in the ileostomy bag? Flatus without any feces Liquid feces Semi-formed, soft feces Hard, formed feces

Liquid feces

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with the assessment? Palpate the client's abdomen to stimulate bowel motility Listen for at least five minutes before documenting absence of bowel sounds Perform abdominal percussion, wait five minutes, then repeat auscultation Repeat auscultation in four hours

Listen for at least five minutes before documenting absence of bowel sounds

The clinical faculty is observing a student nurse perform auscultation of breath sounds. Which of the following demonstrates correct technique by the student nurse? Listens to at least one full inspiration and expiration at each site Listens laterally to three locations on the left and two locations on the right. Listens to the right lung first and then proceeds to the left lung Listens as the client inhales and then goes to the next site during exhalation

Listens to at least one full inspiration and expiration at each site

During the musculoskeletal assessment of a pregnant client, the nurse notes an increased concave curvature of the lumbar spine. The nurse would document this finding as which of the following? Lordosis Osteoporosis Scoliosis Kyphosis

Lordosis

The nurse is assessing a client admitted to the unit with pleuritis. Which of the following sounds would the nurse expect to hear on auscultation? Low-pitched grating sound on inspiration and expiration Bubbling, moist sounds during early inspiration Sound like rolling hair between the finger Low-pitched, snoring sounds during expiration

Low-pitched grating sound on inspiration and expiration

A nurse is inspecting a client's eyelids and eyelashes. Which of the following would the nurse document as a normal finding? Inward turning of the eyelashes Drooping upper eyelid White sclera is visible above iris with eyes naturally opened Lower eyelid touches the lower border of the iris

Lower eyelid touches the lower border of the iris

After assisting a client to have a bowel movement on a bedpan, the nurse notes the stool has a white discoloration. The nurse would check the client's medication record for administration of which medication? Iron Vancomycin (antibiotic) Aspirin Maalox (antacid)

Maalox (antacid)

The nurse is testing a client's equilibrium with the Romberg test. Which client action would indicate a negative (normal) Romberg test? Starting to lose balance during the exam Maintaining the position during the exam Swaying moderately during the exam Moving the feet apart during the exam

Maintaining the position during the exam

When assessing muscle strength, the nurse notes that the client is unable to move her right arm against both resistance and then gravity. Which of the following actions would the nurse perform next? Document strength of 0 Palpate the client's shoulder joint Inspect the arm for palpable contraction of the muscle Move arm passively through its range of motion

Move arm passively through its range of motion

A nurse in the emergency department assesses a client's pupillary reaction and observes bilateral pinpoint pupils. The nurse interprets this finding as suggesting which of the following? Macular degeneration Increased intracranial pressure Peripheral nervous system injury Narcotic use

Narcotic use

The nurse is performing the positions test on a client. During the assessment, the nurse notes oscillating movements of the client's eyes. The nurse would correctly document this finding as which of the following? Strabismus Extropion Nystagmus Entropion

Nystagmus

The nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. To test for consensual response, the nurse would use which of the following techniques? Compare the measurement between the client's pupils when dilated and when constricted Have the client state when they see the nurse's fingers enter their peripheral field of vision Observe for eye movement when the opposite eye is covered with an opaque card Observe the pupil reaction when a light is shone into the opposite eye

Observe the pupil reaction when a light is shone into the opposite eye

During the assessment of a client's internal eye structures, the nurse notes a white optic disc. The nurse understands which of the following to be the cause of this finding? Macular degeneration Absence of rods and cones Optic nerve atrophy Glaucoma

Optic nerve atrophy

The nurse is preparing to assess a client's carotid arteries. Which nursing action would be most appropriate? Ask the client to breathe in and out deeply. Palpate each artery individually to compare. Palpate the arteries before auscultating them. Use the diaphragm of the stethoscope.

Palpate each artery individually to compare.

The nurse is assessing the motor function of a client's cranial nerve V (trigeminal). Which of the following actions would the nurse take? Ask client to differentiate sharp and dull sensations on the face. Assess dilatation of the client's pupils with direct light. Palpate temporal and masseter muscles while client clenches the teeth. Have the client smile, frown, and wrinkle the forehead.

Palpate temporal and masseter muscles while client clenches the teeth.

A client shows the nurse a "bump" on his neck. The nurse observes a palpable, raised, solid, 0.2 cm in diameter lesion. The nurse would document the presence of which of the following? Pustule Macule Papule Nodule

Papule

The nurse notes unequal chest expansion during inspection of the client's chest. Which of the following does the nurse expect as the cause of this finding? Bulging of the intercostal spaces is present Part of the lung is obstructed or collapsed The client has chronic obstructive pulmonary disease (COPD) Accessory muscles are used to augment respiratory effort

Part of the lung is obstructed or collapsed

The nurse is preparing to test the client's cranial nerve VIII (acoustic). Which of the following actions would the nurse perform? Perform the whisper test Touch the face with sharp and dull objects Place sugar on the anterior portion of the tongue Test the client's peripheral vision

Perform the whisper test

The nurse is assessing the orientation of a client. The nurse understands which of the following is typically the last level of orientation to be lost? Time Place Person Situation

Person

What four questions might you ask to determine if your client is alert and oriented x 4? Type your four questions in the text box below.

Person: Who are you? Place: Where are you? Time: What year is it? Situation: Why are you here?

While inspecting the skin of a client, the nurse notes multiple pinpoint, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? Cherry angioma Petechiae Purpura Ecchymosis

Petechiae

A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about what assessment finding related to the client's sputum? Brown-tinged Pink and frothy White or cream-colored Yellowish and foul-smelling

Pink and frothy

The nurse has completed a focused assessment of an adult client's mouth, nose, and throat. Which finding would the nurse interpret as being normal? Pink, spongy soft palate Absence of a red glow on transillumination of the sinuses Tonsils 3+ Nasal mucosa pale pink and swollen

Pink, spongy soft palate

To promote relaxation of the client's abdominal muscles during examination, which of the following would be most appropriate for the nurse to do? Place a warm gown on the client Assess painful areas of the abdomen first Encourage the client to hold their breath Place a pillow under both of the client's knees

Place a pillow under both of the client's knees

The nurse asks the client to perform dorsiflexion of the foot. Which of the following actions should the client perform? Point toes toward the floor Point their toes to the ceiling Turn toes outward away from midline of body Turn toes inward toward midline of body

Point their toes to the ceiling

The nurse is assessing the superficial reflexes of a client who has sustained a head injury. The nurse strokes the sole of the foot from heel to ball, noting that the client's toes fan out. The nurse document this finding as which of the following? Positive Cremasteric reflex Sustained clonus Positive Babinski reflex Document as a normal finding

Positive Babinski reflex

During a client's vascular assessment, the nurse is palpating the pulse just behind the client's inner ankle. The nurse is assessing which pulse? Popliteal Dorsalis pedis Posterior tibial Femoral

Posterior tibial

The nurse is assessing a client for possible gallbladder disease. Which of the following techniques would the nurse perform to elicit a positive Murphy's sign? Apply deep pressure and then release at the site of McBurney's point. Press the fingertips under the right costal margin and have the client take a deep breath. Have the client lie on their left side and hyperextend the right leg. Have the client lie supine and internally and externally rotate the leg.

Press the fingertips under the right costal margin and have the client take a deep breath.

A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client's complaint? Provide a laundry list of descriptive words. Restate the question using simpler terms. Document "unable to assess client's discomfort." Ignore the complaint for now and return to it later in the assessment.

Provide a laundry list of descriptive words.

The nurse is evaluating a client using the Glasgow Coma Scale (GCS). Which of the following components would not be used during this evaluation? Pupillary response Motor response Eye opening response Verbal response

Pupillary response

A hospitalized client on strict bedrest is having difficulty having a bowel movement. Which of the following actions would the nurse take first to assist the client in having a bowel movement? Withhold all opioid pain medication Raise the head of the bed while the client is on the bedpan Administer laxatives once daily Prepare the client for a cleansing enema

Raise the head of the bed while the client is on the bedpan

The nurse is assessing a client's gait. Which of the following would indicate to the nurse that further evaluation is warranted? Stands on heels and toes Weight evenly distributed Shuffling of feet Arms swinging in opposition to legs

Shuffling of feet

The nurse is caring for a client with a spinal cord injury following a motor vehicle accident. The client tells the nurse that he continues to "wet the bed" without having any sensation that he needs to void. The nurse would suspect this client is experiencing which type of urinary incontinence? Stress Overflow Reflex Mixed

Reflex

The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location? Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant

Right lower quadrant

The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What nursing diagnosis should the nurse associate with this health problem? Risk for Oral Infection related to dysphagia Risk for Aspiration related to decreased swallowing ability Impaired Verbal Communication related to difficulty with speech Risk for Injury related to potential esophageal trauma

Risk for Aspiration related to decreased swallowing ability

The clinical faculty is reviewing heart sounds with the student nurse. Which of the following would indicate understanding of the S1 heart sound by the student nurse? S1 is the beginning of diastole S1 is the closure of the semilunar valves S1 indicates valve stenosis S1 is the closure of the atrioventricular valves

S1 is the closure of the atrioventricular valves

After asking the client to close their eyes, the nurse places a key in their hand and asks the client to identify the object. When the client is unable to identify the object as a key, the nurse would suspect which of the following? Sensory dysfunction Motor dysfuntion Perception disorder Judgment disorder

Sensory dysfunction

A nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. The nurse should be aware that the electrical signal originates in which location? AV node Purkinje fibers Bundle of His Sinoatrial node

Sinoatrial node

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

Slight kyphosis

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

Slightly above the clavicle

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse cite as a modifiable risk factor? Age Multiple pregnancies Smoking African American

Smoking

An adult client has been diagnosed with swelling of the main bronchi. Which of the following would the nurse most likely hear on auscultation? Coarse crackles Sibilant wheezes Sonorous wheezes Fine crackles

Sonorous wheezes

When assessing a client's abdomen, the nurse palpates a pulsating, nontender, 6-centimeter mass above the umbilicus. Which of the following actions should the nurse take next? Counsel the client about hernia repair Stop palpating and call the physician Refer the client to an oncologist Provide a dietician consult for constipation

Stop palpating and call the physician

The nurse suspects a client has carpal tunnel syndrome and asks her to perform Tinel's test. To perform this test, the client would demonstrate which of the following? Hyperextend the wrists and hold for 90 seconds Tap the inner aspect of the wrist over the median nerve Hold hands palm to palm while extending the wrists 90 degrees for 60 seconds Hold hands back to back while flexing the wrists 90 degrees for 60 seconds

Tap the inner aspect of the wrist over the median nerve

Which of the following findings related to hair would the nurse most likely assess in an older adult female client? Terminal hair growth on chin Patchy hair loss on the scalp Thick elastic scalp hair Increased hair in the axilla and on the legs

Terminal hair growth on chin

The nurse records a client's visual acuity as 20/50 using the Snellen eye chart. The nurse correctly interprets the finding as which of the following? The client can read the chart from 20 feet in the left eye and from 50 feet in the right eye At 50 feet the client can read the whole chart The client can read at 50 feet what a person with normal vision can read at 20 feet The client can read at 20 feet what a person with normal vision can read at 50 feet.

The client can read at 20 feet what a person with normal vision can read at 50 feet.

The nurse is assessing a client's cranial nerves XI (spinal accessory). Which of the following would the nurse expect to observe? The client is able to shrug shoulders against resistance The client's uvula and soft palate rise symmetrically The client can identify the taste of sugar on the tongue The client can repeat words whispered into the ear

The client is able to shrug shoulders against resistance

The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first? The client's general intelligence The client's ability to see and hear The presence of any phobias The client's judgment and insight

The client's ability to see and hear

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

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

When performing a musculoskeletal assessment on an elderly client, which of the following considerations should the nurse keep in mind? The elderly client may have an increased elasticity of tendons, increasing the risk of injury. The elderly client may have an increase in the curvature of the lumbar spine. The elderly client may point their toes outward during ambulation. The elderly client may have decreased flexibility and need frequent breaks.

The elderly client may have decreased flexibility and need frequent breaks.

The nurse is testing for accommodation during a client's eye examination. The nurse correctly performs the exam when they demonstrate which of the following? The nurse shines a penlight onto the bridge of the client's nose and inspects for pupillary constriction. The nurse asks the client to follow the penlight in 6 directions and observes for abnormal movement. The nurse shines a light into the pupil and observes for direct and consensual pupillary constriction. The nurse asks the client to focus on the penlight, and then asks the client to follow the penlight to about 7 cm from the nose.

The nurse asks the client to focus on the penlight, and then asks the client to follow the penlight to about 7 cm from the nose.

The nurse is checking an elderly client for signs of dehydration. Which of the following would be a correct action by the nurse when assessing the client's skin turgor? The nurse pinches the skin over the client's clavicle. The nurse pinches the skin on the back of the client's hand. The nurse pinches the skin on the back of the client's upper arm. The nurse pinches the skin on the client's forearm.

The nurse pinches the skin over the client's clavicle.

The nurse is checking the temperature of a client's extremities for warmth. Which of the following demonstrates correct technique by the nurse? The nurse uses the fingerpads of the dominant hand. The nurse uses two fingertips of each hand. The nurse uses the dorsal surface of the hand. The nurse uses the palmar surface of the hands.

The nurse uses the dorsal surface of the hand.

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

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

The clinical instructor is observing a student nurse perform eye exams. Which technique by the student nurse demonstrates correct understanding of testing the corneal light reflex? The student compares the reflection of the light on the client's eye surface The student compares direct and consensual dilation The student compares the speed of pupillary constriction The student compares how quickly the client blinks each eyelid

The student compares the reflection of the light on the client's eye surface

A nurse is assessing the urine output of a client with Parkinson's disease who is on levodopa. Which of the following is a common finding for a client on this medication? The urine may be brown or black. The urine may be green or blue-green. The urine may be blood-tinged. The urine may be orange or orange-red.

The urine may be brown or black.

When auscultating the left carotid artery, the nurse notes a blowing, swishing sound. What does the nurse suspect is the cause of this finding? Turbulent blood flow through a vessel Right ventricular failure Increased venous pressure Decreased cardiac output

Turbulent blood flow through a vessel

The nurse is unable to palpate the dorsalis pedis pulse on a client. Which action should the nurse take next? Document "absence of dorsalis pedis pulse" in the medical record Call the physician for further follow-up Use a Doppler device to locate the pulse Auscultate the anatomic area with a stethoscope

Use a Doppler device to locate the pulse

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

Use of two fingerpads lightly applied to wrist area along the thumb side

The nurse is preparing to assess a client's lungs by auscultation. The nurse demonstrates correct use of the stethoscope for auscultating high-pitched sounds in the lungs when they do which of the following? Uses both the bell and the diaphragm Uses the bell of the stethoscope Uses the diaphragm of the stethoscope Listens over the client's gown to provide for privacy

Uses the diaphragm of the stethoscope

A nurse is interviewing a client in the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? Sitting across the room from the client Standing while the client is seated Using a moderate amount of eye contact Limiting all facial expressions

Using a moderate amount of eye contact

The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem? Angiomas Vitiligo Striae Ecchymosis

Vitiligo

A client in the clinic complains that his urine has turned a dark red color. When reviewing the client's current medications, which medication would the nurse suspect as the cause of the red urination? Spironolactone (diuretic) Pyridium Warfarin (anticoagulant) B-complex vitamin

Warfarin (anticoagulant)

The nurse is performing the ballottement test during the assessment of a client's knee. The nurse understands that performing this test would give further information on which of the following? Whether the client experiences pain during range of motion Whether the client is experiencing increased fluid in the knee joint Whether the client's knee joint is capable of flexion and extension Whether the swelling in the knee joint is a normal age-related change or an infection

Whether the client is experiencing increased fluid in the knee joint

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

Working