NCLEX 4000 Questions with answers Health Assessment

When inspecting a clients skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding? a) macule b) papule c) vesicle d) pustule

c) vesicle macule is a flat nonpalpable spot papule is a mole pustule is acne

a nurse is caring for a client who has suffered a severe stroke. During routine assessment the nurse notices cheyne- strokes respirations which are: a) progressively deeper breaths followed by shallower breaths with apneic sounds b) rapid deep breaths with abrupt pauses between breaths c) rapid deep breaths and irregular breathing without pauses d) shallow breaths with an increased respiratory rate

a) progessively deeper breaths followed by shallower breaths with apneic periods

The ear canal of an infant or young child a) slants upward b) slants downward c) is horizontal d) slants backwards

a) slants upwards slants downward in an adult or older child

a nurse is caring for a client who has experienced an acute exacerbation of Crohns diseaes. which statement best indicates that the disease process is under control a) the client exhibits signs of adequate GI perfussion b) the client expresses positive feelings about himself c) the client verbalizes a manageable level of discomfort d) the client maintains skin integrity

a) the client exhibits signs of adequate GI perfusion

During a physical examination, a nurse asks a client to hold their breath briefly and then uses a stethescope to ausculate over their carotid arteries. Which finding is normal when ausculating over these arteries? a) no sounds over either carotid artery b) faint swishing sounds c) throbbing pulsations bilaterally d) louder over the right carotid artery than over the left

a) there should be no sounds over either carotid artery

When routinely evaluating an elderly client for atypical signs or symptoms the nurse should rememeber that a) aging can reduce an individuals ability to regulate body temperature b) aging can increase pain perception c) anesthesia usually causes postoperative psychotic behavior in a geriatric client d) the risk of developing emphesema is highest in elderly people

a)aging can reduce an individuals ability to regulate body temperature d is not the answer because smokers have the highest risk of developing emphesema

a nurse prepares to measure a clients blood pressure. What is the correct procedure for measuring blood pressure? a) wrapping the cuff around the limb with the uninflated bladder covering about 1/4th the limb circumference b) measuring the arm 2'' above the antecubital space c) wrapping the cuff around the limb with the uninflated bladder covering about 3 quarters of the limb circumference d) using a bladder that is 6''

c) wrapping the cuff around the limb with the uninflated bladder, covering about 3 quarters of the limb circumference

A client comes into the clinic for diagnositc allergy testing. The nurse understands that intradermal injections are administered on which principle a) intradermal injection is less painful b) intradermal drugs are easier to administer c) intradermal drugs diffuse more rapidly d) intradermal drugs diffuse slower

c)diffuse slower because it they did go fast then it could be dangerous if they were allergic

When assessing an elderly patient, the nurse expects to find various aging related physciologic changes that include: a) increased coronary artery flow b) decreased posterior thoracic curve c) decreased peripheral resistance d) delayed gastric emptying

d) delayed gastric emptying (also decreased coronary artery flow, increased posterior thoracic curve and increased peripheral resistance)

When assessing an elderly patient the nurse expects to find various aging related physiologic changes such as a) increased coronary artery blood flow b) decreased posterior thoracic curve c) decreased peripheral resistance d) delayed gastric emptying

d) delayed gastric emptying also decreased coronary artery blood flow, increased thoracic curve, increased peripheral resistance

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a) When the infant is sleeping b) At the end of the examination c) Before auscultation of the thorax d) Halfway through the examination

b) At the end of the examination

What complication does a third heart sound s3 indicate? a) ventricular dilation b) systematic hypertension c) aortic valve malfunction d) increased atrial contraction

d) increased atrial contraction rapid filling of the ventricle causes vasodilation that a nurse will ausculatate as s3 increased atrial hypertension is s4 aortic valve malfunction is a murmur

The nurse keeps in mind that the most important reason to share information and offer brief teaching while performing the physical examination is to help: a) The examiner feel more comfortable and gain control of the situation b) Build rapport and increase the patient's confidence in the examiner c) The patient understand his or her disease process and treatment modalities d) The patient identify questions about his or her disease and potential areas of patient education

b) Build rapport and increase the patient's confidence in the examiner

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After putting a call in to the physician and placing the patient on oxygen, which of these is the best action for the nurse to take when assessing the patient further? a) Count the patient's respirations. b) Percuss the thorax bilaterally, noting any differences in percussion tones. c) Call for a chest x-ray and wait for the results before beginning an assessment. d) Inspect the thorax for any new masses and bleeding associated with respirations.

b) Percuss the thorax bilaterally, noting any differences in percussion tones.

A client is diagnosed with deep vein thrombosis (DVT) Which nursing diagnosis should receive the highest priority at this time? a) impaired gas exchange due to increased blood flow b) excess fluid volume related to peripheral vascular disease c) risk for injury related to edema d) ineffective peripheral tissue perfusion related to venous congestion

d) ineffective peripheral tissue perfusion is highest priority due to clot formation impeding blood flow in DVT

A nurse is taking a clients blood pressure and fails to recognize an ausculatory gap. What should the nurse do to avoid recording a low systolic blood pressure a) have the client lie down while taking their blood pressure b) inflate the cuff to at least 200 mm Hg c) take blood pressure readings in both clients arms d) inflate the cuff at least 30 mm Hg after she cannot palpate the radial pulse

d) inflate the cuff at least 30 mm Hg after she cannot palpate the radial pulse

A nurse is evaluating a clients auditory function. To compare air conduction to bone conduction the nurse should use which test a) whispered voice test b) webers test c) watch tick test d) rinne test

d) rinne test compares air conduction to bone conduction whispered voice test is for low pitched tones watch tick assesses high pitched sounds webers evaluates bone conduction only

Which statement regarding the heart sounds is correct? a) s1 and s2 sound equally loud over the entire cardiac area b) s1 and s2 sound fainter at the apex than at the base c) s1 and s2 are fainter at the base than at the apex d) s1 is loudest at the apex and s2 is loudest at the base

d) the s1 sound (lub) is loudest at the apex and the s2 (dub) is loudest at the base

The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a) The slope of the earpieces should point posteriorly (toward the occiput). b) The stethoscope does not magnify sound but does block out extraneous room noise. c) The fit and quality of the stethoscope are not as important as its ability to magnify sound. d) The ideal tubing length should be 22 inches to dampen distortion of sound.

b) The stethoscope does not magnify sound but does block out extraneous room noise.

When assessing a clients abdomen which finding should the nurse report as abmormal a) dullness over the liver b) bowel sounds occuring every 10 seconds c) shifting dullness over the abdomen d) vascular sound over the renal arteries

c) shifting dullness over the abdomen would indicate ascites which is abnormal dullness over the liver, bowel sounds every 10 seconds and vascular sounds over the renal arteries are all normal sounds in the abdomen

a nurse prepares to auscultate a clients carotid arteries for bruits. For this procedure the nurse should a) have the client inhale b) palpate the radial artery c) use the bell of the stethescope d) use the diaphragm of the stethescope

c) the bell is for bruits the patient should be holding their breath not inhaling

Which sentence correctly describes the prone position? a) the body is supine b) arms are elevated at shoulder level c) the body is face down d) the body is facing backwards

c) the body is face down (with the head on the side)

what is a common source of airway obstuction in an unconscious client? a) foreign object b) saliva or mucus c) tongue d) edema

c) tongue

To evaluate a clients cerebellar function a nurse should ask a) do you have any problems with balance? b) do you have difficulty speaking? c) do you have trouble swallowing d) have you noticed any changes in your muscle strenght

a) cerebellar function is about balance and coordination

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later the nurse identifies what as a sign of shock a) confusion b) pale warm and dry skin c) heat rate of 110 beats per minute d) urine output of 30 ml/ hr

a) confusion skin would be pale, warm and clammy not dry

What is the most appropriate nursing diagnosis for a client with acute pancreatitis? a) deficient fluid volume b) excess fluid volume c) decreased cardiac output d) innefective GI tissue perfussion

a) deficient fluid volume

Which component of the clients medical record is the major source of subjective data about the clients health status? a) health history b) physical finding c) lab test results d) radiological findings

a) health history only the health history provides subjective data

A client who is blind is admitted for treatment of gastroenteris. Which nursing diagnosis is the highest priority for this client? a) deficient fluid volume b) risk for injury c) activity intolerance d) impaired physical mobility

A) deficient fluid volume dehyrdation is a sign of gastroenteris

a nurse is providing preoperative teaching to a client. Which type of evaluation should the nurse use in this situation? a) formative b) retrospective c) summative d) informative

A) formative (also called concurrent) which occurs continuously throughout the teaching and learning process informative is not a type of evaluation

a client is admitted to the hospital with pneumonia. He has a history of parkinsons disease. Which assessment should the nurse expect a) impaired speech b) muscle flaccidity c) pleasant and smiling demeanor d) tremors in the fingers`

a) impaired speech

location of aortic stenosis

2nd intercostal R

Best place to auscultate for pulmonic valve

2nd left intercostal space

Pulmonic area is best ausculated at

2nd left intercostal space

Aortic stenosis would be labeled:

2nd right intercostal

Erbs point is best ausculated at:

3rd left intercostal space

a 2 year old child is being examined in the ER for epiglottiditis. Which assessment finding supports the diagnosis a) mid fever b) clear speech c) tripod position d) gradual onset of symptoms

c) tripod position ( to help with breathing

a nurse is assessing a client using light palpation. How does a nurse preform light palpation? a) indenting skin 1/2 to 3/4 inth (1.3-1.9 cm) b)indenting 1 inch to 2 inches c) by indenting the skin 1 inch using both hands d) intending the skin 1 inch then releasing the pressure quickly

a) indenting the skin 1/2 to 3/4 inch or 1.3-1.9 cm using the tips and pads of the finger tups 1.5 inches when preforming deep palpation

A nurse is assessing a clients pulse. Which pulse feature should the nurse document? a) timing in the cycle b) amplitude c) pitch d) intensity

B) amplitude (ARR) Amplitude, Rate, Rhythm

A nurse determines that a client has 20/40 vision. Which statement about this clients vision is true? a) the client can read the entire vision chart at a distance of 40' b) the client can read from a distance of 20' what a person with normal vision can read at 40' c) the client can read the vision chart from a distance of 20' with the right eye and from 40' with the left eye d) the client can read at a distance of 30' what a person can read at a distance of 40'

B) the client can read from a distance of 20' what a person with normal vision can read at 40' the smaller the denominator the worse the vision the numerator is always 20, the distance in feet between the chart and person the denominator indicates what distance normal vision can read the chart

Metabolic Alkalosis

Metabloic alkalosis = high ph and high HC03

Metabolic Acidosis

Metabolic acidosis : low ph and low HC03

While performing an abdominal assessment a nurse should follow which examination sequence a) inspection, ausculation, percussion, palpation b) inspection, ausculation, palpation, percussion c) inspection, percussion, palpation, ausculation d) inspection, palpation, percussion, ausculation

a) inspection, ausculation, percussion, palpation all other sequencing would be inspection, palpation, percussion and then ausculation

Respiratory Acidosis

Respiratory acidosis = low ph and high C02 Hypoventilation

Respiratory Alkalosis

Respiratory alkalosis : high ph and low C02 Hyperventilation

A nurse is auscultating a clients lungs. Where is the area on the vertebrae where the nurse would expect to hear breath sounds at the end of the expiration

T10 between the lungs

A nurse correctly identifies which items as belonging in the dorsal cavity? a) mediastinum b) mouth c) vertebral canal d) reproductive organs

c) vertebral canal dorsal canal consists of the cranial and vertebral canal

Ausculatory gap

a silent internal that may be present between the systolic and diastolic pressures; may lead to serious underestimation of systolic pressure; can be associated with arterial stiffness and atherosclerotic disease absence of Kortotkoff sounds between phase 1 and phase 2 while obtaining blood pressure readings

Rombergs sign

a swaying (falling) when a person stands with feet together and eyes closed. Indicates the person has lost a sense of position

During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? a) "How do you feel today?" b) "Would you please repeat the following words?" c) "Have these medications had any effect on your pain?" d) "Has this pain affected your ability to get dressed by yourself?"

a) "How do you feel today?"

A man is at the clinic for a physical examination. He states that he is "very anxious" about the physical examination. What steps can the nurse take to make him more comfortable? a) Appear unhurried and confident when examining him. b) Stay in the room when he undresses in case he needs assistance. c) Ask him to change into an examining gown and take off his undergarments. d) Defer measuring vital signs until the end of the examination, which allows him time to become comfortable

a) Appear unhurried and confident when examining him.

A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? a) Auscultate the lungs and heart while the infant is still sleeping. b) Examine the infant's hips because this procedure is uncomfortable. c) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. d) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.

a) Auscultate the lungs and heart while the infant is still sleeping.

When preparing to perform a physical examination on an infant, the nurse should: When preparing to perform a physical examination on an infant, the nurse should: a) Have the parent remove all clothing except the diaper on a boy b) Instruct the parent to feed the infant immediately before the examination c) Encourage the infant to suck on a pacifier during the abdominal examination d) Ask the parent to briefly leave the room when assessing the infant's vital signs

a) Have the parent remove all clothing except the diaper on a boy

to evaluate a clients atrial depolarization the nurse observes which part of the ECG waveform? a) P wave b) PR interval c) QRS complex d) T wave

a) P wave p wave is atrial depolarization PR interval is the impule sprading QRS is ventricular depolarization T wave is ventricular repolarization

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a) Palpation b)Inspection c) Percussion d)Auscultation

a) Palpation

The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? a) The diaphragm is used to listen for high-pitched sounds. b) The diaphragm is used to listen for low-pitched sounds. c) The diaphragm should be held lightly against the person's skin to block out low-pitched sounds. d) The diaphragm should be held lightly against the person's skin to listen for extra heart sounds and murmurs.

a) The diaphragm is used to listen for high-pitched sounds.

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? a) The nurse should plan to perform a complete mental status examination. b) The nurse should refer him to a psychometrician. c) The nurse should plan to integrate the mental status examination into the history and physical examination. d) The nurse should reassure his wife that memory loss after a physical shock is normal and will subside soon.

a) The nurse should plan to perform a complete mental status examination.

A nurse is caring for a client who is exhibiting signs and symptoms charachteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? a) assess the clients level of pain and administer prescribed analgesics b) assess the clients level of anxiety and provide emotional support c) prepare the client for pulmonary artery catheterization d) ensure that the clients family is kept informed of his status

a) assess the pain level and administer prescribed analgesics

When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. b) Wash hands before and after every physical patient encounter. c) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. d) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.

b) Wash hands before and after every physical patient encounter.

which client best fits into the middle old population? a) 68 year old with coronary artery disease b) 76 year old with hypertension c) 80 year old with end stage renal disease d) 88 year old with osteoarthiritis

b) a 76 year old with hypertension young old is 65-74 middle old is 75-84 old old is 85 and older

When determining appropriate nursing interventions for a client with medical diagnosis the nurse uses a) developmental anatomy b) applied anatomy c) regional anatomy d) descriptive anatomy

b) applied anatomy developmental anatomy to study structural changes from conception through old age regional anatomy refers to a limited portion of the body descriptive anatomy describes individual body parts in an orderly fashion

A nurse prepares to perform an otoscopic examination on an adult. For proper visualization the nurse should position the clients ear by pullung the: a) lobule down and forward b) auricle up and back c) auricle up and forward d) lobule down and back`

b) auricle up and back for the child pull the auricle down

A nurse is taking the health history of an 85 year old client. Which information will be the most useful to the nurse for planning care? a) general health for the last 10 years b) current health promotion activities c) family history of disease d) marital status

b) current health promotion activities are most important

A nurse is assesing a 47 year old client who has come to the clinic for his annual physical. One of the first physical signs of aging is a) having more frequent aches and pains b) failing eyesight, especially close vision c) increasing loss of muscle tone d) accepting limitations while developing assets

b) failing eyesight, especially close vision is one of the first signs of aging in middle life more frequent aches and pains occur around age 65 loss of muscle tone increases around age 80 accepting limitations while developing assets occurs around age 31-45

When a nurse enters a clients room, the client complains that she is spitting up blood when she coughs. When the nurse takes a quick health history it will include: a) history of the present problem, medications, review of symptoms and major recent operations b) history of the present problem, medications, allergies, and recent major surgeries c) history of the present problem, medications, psychosocial history, and review of systems d) history of the present problem, allergies, medications, review of symptoms, and recent major operatoins

b) history of the present problem, allergies, medications and recent major operations

Using Maslows hierarchy of needs model the nurse assigns the highest priority to: a) arranging a visit from a support group member b) inserting a foley catheter c) raising the side rails on the clients bed d) placing the client in a double room with another client the same age

b) inserting the foley catheter

A nurse is assessing a clients abdomen. Which examination technique should the nurse use first a) ausculation b) inspection c) percussion d) palpation

b) inspection

A client comes in to the clinic for a routine checkup. To assess the clients gag reflex, the nurse should use which method? a) place a tongue blade on the front of the tongue and ask patient to say "ahh" b) place a tongue blade lightly on the posterior aspect of the pharynx c) place a tongue blade on the middle of the tongue and ask the client to cough d) place a tongue blade on the uvula

b) place a tongue blade lightly on the posterior aspect of the pharynx

A client has been receiving an IV solution. What is an appropriate expected outcome for this client a) monitor fluid intake and output every 4 hours b) the client remains free of signs and symptoms of phlebitis c) edema and warmth are noted at IV insertion site d) there is a risk of infection related to IV insertion

b) the client remains free of signs and symptoms of phlebitis

a nurse uses a stethescope to auscultate a clients chest. Which statement about a stethescope with a bell and diaphragm is true? a) the bell detects high pitched sounds best b) the diaphragm detects high pitched sounds best c) the bell detects thrills best d) the diaphragm detects low pitched sounds best

b) the diaphragm detects high pitched sounds the best bell detects low pitch sounds best palpation detect thrills best

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider a) the hand bar of the walker should be well below the clients waist b) when maximum support is required, the walker should be moved ahead around 6''while both legs support the clients weight c) if one leg is weaker than the other, the walker and the stronger leg should move together. The clients weight is supported by his weaker leg d) a standard walker neednt be picked up when moved

b) to prevent falls, the client should move the walker ahead 6''

A nurse is assessing tactile fremitus in a client with pneumonia. For this examination the nurse should use: a) fingertips b) ulnar surface of hand c) dorsal surface of her hand d) finger pads

b) ulnar surface ulnar for tactile fremitus, thrills, and vocal vibrations dorsal for temperature finger tips and finger pads for texture and shape

a nurse is assessing tactile fremitus in a client with pneumonia. For this examination the nurse should use: a) fingertips b) ulnar surface c) dorsal surface d) finger pads

b) ulnar surface ( for tactile fremitus, vocal vibrations and thrills) dorsal for temperature fingertips and pads for texture and shape

During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which of these statements by the nurse is most appropriate? a) "Your atrial dysrhythmias are under control." b) "You have pitting edema and mild varicosities." c) "Your pulse is 80 beats per minute. This is within the normal range." d) "I'm using my stethoscope to listen for any crackles, wheezes, or rubs."

c) "Your pulse is 80 beats per minute. This is within the normal range."

A 2-year-old child has been brought to the clinic for a well-child check-up. The best way for the nurse to begin the assessment is reflected by which statement? a) Ask the parent to place the child on the examining table. b) Have the parent remove all of the child's clothing before the examination. c) Allow the child to keep a security object such as a toy or blanket during the examination. d) Initially focus interactions on the child, essentially "ignoring" the parent, until the child's trust has been obtained.

c) Allow the child to keep a security object such as a toy or blanket during the examination.

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a) Administer the FACT test. b) Ask him to describe his first job. c) Give him the Four Unrelated Words test. d) Ask him to describe what television show he was watching before coming to the clinic.

c) Give him the Four Unrelated Words test.

The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a) Auscultate over the area with a fetoscope b) Use a goniometer to measure the pulsations c) Use a Doppler device to check for pulsations over the area d) Check for the presence of pulsations with a stethoscope

c) Use a Doppler device to check for pulsations over the area

The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a) Wash hands and contact the physician. b) Continue to examine the ulceration and then wash hands. c) Wash hands, put on gloves, and continue with the examination of the ulceration. d) Wash hands, proceed with rest of the physical examination, and then continue with the examination of the leg ulceration.

c) Wash hands, put on gloves, and continue with the examination of the ulceration.

A patient has been in the intensive care unit for 10 days. He has just been moved to the medicalsurgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he: a) May display some disruption in thought content b) Will state, "I am so relieved to be out of intensive care" c) Will be oriented to place and person but may not be certain of the date d) May show evidence of some clouding of his level of consciousness

c) Will be oriented to place and person but may not be certain of the date

When palpating the bladder of an adult the nurse would indentify which finding as normal a) soft smooth bladder b) hard, rough bladder c) nonpalpable bladder d) a palpable bladder located 3'' to 5 '' above the symphasis pubis

c) a nonpalpable bladder or it would be FIRM and smooth and located 1'' to 2'' above the symphasis pubis

To access the effectiveness of cardiac compressions during adult CPR, the nurse should palpate which site? a) radial b) apical c) caratid d) bronchial

c) carotid is the most palpable and assessible

When testing a clients pupils for accomodation a nurse should interpret which finding as normal? a) constriction and divergence b) dialation and convergence c) constriction and convergence d) dilation and divergence

c) constriction and convergence

when developing a care plan for a client with a do not resuscicate (DNR) order a nurse should: a) withhold foods and fluids b) discontinue pain medications as ordered c) ensure assess to individuals who can provide spiritual care with a clients request d) administer lethal doses of medications when requested to do so by a competent terminally ill client

c) ensure assess to individuals who can provide spiritual care

a nurse is developing a nursing diagnosis for a client. Which information should she include a) actions to achieve goals b) expected outcomes c) factors influencing the clients problem d) nursing history

c) factors influencing the clients problem

A nurse must assess skin turgor on an elderly patient. When evaluatin skin turgor, the nurse should remember that: a) overhydration causes the skin to tent b) dehydration causes the skin to appear edamatous and spongey c) inelastic skin turgor is a normal part of aging d) normal skin turgor is moist and boggy

c) it is a normal part of aging to have nonelastic skin turgor normal skin is dry and firm

When assessing the facial lacerations of a middle aged client admitted into the facility 1 week earlier, a nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing? a) contraction b) fibronoplastic c) lag d) inflammation

c) lag the fibrin network dries out and forms a scab

When examining a client who has abdominal pain, a nurse should assess a) any quadrant first b) the symptomatic quadrant first c) the symptomatic quadrant last d) the symptomatic quadrant second or third

c) last

When ausculating a clients abdomen, a nurse detects high pitched gurgles over the lower Right quadrant. Based on this finding,m the nurse suspects a) decreased bowel motility b) increased bowel motility c) nothing abnormal d) abdominal cramping

c) nothing abnormal high pitch gurgles are normal findings

When percussing a clients chest, the nurse should expect to hear: a) hyperresonance b) tympany c) resonance d) dullness

c) resonance is a normal finding over the lung tissue in the chest

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a) Warm the end piece of the stethoscope by placing it in warm water b) Leave the gown on so that the patient does not get chilled during the examination c) Make sure that the bell side of the stethoscope is turned to the "on" position d) Check the temperature of the room and offer blankets to the patient if he or she feels cold

d) Check the temperature of the room and offer blankets to the patient if he or she feels cold

The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of the nurse's technique is most accurate? a) Asking questions enhances the child's autonomy. b) Asking the child for permission helps to develop a sense of trust. c) This is an appropriate statement because children at this age like to have choices. d) Children at this age like to say "No." The examiner should not offer a choice when there is none

d) Children at this age like to say "No." The examiner should not offer a choice when there is none

The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4-year old child. What should the nurse do next? a) Palpate over the area for increased pain and tenderness. b) Ask the child to take shallow breaths and percuss over the area again. c) Refer the child immediately because of an increased amount of air in the lungs. d) Consider this a normal finding for a child this age and proceed with the examination.

d) Consider this a normal finding for a child this age and proceed with the examination.

An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being performed correctly? a) Using the large full circle of light when assessing pupils that are not dilated b) Rotating the lens selector dial to the black numbers to compensate for astigmatism c) Using the grid on the lens aperture dial to visualize the external structures of the eye d) Rotating the lens selector dial to bring the object into focus

d) Rotating the lens selector dial to bring the object into focus

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes: a) She probably doesn't have any problems at all. b) She is just trying to shock people and her dress should be ignored. c) She has manic syndrome because of her abnormal dress and grooming. d) That more information should be gathered to decide whether her dress is appropriate

d) That more information should be gathered to decide whether her dress is appropriate

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? a) The nurse performs the examination from the left side of the bed. b) The nurse examines tender or painful areas first to help relieve the patient's anxiety. c) The nurse follows the same examination sequence regardless of the patient's age or condition. d) The nurse organizes the assessment so that the patient does not change positions too often

d) The nurse organizes the assessment so that the patient does not change positions too often

The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? a) The otoscope is often used to direct light onto the sinuses. b) The otoscope uses a short, broad speculum to help visualize the ear. c) The otoscope is used to examine the structures of the internal ear. d) The otoscope directs light into the ear canal and onto the tympanic membrane.

d) The otoscope directs light into the ear canal and onto the tympanic membrane.

After a stroke the client develops aphasia. The nurse expects to see which assessment finding? a) arm and leg weakness b) absence of a gag reflex c) difficulty swallowing d) inability to speak clearly

d) aphasia is loss of language skills

When ausculating over a clients chest, a nurse assesses a second heart sound (s2) This sound results from a) opening of the mitral and tricuspid vales b) closing of the mitral and tricuspid valves c) opening of the aortic and pulmonic valves d) closing of the aortic and pulmonic valves

d) closing of the aortic and pulmonic valves indicate s2 s1 is the closing of the mitral and tricuspid valves

What description about crackles are true? a) they are grating sounds b) they are high pitched musical squeaks c) they are low pitched noises that sound like snoring d) they may be fine or course

d) crackles can be fine or course they result from air moving through airways that contain fluid and are audiable during both inspiration and expiration plueral fiction sounds like a grating sound wheezes are high pitched musical squeaks

A 10 year old with rheumatic fever must have his heart rate measured while he is awake and while he is sleeping. Why are the two readings necessary? a) to obtain a heart rate that is not affected by medication b) to eleminate interference from the jerky movement of the chorea c) to ensure that the child cannot consciously raise or lower his heart rate d) to compensate for activities effects on the childs heart rate

d) to compensate for activities on the childs heart rate. also to detect tachycardia which would be detected when he is asleep

A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round blisterlike lesions filled with clear fluid. When documenting the findings what medical term should the nurse use to describe this finding? a) pustule b) papules c) plague d) vescicle

d) vesicle (chicken pox, shingles)