Nur101 Medsurg Exam 2

ANS: 50 Pack-years = Number of years smoking × Number of packs per day: 20 × 2.5 = 50.

A nurse is preparing to perform a lung assessment on a patient and discovers through the nursing history the patient smokes. The nurse figures the pack-years for this patient who has smoked two and a half (2 1/2) packs a day for 20 years. Which value will the nuterm-42rse record in the patient's medical record? Record answer as a whole number. _________ pack-years

ANS: B Grade reflexes as follows: 0: No response; 1+: Sluggish or diminished; 2+: Active or expected response; 3+: More brisk than expected, slightly hyperactive; and 4+: Brisk and hyperactive with intermittent or transient clonus.

The nurse is assessing an adult patient's patellar reflex. Which finding will the nurse record as normal? a. 1+ b. 2+ c. 3+ d. 4+

3.Loss of normal red tones in the skin Rationale: 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.

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

ANS: A, C, D Abnormal findings will cause a nurse to follow up. Orthopnea is abnormal and indicates cardiovascular or respiratory problems. Pleural friction rub is abnormal and indicated an inflamed pleura. Crackles are adventitious breath sounds and indicate random, sudden reinflation of groups of alveoli, indicating disruptive passage of air through small airways. Lymph nodes should be nonpalpable; palpable lymph nodes are abnormal. Grade 5 muscle function is normal. A 160-degree angle between nail plate and nail is normal; a larger degree angle is abnormal and indicates clubbing.

A nurse is assessing several patients. Which assessment findings will cause the nurse to follow up? (Select all that apply.) a. Orthopnea b. Nonpalpable lymph nodes c. Pleural friction rub present d. Crackles in lower lung lobes e. Grade 5 muscle function level f. A 160-degree angle between nail plate and nail

ANS: A During Weber's test (lateralization of sound), the nurse places the vibrating tuning fork in the middle of the patient's forehead. During a Rinne test (comparison of air and bone conduction), the nurse places a vibrating tuning fork on the patient's mastoid process and compares the length of time air and bone conduction is heard. Comparing the patient's degree of joint movement to the normal level is a test for range of motion.

A nurse is conducting Weber's test. Which action will the nurse take? a. Place a vibrating tuning fork in the middle of patient's forehead. b. Place a vibrating tuning fork on the patient's mastoid process. c. Compare the number of seconds heard by bone versus air conduction. d. Compare the patient's degree of joint movement to the normal level.

ANS: B Abdominal pain can be related to bowels. If stools are black or tarry (melena), this may indicate gastrointestinal alteration. The nurse should caution patients about the dangers of excessive use of laxatives or enemas. There is not enough information about the abdominal pain to recommend laxatives. Determine if the patient is pregnant, and note her last menstrual period. Pregnancy causes changes in abdominal shape and contour. Assess painful areas last to minimize discomfort and anxiety.

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which action will the nurse take when performing an abdominal assessment? a. Assess the area that is most tender first. b. Ask the patient about the color of her stools. c. Recommend that the patient take more laxatives. d. Avoid sexual references such as possible pregnancy.

3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants Rationale: 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. Bowel sounds will be more high-pitched and louder (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds.

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

ANS: C Patients who are Chinese American often believe that examination of the external genitalia is offensive. Before proceeding with the examination, the nurse first determines how the patient feels about the procedure and explains the procedure to answer any questions and to help the patient feel comfortable with the assessment. Once the patient is ready to have her external genitalia examined, the nurse places the patient in the lithotomy position and drapes the patient appropriately. Typically, nurses ask adolescents if they want a parent present during the examination. The patient in this question is 25 years old; asking if she would like her mother to be present is inappropriate.

An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old American woman of Chinese descent. Which action will the nurse do first? a. Place the patient in the lithotomy position. b. Drape the patient to enhance patient comfort. c. Assess the patient's feelings about the examination. d. Ask the patient if she would like her mother to be present in the room.

ANS: B The diagnosis of entropion can lead to lashes of the lids irritating the conjunctiva and cornea. Irritation can lead to infection. Exophthalmos is a bulging of the eyes and usually indicates hyperthyroidism. An abnormal drooping of the lid over the pupil is called ptosis. In the older adult, ptosis results from a loss of elasticity that accompanies aging. Hyperactive sounds are loud, "growling" sounds called borborygmi, which indicate increased GI motility.

An older-adult patient is being seen for chronic entropion. Which condition will the nurse assess for in this patient? a. Ptosis b. Infection c. Borborygmi d. Exophthalmos

ANS: B Older adults are especially at risk for hearing loss caused by ototoxicity (injury to auditory nerve) resulting from high maintenance doses of antibiotics (e.g., aminoglycosides). While eyes and skin are important, they are not the priority. Reflexes are expected to be diminished in older adults.

An older-adult patient is taking aminoglycoside for a severe infection. Which assessment is the priority? a. Eyes b. Ears c. Skin d. Reflexes

ANS: A A small amount of thick, white smegma sometimes collects under the foreskin in the uncircumcised male and is considered normal. Penile pain or swelling, genital lesions, and urethral discharge are signs and symptoms that may indicate sexually transmitted infections (STI). All men 15 years and older need to perform a male-genital self-examination monthly. The nurse needs to assess a patient's sexual history and use of safe sex habits. Sexual history reveals risks for STI and HIV.

During a genitourinary examination of a 30-year-old male patient, the nurse identifies a small amount of a white, thick substance on the patient's uncircumcised glans penis. What is the nurse's next step? a. Record this as a normal finding. b. Avoid embarrassing questions about sexual activity. c. Notify the provider about a suspected sexually transmitted infection. d. Tell the patient to avoid doing self-examinations until symptoms clear.

ANS: D Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not clean is used. The stethoscope should be cleaned before use on each patient with isopropyl alcohol. Running water over the stethoscope does not kill bacteria. Betadine is an inappropriate cleaning solution and may damage the equipment. Draping the stethoscope around the neck is not advised.

Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse next enters the patient's room and identifies self, washes hands with soap, and states the purpose of the visit. The nurse performs proper identification of the patient before auscultating the patient's lungs. Which critical health assessment step should the nurse have performed? a. Running warm water over stethoscope b. Draping stethoscope around the neck c. Rubbing stethoscope with betadine d. Cleaning stethoscope with alcohol

ANS: C This patient has gained 6 pounds in a 24-hour period. A weight gain of 5 pounds (2.3 kg) or more in a day indicates fluid retention problems, not nutritional intake. A weight loss is considered significant if the patient has lost more than 5% of body weight in a month or 10% in 6 months. A downward trend may indicate a reduction in nutritional reserves that may be caused by decreased intake such as anorexia.

On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. Which condition will the nurse assess for in this patient? a. Anorexia b. Weight loss c. Fluid retention d. Increased nutritional intake

Correct Answer: 10 pack-years Rationale: 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 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

4.One week after menstruation begins Rationale: The breast self-examination should be performed regularly, 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.

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

Rationale: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 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.

1."This is mostly used in a walk-in clinic or emergency department." Rationale: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 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."

2.Just under the left clavicle Rationale: 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.

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

4. "When was the last time you had your blood pressure checked?" Rationale: The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the client's major modifiable risk factors.

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?"

1.Assess the child's physical status. Rationale: 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.

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.

3.A physical obstruction to the transmission of sound waves Rationale: 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.

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.Redness and swelling in the ear canal Rationale: 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.

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.Wheezes Rationale: 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. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

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

2.Instruct the client that he or she may need glasses when driving. Rationale: 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.

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.

Correct Answer: 4, 1, 2, 5, 3 Rationale: The confrontation test is a gross measure of peripheral vision. It compares the person's peripheral vision with the examiner's, whose vision is assumed to be normal. If the client does not see the object at the same time as the nurse, peripheral field loss is expected. The client should be referred to an eye care specialist. The procedure is conducted in the following order: stand 2 to 3 ft (60 to 90 cm) in front of the client and face him or her; client covers 1 eye on request; nurse covers the eye opposite the one covered by the client; an object is gradually brought inward from the periphery; and the client reports when the object is first noted.

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

ANS: A Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less than 1 cm. Wheals are irregularly shaped, elevated areas of superficial localized edema that vary in size. They are common with mosquito bites and hives. Papules are palpable, circumscribed, solid elevations in the skin that are smaller than 1 cm. Pustules are elevations of skin similar to vesicles, but they are filled with pus and vary in size like acne.

A febrile preschool-aged child presents to the after-hours clinic. Varicella (chickenpox) is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. Which type of skin lesion will the nurse report? a. Vesicles b. Wheals c. Papules d. Pustules

ANS: D Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient who has jaundice. Oxygen saturation will be used for cyanosis. Cherry-colored lips indicate carbon monoxide poisoning.

A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Which laboratory test will the nurse expect to be ordered, based upon the physical findings? a. Oxygen saturation b. Liver function test c. Carbon monoxide d. Thyroid-stimulating hormone test

ANS: A The most common symptoms of testicular cancer are a painless enlargement of one testis and the appearance of a palpable, small, hard lump, about the size of a pea, on the front or side of the testicle. Normally, the testes feel smooth, rubbery, and free of nodules. Use of diuretics, sedatives, or antihypertensives can lead to erection or ejaculation problems.

A male student comes to the college health clinic. He hesitantly describes that he found something wrong with his testis when taking a shower. Which assessment finding will alert the nurse to possible testicular cancer? a. Hard, pea-sized testicular lump b. Rubbery texture of testes c. Painful enlarged testis d. Prolonged diuretic use

ANS: A Products containing lindane, a toxic ingredient, often cause adverse reactions; the nurse will need to follow up to correct the misconception. All the rest are correct. Instruct parents who have children with head lice to shampoo thoroughly with pediculicide (shampoo available at drugstores) in cold water at a basin or sink, comb thoroughly with a fine-toothed comb, and discard the comb. A dilute solution of vinegar and water helps loosen nits.

A nurse identifies lice during a child's scalp assessment. The nurse teaches the parents about hair care. Which information from the parents indicates the nurse needs to follow up? a. We will use lindane-based shampoos. b. We will use the sink to wash hair. c. We will use a fine-toothed comb. d. We will use a vinegar hair rinse.

ANS: B Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care, not just the patient's medical care. Assessment data help to evaluate the effectiveness of medications and to determine a patient's health care needs, including the need for patient education. Nurses also use assessment data to identify patients' psychosocial and cultural needs.

A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which statement made by the new graduate nurse requires the preceptor to intervene? a. "I will use the information from my assessment to figure out if your antihypertensive medication is working effectively." b. "Nursing assessment data are used only to provide information about the effectiveness of your medical care." c. "Nurses use data from their patient's physical assessment to determine a patient's educational needs." d. "Information gained from physical assessment helps nurses better understand their patients' emotional needs."

1. Koilonychia = c. Spoon nails 2. Venous problems = a. Lower extremity swollen and warm with normal pulse 3. Lordosis = f. Swayback 4. Melena = g. Black, tarry stools 5. Arterial problems = d. Lower extremity pale and cool with decreased pulse 6. Jugular vein distention = b. Neck vein visible when sitting 7. Tinnitus = e. Ringing in ears

A nurse is assessing a group of patients. Match the assessment finding the nurse observed to its condition. a. Lower extremity swollen and warm with normal pulse b. Neck vein visible when sitting c. Spoon nails d. Lower extremity pale and cool with decreased pulse e. Ringing in ears f. Swayback g. Black, tarry stools 1. Koilonychia 2. Venous problems 3. Lordosis 4. Melena 5. Arterial problems 6. Jugular vein distention 7. Tinnitus

ANS: A, C, E Cranial nerve IX is the glossopharyngeal, which controls taste and ability to swallow. The nurse asks the patient to identify sour (lemon) or sweet (sugar) tastes on the back of the tongue and uses a tongue blade to elicit a gag reflex. Ophthalmoscopes are used for vision. A Snellen chart is used to test cranial nerve II (optic).

A nurse is assessing a patient's cranial nerve IX. Which items does the nurse gather before conducting the assessment? (Select all that apply.) a. Vial of sugar b. Snellen chart c. Tongue blade d. Ophthalmoscope e. Lemon applicator

ANS: C The bell is best for hearing low-pitched sounds such as vascular (bruits) and certain heart sounds (low-pitched murmurs), and the diaphragm is best for listening to high-pitched sounds such as bowel and lung sounds and high-pitched murmurs.

A nurse is auscultating different areas on an adult patient. Which technique should the nurse use during an assessment? a. Uses the bell to listen for lung sounds b. Uses the diaphragm to listen for bruits c. Uses the diaphragm to listen for bowel sounds d. Uses the bell to listen for high-pitched murmurs

ANS: A A fourth heart sound (S4) occurs when the atria contract to enhance ventricular filling. An S4 is often heard in healthy older adults, children, and athletes, but it is not normal in adults. Because S4 also indicates an abnormal condition, report it to a health care provider. An S3 is considered abnormal in adults over 31 years of age but can often be heard normally in children and young adults. Vesicular lungs sounds in the periphery and bronchovesicular lung sounds in between the scapula are normal findings.

A nurse is caring for a group of patients. Which patient will the nurse see first? a. An adult with an S4 heart sound b. A young adult with an S3 heart sound c. An adult with vesicular lung sounds in the lung periphery d. A young adult with bronchovesicular breath sounds between the scapula posteriorly

ANS: B For an individual to explain common phrases such as "A stitch in time saves nine" or "Don't cry over spilled milk" requires a higher level of intellectual function or abstract thinking. Knowledge-based assessment is factual. Assess knowledge by asking how much the patient knows about the illness or the reason for seeking health care. To assess past (long-term) memory, ask the patient to recall the maiden name of the patient's mother, a birthday, or a special date in history. It is best to ask openended questions rather than simple yes/no questions. Patients demonstrate immediate recall (recent memory) by repeating a series of numbers in the order in which they are presented or in reverse order.

A nurse is performing a mental status examination and asks an adult patient what the statement "Don't cry over spilled milk" means. Which area is the nurse assessing? a. Long-term memory b. Abstract thinking c. Recent memory d. Knowledge

ANS: C Supine is the most normally relaxed position. If the patient becomes short of breath easily, raise the head of the bed. Supine position would be easiest for a weak, older-adult person during the examination. Lateral recumbent and prone positions cause respiratory difficulty for any patient with respiratory difficulties. Sims' position is used for assessment of the rectum and the vagina.

A nurse is preparing to perform a complete physical examination on a weak, older-adult patient with bilateral basilar pneumonia. Which position will the nurse use? a. Prone b. Sims' c. Supine d. Lateral recumbent

3."I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." Rationale: To elicit Homans' sign, the nurse asks the client to extend the legs flat on the bed. The nurse then grasps the foot and dorsiflexes it forward. If this causes any discomfort or resistance, the nurse should notify the primary health care provider that Homans' sign may be present. The statements in the remaining options are incorrect descriptions of this assessment technique.

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."

ANS: A The child needs an eye examination with an ophthalmologist or optometrist. Normal vision is 20/20. The larger the denominator, the poorer the patient's visual acuity. For example, a value of 20/60 means that the patient, when standing 20 feet away, can read a line that a person with normal vision can read from 60 feet away. Strabismus is a (congenital) condition in which both eyes do not focus on an object simultaneously: The eyes appear crossed. Acuity may not be affected; Snellen test does not test for strabismus. Presbyopia is impaired near vision that occurs in middle-aged and older adults and is caused by loss of elasticity of the lens. Cataracts, a clouding of the lens, develop slowly and progressively after age 35 or suddenly after trauma.

A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes. Which response by the nurse is the best regarding the eye examination results? a. Your child needs to see an ophthalmologist. b. Your child is suffering from strabismus. c. Your child may have presbyopia. d. Your child has cataracts.

ANS: D The order of an abdominal examination differs slightly from that of other assessments. Begin with inspection and follow with auscultation. By using auscultation before palpation, the chance of altering the frequency and character of bowel sounds is lessened.

A patient in the emergency department is reporting left lower abdominal pain. Which proper order will the nurse follow to perform the comprehensive abdominal examination? a. Percussion, palpation, auscultation b. Percussion, auscultation, palpation c. Inspection, palpation, auscultation d. Inspection, auscultation, palpation

ANS: D Most states mandate a report to a social service center if nurses suspect abuse or neglect. When abuse is suspected, the nurse interviews the patient in private, not with a teacher. Observe the behavior of the individual for any signs of frustration, explanations that do not fit his or her physical presentation, or signs of injury. The nurse knows how to proceed and does not need to talk to the principal about what to do. Disregarding the finding is not advised because victims often will not complain or report that they are in an abusive situation.

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Which action will the nurse take next? a. Talk to the principal about how to proceed. b. Disregard the finding based upon child's response. c. Interview the patient in the presence of the teacher. d. Contact social services and report suspected abuse.

ANS: B A common benign condition of the breast is benign (fibrocystic) breast disease. This patient has symptoms of fibrocystic disease, which include bilateral lumpy, painful breasts sometimes accompanied by nipple discharge. Symptoms are more apparent during the menstrual period. When palpated, the cysts (lumps) are soft, well differentiated, and movable. Deep cysts feel hard. Although a common condition, benign breast disease is not normal; therefore, the nurse does not tell the patient that this is a normal finding. During examination of the nipples and areolae, the nipple sometimes becomes erect with wrinkling of the areola. Therefore, consulting a breast surgeon to treat her nipples and areolae is not appropriate.

A teen patient is tearful and reports locating lumps in her breasts. Other history obtained is that she is currently menstruating. Physical examination reveals soft and movable cysts in both breasts that are painful to palpation. The nurse also notes that the patient's nipples are erect, but the areola is wrinkled. Which action will the nurse take after talking with the health care provider? a. Reassure patient that her symptoms are normal. b. Discuss the possibility of fibrocystic disease as the probable cause. c. Consult a breast surgeon because of the abnormal nipples and areola. d. Tell the patient that the symptoms may get worse when her period ends.

ANS: D Hearing is the priority. Risk factors for hearing problems include low birth weight, nonbacterial intrauterine infection, and excessively high bilirubin levels. Hearing loss due to ototoxicity (injury to auditory nerves) can result from high maintenance doses of antibiotics. Cardiac, respiratory, and eye examinations are important assessments but are not relevant to this child's condition.

During a routine pediatric history and physical, the parents report that their child was a very small, premature infant that had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born and developed an infection that required "every antibiotic under the sun" to reach a cure. Which exam is a priority for the nurse to conduct on the child? a. Cardiac b. Respiratory c. Ophthalmic d. Hearing acuity

ANS: A A bruit is the sound of turbulence of blood passing through a narrowed blood vessel and is auscultated as a blowing sound. A bruit can reflect cardiovascular disease in the carotid artery of middle-aged to older adults. Intensity or loudness is related to the rate of blood flow through the heart or the amount of blood regurgitated. A thrill is a continuous palpable sensation that resembles the purring of a cat. Jugular venous distention, not bruit, is a possible sign of right-sided heart failure. Some patients with heart disease have distended jugular veins when sitting. Phlebitis is an inflammation of a vein that occurs commonly after trauma to the vessel wall, infection, immobilization, and prolonged insertion of IV catheters. It affects predominantly peripheral veins.

During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. Which assessment finding will the nurse report to the health care provider? a. Bruit b. Thrill c. Phlebitis d. Right-sided heart failure

ANS: C Pale nasal mucosa with clear discharge indicates allergy. Clubbing is due to insufficient oxygenation at the periphery resulting from conditions such as chronic emphysema and congenital heart disease; it is noted in the nails. A sinus infection results in yellowish or greenish discharge. Habitual use of intranasal cocaine and opioids causes puffiness and increased vascularity of the nasal mucosa.

During a school physical examination, the nurse reviews the patient's current medical history. The nurse discovers the patient has allergies. Which assessment finding is consistent with allergies? a. Clubbing b. Yellow discharge c. Pale nasal mucosa d. Puffiness of nasal mucosa

ANS: C Human papillomavirus (HPV) infection increases the person's risk for cervical cancer. HPV vaccine is recommended for females aged 11 to 12 years but can be given to females ages 12 through 26; males can also receive the vaccine. HPV is not a risk factor for breast, ovarian, and testicular cancer.

During a sexually transmitted illness presentation to high-school students, the nurse recommends the human papillomavirus (HPV) vaccine series. Which condition is the nurse trying to prevent? a. Breast cancer b. Ovarian cancer c. Cervical cancer d. Testicular cancer

ANS: C A normal finding is pupils constricting when directly illuminated with a penlight. A pulse strength of 3 indicates a full or increased pulse; 2 is normal. 1+ pitting edema is abnormal; there should be no edema for a normal finding. Hyperactive bowel sounds are abnormal and indicate increased GI motility; normal bowel sounds are active.

The nurse completed assessments on several patients. Which assessment finding will the nurse record as normal? a. Pulse strength 3 b. 1+ pitting edema c. Constricting pupils when directly illuminated d. Hyperactive bowel sounds in all four quadrants

4.Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal. Rationale: 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.

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.

ANS: C Females considered to be at higher risk include those who smoke, have multiple sex partners, and have a history of sexually transmitted infections. Of all the assessment findings listed, the 22-yearold smoker with multiple sexual partners has the greatest number of risk factors for cervical cancer. The other patients are at lower risk: not sexually active, celibate, and do not smoke.

The nurse considers several new female patients to receive additional teaching on the need for more frequent Pap test and gynecological examinations. Which assessment findings reveal the patient at highest risk for cervical cancer and having the greatest need for patient education? a. 13 years old, nonsmoker, not sexually active b. 15 years old, social smoker, celibate c. 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners d. 50 years old, stopped smoking 30 years ago, has history of multiple pregnancies

1.It is painless and safe. Rationale: The nurse should reassure the client that pulse oximetry is a safe, painless, noninvasive method of monitoring oxygen saturation levels. No discomfort is involved because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe. The machine does have an alarm that will sound in response to interference with monitoring or when the percent of oxygen saturation falls below a preset level.

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.

2.History of headaches 3.Previous back injury 4.History of hypertension 5.History of diabetes mellitus Rationale: 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 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.Focus on a distant object. Rationale: 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 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.

3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Rationale: Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.

The nurse is assessing a client 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. Rationale: Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.

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.

4.Over the fifth intercostal space in the left midclavicular line Rationale: 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 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

ANS: C To assess skin turgor, grasp a fold of skin on the back of the forearm or sternal area with the fingertips and release. Since the skin on the back of the hand is normally loose and thin, turgor is not reliably assessed at that site. Pressing lightly on the forearm can be used to assess for pitting edema or pain or sense of touch. Pressing lightly on the fingertips and observing nail color is assessing capillary refill.

The nurse is assessing skin turgor. Which technique will the nurse use? a. Press lightly on the forearm. b. Press lightly on the fingertips. c. Grasp a fold of skin on the sternal area. d. Grasp a fold of skin on the back of the hand.

ANS: C Using the inverted otoscope grip while pulling the auricle downward and back is a common approach with infant/child examinations because it prevents accidental movement of the otoscope deeper into the ear canal, as could occur with an unexpected pediatric reaction to the ear examination. The other techniques could result in injury to the infant's tympanic membrane. Insert the scope while pulling the auricle upward and backward in the adult and older child. Hold the handle of the otoscope in the space between the thumb and index finger, supported on the middle finger.

The nurse is assessing the tympanic membranes of an infant. Which action by the nurse demonstrates proper technique? a. Pulls the auricle upward and backward. b. Holds handle of the otoscope between the thumb and little finger. c. Uses an inverted otoscope grip while pulling the auricle downward and back. d. Places the handle of the otoscope between the thumb and index finger while pulling the auricle upward.

1.Pallor 2.Pain and point of tenderness 3.Paralysis distal to the fracture site 5.Sensation distal to the fracture site Rationale: 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 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

4.Ask the client to give permission for a family member to stay during the interview. Rationale: 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 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.

2.The client has a rash on the chest and arms. Rationale: Subjective data, collected during the health history, consist of information that the client says about himself or herself. Objective data are obtained through the physical examination and vital sign measurements, what the nurse observes, and laboratory study and diagnostic test results. The remaining options identify subjective data.

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.

ANS: B Lithotomy is the position for examination of female genitalia. The lithotomy position provides for the maximum exposure of genitalia and allows the insertion of a vaginal speculum. Sitting does not allow adequate access for speculum insertion and is better used to visualize upper body parts. Dorsal recumbent is used to examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, and abdomen. Knee-chest provides maximal exposure of the rectal area but is embarrassing and uncomfortable.

The nurse is examining a female with vaginal discharge. Which position will the nurse place the patient for proper examination? a. Sitting b. Lithotomy c. Knee-chest d. Dorsal recumbent

1.After a shower or bath Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing a TSE.

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.Left shoulder Rationale: 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 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

ANS: A Recommended preventive screenings include a digital rectal examination of the prostate and prostate-specific antigen test starting at age 50. CA 125 blood tests are indicated for women at high risk for ovarian cancer. Patients over the age of 65 need to have complete eye examinations yearly. Colonoscopy every 10 years is recommended in patients 50 years of age and older.

The patient is a 45-year-old African-American male who has come in for a routine annual physical. Which type of preventive screening does the nurse discuss with the patient? a. Digital rectal examination of the prostate b. Complete eye examination every year c. CA 125 blood test once a year d. Colonoscopy every 3 years

4.A complete health database Rationale: 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 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. Palpate for increased skin temperature around the wound edges. Rationale: 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 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.

3.A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed Rationale: In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years, it indicates the presence of central nervous system disease.

The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? 1.An involuntary rhythmic, rapid twitching of the eyeballs 2.A dorsiflexion of the ankle and 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 Rationale: In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease.

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

4.Holding the sides of the client's great toe and, while moving it, asking what position it is in Rationale: 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 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

1.Stroking the foot from the heel to the toe Rationale: The plantar reflex is assessed by stroking the outer plantar surface of the foot from the heel to the toe. The anal reflex is assessed by stimulating the perianal area or gently inserting a gloved finger in the rectum. Pupillary response is tested using a flashlight. The pharyngeal (gag) reflex is tested by touching the back of the throat with an object such as a tongue depressor. A positive response to each of these reflexes is considered normal.

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

2.Cloves, peppermint, and soap Rationale: The sensory function of the olfactory nerve controls the sense of smell. To test this nerve, the nurse would ask the client to close the eyes and occlude 1 nostril and identify a nonirritating and familiar odor such as coffee, tea, cloves, soap, chewing gum, peppermint. The test is then repeated on the other nostril. The supplies noted in the remaining options are used for testing cranial nerves VIII, II, and V, respectively.

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

ANS: A Nonambulatory patients are best examined in a side-lying Sims' position. Forward bending would require the patient to be able to stand upright. Knees to chest would be difficult to maintain in a nonambulatory male and is embarrassing and uncomfortable. Dorsal recumbent does not provide adequate access for a rectal examination and is used for abdominal assessment because it promotes relaxation of abdominal muscles.

The nurse is preparing for a rectal examination of a nonambulatory male patient. In which position will the nurse place the patient? a. Sims' b. Knee-chest c. Dorsal recumbent d. Forward bending with flexed hips

1.Provide sufficient lighting. 2.Set the room temperature at a comfortable level. 5.Make sure that the client will be seated comfortably at eye level with the nurse. Rationale: When preparing the physical environment for an interview, 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. The nurse should set the room temperature at a comfortable level. The nurse should arrange seating so that both the nurse and the client are seated comfortably at eye level. The distance between the nurse and the client should be set by the nurse at 4 to 5 ft (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 by the client as distant and aloof. The nurse avoids facing the client across a desk or table because this creates a barrier. Distracting objects and equipment should be removed from the interview area.

The nurse is preparing to interview a client to collect data about the client's health history. The nurse should take which actions to make sure that the physical environment is ready? Select all that apply. 1.Provide sufficient lighting. 2.Set the room temperature at a comfortable level. 3.Ensure that the distance between the nurse and client is no more than 2 ft (60 cm). 4.Arrange seating so that the nurse sits behind the desk across from the client. 5.Make sure that the client will be seated comfortably at eye level with the nurse. 6.Leave equipment needed for the physical exam on the desk so it is readily available.

3.Supine with the head raised slightly and the knees slightly flexed Rationale: 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. Sims' 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 preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination? 1.Sims' 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

1.The right eye is tested, followed by the left eye, and then both eyes are tested. Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 ft (6 meters) from the chart.

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 ft (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 ft (12 meters) from the chart and to read the line that can be read 200 ft (60 meters) away by an individual with unimpaired vision.

1.Number of pack-years Rationale: 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 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

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)." Rationale:When recording visual acuity as measured by the Snellen chart, the nurse would record the numerical fraction noted at the end of the last line successfully read on the Snellen chart. The top number (numerator) indicates the distance the client is standing from the chart, and the denominator gives the distance at which a normal eye could have read that particular line. Thus 20/30 means that the client can read at a distance of 20 ft (6 meters) what a client with normal vision can read at 30 ft (9 meters). Normal visual acuity is 20/20. Legal blindness is defined as the best corrected vision in the better eye of 20/200 or less.

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)."

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. Rationale: 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 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).

4.At a specific day of the month and on that same day every month thereafter Rationale: 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 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

ANS: D Inspection is the use of vision and hearing to distinguish normal from abnormal findings. Light palpation determines areas of tenderness and skin temperature, moisture, and texture. Deep palpation is used to examine the condition of organs, such as those in the abdomen. Caution is the rule with deep palpation. Deep palpation is performed after light palpation; however, deep palpation is not performed on a fractured leg. Auscultation is used to evaluate sound and is not used to assess a fractured leg.

The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. Which proper sequence will the nurse follow to perform the initial assessment? a. Light palpation, deep palpation, and inspection b. Inspection, light palpation, and deep palpation c. Auscultation and light palpation d. Inspection and light palpation

1.Rhythmic respirations with periods of apnea Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

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

3.Client reports difficulty sleeping at night. Rationale: The purpose of a physical assessment is to collect both subjective data and objective data. Subjective data, collected during the health history, consist of information that the client says about himself or herself. Objective data are obtained through the physical examination and vital sign measurements, what the nurse observes, and laboratory study and diagnostic test results.

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.

1.Elevate the shoulders. Rationale: The spinal accessory nerve has only a motor component. This cranial nerve is assessed by asking the client to elevate the shoulders, which may be done with or without resistance. It can also be assessed by asking the client to turn the head from 1 side to the other, resist attempts to pull the chin toward midline, and push the head forward against resistance. The incorrect options are assessed as part of glossopharyngeal nerve (CN IX) and vagus nerve (CN X) testing, which are done together.

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."

ANS: C According to the guidelines of the Glasgow Coma Scale, the patient has a score of 9. Opening eyes to pain is 2 points; inappropriate word use is 3 points; and flexion withdrawal is 4 points. The total for this patient is 2 + 3 + 4 = 9.

The paramedics transport an adult involved in a motor vehicle accident to the emergency department. On physical examination, the patient's level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli. Which value will the nurse report for the patient's Glasgow Coma Scale score? a. 5 b. 7 c. 9 d. 11

ANS: C The two types of aphasias are sensory (or receptive) and motor (or expressive). The patient cannot form words coherently, indicating expressive or motor aphasia is present. The patient responds correctly to questions and instructions, indicating receptive or sensory aphasia is not present. Patients sometimes suffer a combination of receptive and expressive aphasia, but this is not the case here.

The patient has had a stroke that has affected the ability to speak. The patient becomes extremely frustrated when trying to speak. The patient responds correctly to questions and instructions but cannot form words coherently. Which type of aphasia is the patient experiencing? a. Sensory b. Receptive c. Expressive d. Combination

ANS: C With the patient sitting or standing erect, use direct or indirect percussion to assess for kidney inflammation. With the ulnar surface of the partially closed fist, percuss posteriorly the costovertebral angle at the scapular line. If the kidneys are inflamed, the patient feels tenderness during percussion. Use a systematic palpation approach for each quadrant of the abdomen to assess for muscular resistance, distention, abdominal tenderness, and superficial organs or masses. Light palpation would not detect kidney tenderness because the kidneys sit deep within the abdominal cavity. Posteriorly, the lower ribs and heavy back muscles protect the kidneys, so they cannot be palpated. Kidney inflammation will not cause abdominal movement. However, to inspect the abdomen for abnormal movement or shadows, the nurse should stand on the patient's right side and inspect from above the abdomen using direct light over the abdomen.

The patient presents to the clinic with dysuria and hematuria. How does the nurse proceed to assess for kidney inflammation? a. Uses deep palpation posteriorly. b. Lightly palpates each abdominal quadrant. c. Percusses posteriorly the costovertebral angle at the scapular line. d. Inspects abdomen for abnormal movement or shadows using indirect lighting.

ANS: D Vesicular breath sounds are normal breath sounds; the inspiratory phase is 3 times longer than the expiratory phase. Bronchovesicular breath sounds have an inspiratory phase equal to the expiratory phase. Bronchial breath sounds have an expiration phase longer than the inspiration phase at a 3:2 ratio.

Upon assessment, the patient is breathing normally and has normal vesicular lung sounds. Which expected inspiratory-to-expiratory breath sounds will the nurse hear? a. The expiration phase is longer than the inspiration phase. b. The inspiratory phase lasts exactly as long as the expiratory phase. c. The expiration phase is 2 times longer than the inspiration phase. d. The inspiratory phase is 3 times longer than the expiratory phase.

3.Right upper quadrant Rationale: The liver is located in the right upper quadrant of the abdomen; therefore, the locations in the remaining options are incorrect.

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

ANS: B The skin is normally free of lesions, except for common freckles or age-related changes such as skin tags, senile keratosis (thickening of skin), cherry angiomas (ruby red papules), and atrophic warts. Basal cell carcinoma is most common in sun-exposed areas and frequently occurs in a background of sun-damaged skin; it almost never spreads to other parts of the body. Squamous cell carcinoma is more serious than basal cell and develops on the outer layers of sun-exposed skin; these cells may travel to lymph nodes and throughout the body. Report abnormal lesions to the health care provider for further examination. Petechiae are nonblanching, pinpoint-size, red or purple spots on the skin caused by small hemorrhages in the skin layers.

While assessing the skin of an 82-year-old patient, a nurse discovers nonpainful, ruby red papules on the patient's trunk. What is the nurse's next action? a. Explain that the patient has basal cell carcinoma and should watch for spread. b. Document cherry angiomas as a normal older adult skin finding. c. Tell the patient that this is a benign squamous cell carcinoma. d. Record the presence of petechiae.

3.A blowing or swooshing noise Rationale: 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.

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

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)." Rationale: 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).

he 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)."