Online Assessment Quizzes

A group of students is giving a presentation about the spleen. What is one of the functions of the spleen?

Activates B and T lymphocytes

The RN enters a hospitalized client's room and observes that bedside bronchoscopy equipment has been left at the bedside, the client's morphine analgesia unit is unlocked, and the client's respirations are 6 breaths/minute. What is the nurse's priority action?

Administer narcotic antidote

A client diagnosed with rheumatoid arthritis exhibits edema, redness, and tenderness of the fingers. What is the nurse's priority action?

Administer prescribed anti-inflammatory

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse's next response should be to:

Ask the patient to lock her fingers and pull

A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client?

Assess characteristics of the pain

A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?

Balance

The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening?

Bruit

A client tells the nurse that his eyes "are not working right." When the nurse asks what the client means, the client states, "It is like one eye is moving faster than the other." What test would be most appropriate for the nurse to use to assess this client?

Cardinal fields

A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action?

Check for pulse, color, temperature, and capillary refill

The student nurse would learn that there are what types of family violence? (Mark all that apply.)

Child maltreatment Elder abuse Intimate partner violence

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect which of the following?

Chronic obstructive pulmonary disease

The purpose of a health assessment includes what? (Select all that apply.)

Collecting information about the health status of the client. Evaluating client outcomes. Synthesizing collected data.

When inspecting the hair, what would the nurse note? (Select all that apply.)

Color Condition of hair shaft Hair shafts that are shiny

When assessing a client's strength, it is necessary to

Compare one side to the other

What type of assessment would a nurse perform on a patient being admitted to the hospital?

Comprehensive

A client presents at the urgent care clinic with severe pain and pressure around the eyes. The nurse practitioner suspects a sinus infection. What is considered the gold standard diagnostic technique in evaluating sinus disease?

Computed tomography (CT) scanning

A couple adopts an 8-month-old infant. The clinic nurse writes a care plan that includes the diagnosis of risk for delayed child development related to recent adoption. What would be an appropriate nursing intervention for this infant/family?

Consider visits by a home health nurse to assess the environment for safety and comfort. (Teach parents to stimulate the infant as needed)

What is the most common use of SBAR?

Contacting a provider regarding a client issue

A mother brings her 2-year-old child to the clinic stating that the child is cross-eyed. What test would the nurse perform to test for strabismus?

Corneal light reflex

When documenting the findings of a neurologic assessment, which of the following would be most important?

Describe the client's response

The nurse is assessing an adult client who complains about being "very tired" all the time. What is the best way to assess this client?

Divided over several time periods

What additional health history question related to the abdominal system is appropriate for a client of African American decent?

Do you or your parents have sickle cell disease or carry the trait?

A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what?

Dorsiflexion and plantar flexion

The nurse is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver in the right upper quadrant?

Dullness

The nursing instructor is discussing with the nursing students different types of health histories. A student asks when it would be appropriate to take a comprehensive health history. What would be the instructor's best answer? (Select all that apply.)

During a hospital admission. During an annual physical examination. At a screening for sports participation.

A new client presents at the clinic and reports difficulty hearing. During the interview, the client asks the nurse to repeat questions several times. Examination of the ears reveals large amounts of cerumen filling the canals bilaterally. What would be an appropriate outcome for this client?

Ears will be cleaned at the clinic with hearing improved

The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action?

Ensure a patent airway

A nurse is caring for a client with inflammatory bowel changes and has identified a nursing diagnosis of "Diarrhea related to inflammatory changes in the bowel." What would be an appropriate intervention for this diagnosis?

Ensure adequate hydration and electrolyte replacements

When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first?

Ensure no injury to the cervical spine

The RN notes the following assessment findings on a hospitalized older adult client admitted with a diagnosis of acute confusion and urinary tract infection: BP 131/75, P 70, RR 18, temp 97.2, oriented to person, place, time, and purpose; denial of urinary complaints. What is the nurse's next action?

Ensure the call bell is within reach before leaving the room

A college football player has been hospitalized with a knee injury. When sending his diet orders to the hospital kitchen, the nurse knows what to include?

Extra servings of protein

The nurse is caring for a client who fell from a two-story building and was brought to the emergency department by ambulance. Initial findings include asymmetry of the thorax and paradoxical respirations. The nurse would document these findings as what?

Flail chest

When percussing the scapula of a client, which of the following would the nurse expect to hear?

Flatness

What does Healthy People have as its focus areas for the GI tract? (Mark all that apply.)

Food-borne illness Hepatitis Colorectal cancer

The medical record serves many purposes. What are they? (Select all that apply.)

Framework for medical information Means for financial reimbursement Research Care planning

A nurse asks a client to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following?

Fremitus

What components of sound does the cochlea interpret? (Select all that apply.)

Frequency Amplitude

When doing a risk assessment of the nose, sinuses, mouth, and throat, what finding might indicate an allergy?

Frequent childhood infections

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe.

Frontal

When assessing a client, the first skill used is inspection. What purpose does inspection serve?

Gathering information

What term is this quote describing? "__________ encompasses the evolutionary development which has made man the teaching, instituting, and learning animal."

Generativity

The nurse is conducting a comprehensive health assessment of an adult Hispanic man. Which of the following abnormal findings would be most likely in this client?

Gingivitis

When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are clients most likely at increased risk for if a first-degree relative has it?

Glaucoma

Which of the following tools would a nurse practitioner be more likely than a registered nurse to use during the performance of a musculoskeletal assessment on a client?

Goniometer

A client is given a nursing diagnosis of activity intolerance related to pain and claudication with ambulation. What would be an appropriate intervention for this client?

Gradually increase activity

A mother of three young children is newly diagnosed with breast cancer. The client tells the nurse that she is so sad and cannot stop crying. She adds that she feels like she is less of a woman and is having trouble sleeping. When initiating the plan of care, what would be the most appropriate nursing diagnosis?

Grieving

The nurse is palpating the abdomen of a client newly admitted to the unit. What would be an abnormal finding?

Guarding

When caring for clients in any health care environment, what is the most important technique for preventing infection?

Hand Hygiene

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?

Have the client cough and then listen again

When assessing a breast, what signs/symptoms might indicate a malignancy? (Mark all that apply.)

Hyper-pigmentation Peau d'orange Unilateral vascular appearance

The nursing instructor is discussing the collection of subjective information when assessing a client with arterial, venous, and lymphatic disorders. What would the instructor tell the students to include in the subjective portion of the health assessment?

Identification of cardiovascular risk factors

At the beginning of the shift, an older adult hospitalized for pneumonia complains of shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time?

Immediate (Focused)

The nurse is developing a plan of care for a client found to have a strength problem. What would be an appropriate nursing diagnosis for this client?

Impaired physical mobility

A nurse caring for a client admitted 2 days ago following a cerebral vascular accident. The nurse notes that the client is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this client?

Impaired swallowing

When assessing cranial nerves IX and X, which of the following would the nurse consider as an abnormal finding?

Impaired swallowing

A school age child is brought to the pediatric clinic by her mother, who tells the nurse that the child has a sore on her leg that "just keeps getting bigger." On examination, the nurse practitioner notes an area of vesicles and bulla, some of which have ruptured and are oozing serous fluid. A honey-colored crust covers the area. What would the nurse suspect the lesion is?

Impetigo

Which of the following assessment findings would lead the nurse to suspect that a client has Bell's palsy?

Inability to wrinkle the forehead

The nurse is caring for an adult client who presents at the clinic with reports of general malaise and fatigue. Physical assessment reveals that the client's lips are dry and cracked. What might this indicate?

Inadequate hydration

The RN should intervene and further educate the nursing assistant when observing which action?

Independently pulling an immobile client up in bed

For what is light palpation appropriate? (Select all that apply.)

Inflamed areas of skin Skin texture Surface lesions

A nurse is teaching a client about self breast examination. What would the nurse emphasize? (Mark all that apply.)

Inspection Timing Palpation

An adult comes to the clinic reporting pain in the right lower quadrant. When assessing the client's pain, what elements would the nurse include? (Mark all that apply.)

Intensity Quality Functional goal

When conducting a focused health assessment, the nurse asks questions specifically targeting what?

Issues and symptoms specific to the client

A normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus?

Just below the cricoid cartilage

A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?

Kiesselbach's plexus

A school age client has been diagnosed with genu valgum. What is the other name for this disease?

Knock kneed

The nurse is assessing the musculoskeletal system of a teenage boy for participation in athletics. The nurse would expect to find that this client's bones are what as compared to a female of the same age?

Larger and stronger

The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action?

Leave the room to obtain another armband for the client

Students are practicing documentation of peripheral vascular and lymphatic assessment before going into the clinical setting. A student documents the following: Lower left leg cool to touch with dorsalis pedis, back knee pulse and femoral pulse palpable. How could the following charting be changed to communicate information in appropriate medical terminology?

Left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable

When conducting a generalized assessment of a new client, for what would the nurse inspect the neck?

Limitations in movement. (Lymph node enlargement)

Which of the following would be most important for the nurse to remember when auscultating the thorax?

Listen at each site for at least one complete respiratory cycle

An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.)

Location Size Texture

As a beginning nurse, how can abnormal assessment findings best be evaluated for the need for further investigation? (Select all that apply.)

Look for trends in declining status. consult with other healthcare providers. Review diagnostic test results Ask for a more experienced nurse's opinion

After teaching a group of students about age-related changes in the lungs, the instructor determines that the teaching was successful when the students identify which of the following as an age-related change?

Loss of elasticity

A hospitalized client complains of pain 10/10 one hour after receiving a dose of intravenous Morphine sulfate intravenously. The next dose is not due for over an hour. What is the nurse's best action?

Notify the healthcare provider

A modifiable risk factor for breast cancer includes what?

Obesity

An older adult is admitted to the unit with abdominal pain. The nurse doing the admission assessment knows what about pain in older adults?

Older adults may be reluctant to report pain

An older adult client has been admitted to the unit. The client has problems with fine motor movement. What would be important to do for this client?

Open all packages and arrange the meal tray while communicating actions to the client

Which of the following would be best for a nurse to use when assessing for fremitus in a client?

Palmar base (ulnar surface)

While auscultating a client's abdomen, the student notes abnormal bowel sounds. The student's nursing preceptor asks the student to describe the sounds. The student describes them as high-pitched, rushing sounds. The nursing preceptor would know that these sounds indicate what?

Partial intestinal obstruction

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?

Perform a focused assessment

When assessing the extremities of a client, the nurse notes muscle atrophy. What does the nurse know may be the cause?

Peripheral arterial disease

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?

Peripheral neuropathy

A client presents at the emergency room reporting "the worst headache I have ever had." What are critical nursing behaviors for this client? (Select all that apply.)

Physical examination for neurological changes. Focused history

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the client's is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

Pinch a fold of skin on the client's forearm (Pinch a fold of skin on the client's abdomen)

In order to help out the staff in completing admission tasks during a busy shift, the charge nurse is completing the admission database for a staff nurse. What is the charge nurse's best action?

Place the completed assessment in the medical record

When auscultating the client's lungs, how should the nurse position the earpieces of the stethoscope?

Pointed toward the nose

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

Positive Romberg sign

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

Posterior tibial

The nurse is receiving report on a client with a nursing diagnosis of activity intolerance. What would be an appropriate nursing intervention for this client?

Promote reconditioning

A way to use nonverbal communication is through silence. The purposeful use of silence during the interview allows clients to what?

Provide accurate answers

The nurse is in the client's room after she has given birth one day ago and observes a family member offering the baby a bottle after the infant has breastfed. The family member states to the new mother, "This baby is not fat enough and needs to eat double the first few weeks." What is the nurse's best action?

Provide information to the client and family about newborn nutritional needs

When doing a shift assessment on a new client, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this?

Pulses 2-3+

A client with an acute appendicitis is ordered a barium enema. What should the nurse do first?

Question the order because you thought a barium enema was contraindicated in cases like this.

Which information in the client's history is a priority safety concern?

Recent immigrant complains of cough. (Diminished sense of smell and taste)

What do nursing activities that promote health and prevent disease accomplish? (Select all that apply.)

Reduce the risk of disease. Maintain optimal functioning. Reinforce good habits

The nursing instructor is discussing the different types of pain with the nursing class. What type of pain would the instructor explain originates from a specific site, yet the client feels the pain at another site?

Referred pain

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing?

Reflexes

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action?

Review the client's prescribed medication orders

When delegating tasks, the RN adheres to the Five Rights of Delegation principle which includes which rights? (Select all that apply.)

Right task Right circumstances Right person Right directions

Students are learning about subjective data collection. What data are collected subjectively? (Mark all that apply.)

Risk factors Common symptoms Family history

A trauma client reports pain in the left lower extremity. The nurse notes that the extremity has pallor. Pedal pulses are diminished, and paresthesia is present. What nursing diagnosis might the nurse use?

Risk for peripheral neurovascular dysfunction

A client is thought to have a balance problem. What would be an advanced method of assessing balance in this client? (Mark all that apply.)

Romberg's test Standing Hopping on one foot

An oncology nurse is caring for a client newly diagnosed with an occult nasopharyngeal malignancy. Where would the nurse expect this malignancy to be?

Rosenmuller's fossa

Nursing students are learning about different methods of charting in the clinical laboratory. What method would they learn that is a shared mental model for improving communication between and among clinicians?

SBAR

A nursing instructor is explaining to students about primary prevention services that nurses offer as part of their professional responsibilities. What would the instructor list as these services?

Screening

Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.)

Shape of the lips Shape of the nose Shape of the eyes

When assessing a client, the nurse asks if the client has ever had varicella. The nurse knows that varicella always precedes what?

Shingles

What type of family violence is among the most common type that children experience?

Sibling violence

The nurse is assessing the pain of an older adult client who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the patient's pain?

Sleep patterns

When assessing the apices of the lungs, the nurse would locate them at which position?

Slightly above the clavicle

Included in the subjective assessment of the breast are the client's statements about what? (Mark all that apply.)

Surgeries Nipple discharge Personal history

To increase the number of people with a specific source of ongoing care, what would a nurse teach the client?

Teach the client to have regular visits for screening and health promotion

When collecting subjective data, the nurse gives the client time and encouragement to do what?

Tell about the client's concerns

A client arrives at the emergency department by ambulance after an accident while playing softball. The client's left leg is swollen and deformed. The client describes the pain as a 9 on a 10-point scale. When the nurse assesses the client's blood pressure, what would the nurse expect to find?

The blood pressure is elevated

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

The client exhibits no signs or symptoms of infection

While assessing respirations and heart rate in a school aged client, the nurse finds that the client's heart rate increases during inspiration and decreases during expiration. What would be the most correct way to document this finding?

The client has a sinus arrhythmia

A nurse is admitting a client to the hospital. When reviewing the client's medical record, the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means?

The client has unilateral hearing loss

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client?

The client may not want her sister to know her private information

A nurse conducting a comprehensive nutritional assessment is assisting the client in completing a 24-hour food recall. What does the research show regarding the client's ability to recall intake?

The client often underestimates high intakes

The nurse is performing a generalized assessment of an older adult. The nurse notes that the client's skin is thin and rough with abrasions. The client tells the nurse that it seems to take "forever" for scratches to heal, "a lot longer than when I was younger.". How would the nurse note these findings in the client's medical record?

The client states that wounds are taking longer to heal

A teenage client is brought to the emergency department with an injury to the left ankle after a skateboard accident. Diagnostic films show a fracture across the epiphyses. The doctor explains that the client may not have full range of motion and that the left leg may be shorter than the right leg. The parents ask why one leg may be shorter than the other. What would be the nurse's best answer?

The fracture crosses the part of the bone where the bone lengthens

What is egocentrism?

The inability to distinguish one's own perspective from another person's

The nurse is assessing risk factors on a new clinic client. These risk factors are assessed according to what?

The individual's risks

A student nurse is taking a nursing test and is asked a question about the columella. What is the best description of the term columella?

The structure that divides the nares

The Joint Commission mandates that nurses assess and reassess a client's pain level. A nurse's healthcare facility mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?

The time it takes a pain medication to decrease pain intensity

When the nurse is assessing the client's skin, an ulcer is identified. What would indicate to the nurse that it is a venous ulcer?

The ulcer is superficial and pale

The nursing students are learning about the abdomen. The nursing instructor would tell the class that the abdominal cavity is bordered on the back by

The vertebral column

The nurse is admitting a new client to the floor and asks if the client has any dizziness. Why does the nurse do this?

To check for possible dehydration

Why do nursing students review medical records? (Select all that apply.)

To enhance clinical learning. To better understand complex clinical situations.

A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?

To have up-to-date information on which to base clinical decisions

The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as the nurse completes the assessment. What is the purpose of the mnemonic?

To remember the elements that are important to assess with a symptom

A nursing instructor is discussing areas of health promotion related to the nose, sinuses, mouth, and throat. What topics would the instructor be most likely to cite? (Select all that apply.)

Tobacco use Obstructive sleep apnea Oral health

An nurse practitioner is conducting the physical assessment of a school age child. The child's mother states that it seems like her child always has a strep throat. For what intervention might this indicate a need?

Tonsilectomy

A 3-month-old infant has been diagnosed with congenital hip dislocation. What is a confirmatory test for this disease?

Trendelenburg's test

A student is performing a physical assessment on a client. While assessing the abdomen, the student percusses for the spleen. What sound would be normal for the student to hear?

Tympany

A caregiver brings a handicapped client to the ED reporting altered level of consciousness and refusal to eat by the client. The client is found to be severely dehydrated. The nurse suspects neglect and asks the caregiver several questions regarding the client's activities, diet, and care. The caregiver states, "I didn't know it could hurt him if he didn't drink anything." This is an example of what kind of abuse?

Unintentional

The nursing instructor is explaining to students the difference between the language used when a nurse talks to the client and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record?

Use medical terminology when documenting in the medical record

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

Use of safety equipment

A client complains, "I feel like the whole room is spinning around me, and it makes me nauseous sometimes." What term should the nurse use to document the client's symptom?

Vertigo

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as:

Vertigo

The nurse is caring for a client with an eye injury. The client asks about the eye, and the nurse explains its structures and functions. What would the nurse tell the client is the largest chamber of the eye?

Vitreous

A client reports experiencing leg cramps, usually after walking around the park. Which follow up question by the nurse provides the best information about the client's claudication distance?

"How far do you walk before the leg cramps begin?"

The parents of a newborn appear anxious and express concern upon seeing the pediatrician palpate and gently express a small amount of whitish, milk-like liquid from the baby's nipples. What is the nurse's best response?

"Nothing is wrong with your baby. This liquid will clear up spontaneously."

A student nurse asks the instructor why it is necessary to do a comprehensive health assessment on a new client. What would be the instructor's best response?

"The comprehensive health assessment integrates all body systems and helps give the nurse an overall impression of the client's condition."

An older female client states she is upset about her sagging breasts. She states, "I know it's because I haven't been sexually active since my husband died and my hormones are all dried up." What is the nurse's best response?

"What you're experiencing is an expected effect of the aging process."

Research has found that there is a dramatic increase in the incidence of peripheral arterial disease during what time period in a person's life?

7th and 8th decades

The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment?

A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?

"Do you live alone or with someone?"

Which of the following scores for distance vision indicates the patient with the poorest vision?

20/200

What is the importance of assessing vital signs? (Select all that apply.)

Establish a baseline. Monitor risks for alterations in health. Evaluate the client's responses to treatment.

A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?

Seated in a chair at eye level with the client

The nurse is caring for a newly admitted adult client. When performing the general survey of this client, the nurse knows that accurate measurements provide critical information about what?

State of health

What tool does the nurse use to auscultate the client's abdomen?

Stethoscope

The open space between the eyelids is called what?

The palpebral fissure

Normal movement of the eye involves what cranial nerves? (Mark all that apply.)

VI III IV

In the Hispanic culture, a common rite of passage for a female teenager is called what?

Quinceanera

Clients in health care settings often are anxious. What behaviors would lead a nurse to believe that a client is anxious? (Select all that apply.)

Rapid speech Nail-biting Defensive tone Sweating

The nurse is conducting a head-to-toe assessment on a client. The nurse would would be concerned if the following characteristics were noted? (Select all that apply.)

Rashes Lesions Pressure ulcers

The RN working on a surgical unit should question which of these orders before completing it?

Reapply a staple in an incision

A nurse has assessed that a client's condition is worsening. The nurse is telephoning the primary care provider and providing an SBAR report about the client's condition. What would be important for the nurse to document? (Select all that apply.)

Time Information received Name of the provider

To make a legal entry into the medical record, the nurse must document what?

Time of the assessment

Which of the following veins drain into the superior vena cava? (Mark all that apply.)

Upper extremities Head Upper torso

Which assessment finding on a hospitalized adult client requires urgent intervention?

Urine output of 100 mL in 8 hours

During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+

2

A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action?

Ask the client when the pain began

A client in the emergency department is short of breath. While collecting the history, what is the nurse's best action?

Ask the client's relatives about the client's history (Physical assessment is all that is necessary at this time)

A nurse in the emergency department is caring for a nonverbal client. What would be the best way for the nurse to assess this client's level of pain?

Ask the family if they have noticed any changes in the client's behavior

The nurse is gathering a complete history of the client's present illness. The nurse knows that the most appropriate way to begin to gather this information is what?

Asking open-ended questions

The nurse is assessing a client who presents with shoulder pain. No signs of inflammation are present. What is the nurse's priority action?

Assess for shortness of breath.

An Afghani woman is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client?

Assess if the client speaks and understands English

The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?

Assists in friction protection

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?

Astereognosis

The triage nurse suspects malnutrition in an older adult with altered mental status who has been brought to the emergency department by family members. What visible signs might the nurse have noticed that would lead to the suspicion of malnutrition? (Mark all that apply.)

Atrophied tongue Temporal muscle wasting Generalized muscle weakness Dry eyes

The RN caring for a newly admitted client after central-line placement should complete which priority assessment?

Auscultate lung sounds bilaterally

A client presents to the emergency department following a motor vehicle collision in which the client sustained a significant blow to the area of the right ear. The client tells the nurse that something is leaking from the right ear. What should the nurse suspect?

Basilar skull fracture

Which client-satisfaction related intervention of staff nurses may lead to improved client outcomes?

Bedside hand-off reports

For a nursing exam, students must label a diagram using the correct medical terminology. Where would the students label the metacarpophalangeal joint?

Between the hand and the finger

The nurse should use which assessment tool to assess the client's risk for skin breakdown?

Braden Scale

The nurse is auscultating the abdomen and hears a swooshing sound in the abdominal area. The nurse would document this sound as a what?

Bruit

The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by

Cirrhosis and nephrosis

HIPAA gives clients greater control over their medical records. What else does HIPAA provide?

Client recourse if privacy protections are violated

When using Gordon's framework for a functional health assessment, the nurse asks a client, "Have you made any changes in your environment because of vision, hearing, or memory decrease?" What functional health pattern is the nurse assessing?

Cognition

A nurse is teaching a class on hypertension in a community setting. What risk factor would the nurse be sure to address to the class?

Family History

In what life stage, defined by Erikson, is group identity important?

Adolescence

When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should this client receive?

Altered tissue perfusion, arterial related to reduced blood flow

The RN may delegate which care component to a nursing assistant?

Ambulation assistance

An older adult has been admitted to the emergency department. The client reports pain in his back and abdomen and shortness of breath. What might the nurse suspect is wrong?

Aortic aneurysm

The nurse is performing visual acuity testing on an older adult who has fallen and fractured their femur. What finding would be considered normal for this client? (Select all that apply.)

Arcus senilis Decreased tear production Cataract

When palpating a client's liver, the nurse feels a firm edge. What would this indicate to the nurse?

Cirrhosis

When testing for accommodation, what reaction would you expect to see?

Pupils converge and constrict

A nursing instructor is describing the peripheral nervous system to a group of students. The instructor would explain that there are how many pairs of spinal nerves?

31

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

6

When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?

68-year-old African American male with hypertension

While assessing a client's eyes, the nurse notes a depressed corneal response. In what type of client would this finding be considered normal?

A client wearing contact lenses

When considering the culture of a client, the nurse would be aware that in some cultures

A health care provider of the same gender is preferred

The nurse can best practice effective care by exhibiting which behavior during a cultural assessment?

Acknowledge own prejudicies that might create barriers to care

A nurse has just finished assessing a client's spine and neck muscles. How would the nurse document normal findings?

C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender

A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what?

Crepitus

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world is a definition of what?

Culture

Why is the appearance of urine important to evaluate during an abdominal exam?

Dark urine could indicate dehydration

The nurse should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client?

Decrease to 44 beats/minute

The triage nurse on the adolescent unit knows that puberty can contribute to what?

Depression

A newly admitted client has given their health history and undergone a physical assessment. Laboratory data and diagnostic study results are on the chart. What is the nurse's next step in caring for the client?

Develop a plan of care

The nurse is caring for an older adult client with a nasogastric feeding tube ordered by the physician. The nurse notes that the client is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?

Deviated septum

The nurse is caring for a client who is vomiting. When inspecting the vomitus, the nurse notes that it appears to contain coffee grounds. This would indicate what to the nurse?

Digested blood

A nursing instructor is discussing therapeutic versus nontherapeutic responses with nursing students. Which of the following would the nurse identify as nontherapeutic?

Distraction

A middle aged client is admitted to the observation unit with right lower quadrant pain. The client has not kept down any food or drink for 24 hours. The client's temperature is 38.6°C orally (101.5°F). The client describes the pain as "achy with periods of sharp, stabbing sensations." What would be the most appropriate nutritional nursing diagnosis for a client with these assessment data?

Fluid volume less than body requirements related to an inability to tolerate fluids

What are the types of nursing assessments? (Select all that apply.)

Focused Emergency Comprehensive

A clinical instructor is discussing with a clinical group how to take a history of the client's present illness. A student asks how to best guide the interview. What would be the instructor's most appropriate answer?

Follow the cues of the client during the interview

What does the nurse knows about normal blood pressure?

Follows a diurnal rhythm

The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube?

Helps to regulate pressure in the middle ear

Student nurses are spending time in the laboratory learning the proper use of an otoscope. What technique would these students learn for best visualization of the tympanic membrane in an adolescent?

Hold the ear at the helix and lift up and back

When assessing a client's deep tendon reflexes, which technique would be most appropriate for the nurse to use?

Hold the reflex hammer between the thumb and the index finger

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam?

Hop on one foot

Nursing students are learning how to identify different areas of the abdomen. What is the lower middle area called?

Hypogastric

The lymphatic system functions to? (Mark all that apply.)

Maintain protein balance Maintain fluid balance Fight infection

The nurse is presenting an educational event for a local civic group about the risk factors for neck cancer. What would the nurse list? (Select all that apply.)

Male gender Tobacco use Age older than 50 years

What is the purpose of the tongue? (Select all that apply.)

Manipulates solids and liquids when eating and drinking. Helps with the identification of sweet, sour, salty, and bitter tastes. Assists in speech production

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best?

Measure for new compression stockings

What structure in the abdomen provides the blood vessels to the intestinal tract?

Mesentery

The linea alba is located where?

Middle of the ventral abdominal wall

What is considered true for varicose veins? (Mark all that apply.)

More common in women Seen more often in people older than 50 years May be familial

When palpating a client's inguinal lymph nodes, what technique should be used?

Move the finger pads over the area using a gentle circular motion

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient:

Moves the head and shoulders against resistance with equal strength

When assessing the tympanic membrane, where would the nurse expect to visualize the malleus?

Near the center

The nurse aide reports to the nurse that an older adult client has abnormal vital signs. What is important to remember in this type of situation?

Normal readings vary according to age

A nurse is performing a physical exam on an older client. She reports that her feet feel numb. What assessment should the nurse perform first?

Palpate the dorsalis pedis pulses

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

Palpate the temporal and masseter muscles while the client clenches teeth

What does examination of the skin involve? (Select all that apply)

Palpation Inspection

Which assessment techniques would a nurse use on the external ear? (Select all that apply)

Palpation Inspection

When assessing for acute arterial occlusion, what would the nurse include? (Mark all that apply.)

Paralysis Paresthesia Pain Pallor

The nurse is caring for a client suffering from a nutritional deficiency. The nurse expects that the client has a dysfunction of which abdominal body part?

Small intestine

A nurse is preparing a teaching plan for a client newly diagnosed with peripheral arterial disease. The nurse knows to address in this teaching plan the most modifiable risk factors. What risk factors would the nurse include? (Mark all that apply.)

Smoking Activity level

A nursing student is helping with a group presentation on social assessment. What would be most important for the student to include in the group presentation?

Social assessment emphasizes the interconnectedness of physical, psychosocial, and spiritual dimensions of health

When a nurse asks a patient "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

Suicide ideation

Parents bring a school age child to the emergency department after a bicycle accident. The father tells the nurse that the child was not wearing a helmet when thrown over the handlebars, striking the child's head on the sidewalk. What would be the most important information for the nurse to include in education for this child and family?

Use of safety equipment

Cues for hearing loss include which of the following? (Select all that apply.)

Using loud and monotonous voice Concentrating on lip movement Leaning forward to hear Asking to repeat questions

The nurse is admitting an older male client diagnosed with congestive heart failure. Several risk factors for falls have been identified on the admission database. What is the nurse's best action to prevent falls?

Utilize safety alarms that are available on the unit

The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.)

VII IX XII

After collecting subjective and objective data for the admission database, what is the nurse's next action?

Validate the client's identified problems

A nurse is teaching a class on diet and nutrition to a group of mothers who are breast-feeding their infants. What would the nurse tell the group is the emphasis of nutritional guidelines?

Variety

When auscultating the chest near the collar bone of a school aged child, the nurse would be most likely to hear what benign heart sound?

Venous hum

A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax?

Vertebral line

A newborn is born with cleft lip/palate. As a nursing student, you know that this is:

the most common congenital malformation of the oral cavity