Saunders 2

The nurse provides information to a client regarding breast self-examination (BSE). Which client statement indicates a need for further teaching regarding BSE?

"I don't need to do that; I'm too old for that."

When collecting physical assessment data, the nurse understands that the spleen is located in which abdominal quadrant? Refer to figure.

2

examination. The initial step should be which?

inspection

The nurse is auscultating bowel sounds. Which are appropriate data collection methods? Select all that apply.

1. Divide the abdomen into four quadrants at the umbilicus. 2. Do not feed the client if no sounds are audible in 5 minutes. 3. Listen in each quadrant for gurgling sounds indicating movement.

The nurse is preparing to perform an abdominal assessment on a client. The nurse places the client in which best position to perform the assessment? Refer to figure.

2

The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first? Refer to figure.

3

The nurse is checking the apical heart rate of a client with a complaint of angina. The nurse places the stethoscope in which anatomical area? Refer to figure.

4

The nurse notes documentation that a client has conductive hearing loss. The nurse understands that which is a cause of this type of hearing loss?

A physical obstruction to the transmission of sound waves

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. The nurse understands that this indicates which finding?

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

The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?

Oral mucosa

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). The nurse explains that which is the best time to perform this exam?

After a shower or bath

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test

Examines visual fields or peripheral vision

While collecting data related to the cardiac system on a client diagnosed with an incompetent heart valve, the nurse auscultates a murmur. Which best describes the sound of a heart murmur?

Gentle blowing or swooshing sounds

To assess for the presence of the posterior tibialis pulse, the nurse should palpate which areas?

In the groove behind the medial malleolus and the Achilles tendon

The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first?

Inspecting the abdomen

A nursing student enrolled in a physical assessment course is asked to describe the probable signs of pregnancy. Which are probable signs indicating possible pregnancy? Select all that apply.

McDonald's, Chadwick's, Hegar's

The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which identifies the accurate procedure for this visual acuity test?

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

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 note documented in the health record when collecting data related to the respiratory system for this client?

Wheezing

Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action should the nurse take?

Document the findings

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On data collection of the client, the nurse expects to note which finding?

Rhythmic respirations with periods of apnea

The nurse is preparing to assist the health care provider to test the extraocular movements in a client for muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done to assess for muscle weakness in the eye?

Testing the six cardinal positions of gaze

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How should the nurse interpret this result?

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.

The nurse notes that the physical assessment findings for a client with meningeal irritation indicate a positive Brudzinski sign. The nurse understands that which observation was made?

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

The nurse is collecting medication information from a client, and the client states that she is taking garlic as an herbal supplement. The nurse understands that the client is most likely treating which condition?

Hyperlipidema

Which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly?

Asks the client to block one ear at a time

The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply.

Auscultating lung sounds, Obtaining the client's temperature, Obtaining information about the client's respirations

The nurse employed in the emergency department is collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the data collection procedures. Which finding would most likely assist in verifying the suspicion?

Bald spots on the scalp