Saunders Comprehensive Review

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the health care provider (HCP)?

Pulsation between the umbilicus and the pubis

A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The clinic nurse should teach the group which point about this procedure?

Do the exam on the same day every month.

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?

Number of pack-years

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

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

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?

A physical obstruction to the transmission of sound waves

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?

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

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 week after menstruation begins

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?

A complete health database

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

Test the 6 cardinal positions of gaze.

The 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?

"The client can read at a distance of 20 feet (6 meters) what a person with normal vision can read at 40 feet (12 meters)."

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.

- Set the room temperature at a comfortable level. - Remove distracting objects from the interviewing area. - Ensure comfortable seating at eye level for the client and nurse.

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?

A blowing or swooshing noise

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion?

Difficulty walking

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?

Focus on a distant object.

A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate. The client returns to the health care provider's (HCP's) office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment?

Follow-up database

The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse should next ask the client to take which action?

Identify 3 numbers or letters traced in the client's palm.

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?

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.

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive?

Pain with dorsiflexion of the foot

The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this examination?

Pull the pinna up and back before inserting the speculum.

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?

Rhythmic respirations with periods of apnea

When assessing a client's liver during an assessment, the nurse should palpate which abdominal quadrant?

Right upper quadrant

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?

That the best time for the examination is after a shower

The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what should the nurse test?

The 6 cardinal fields of gaze

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?

The functional status of the vestibular apparatus in the inner ear

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area?

The major bronchi

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?

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 hear when performing a respiratory assessment on this client?

Wheezes

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?

After a shower or bath

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.

(arranged in order) - Stands 2 to 3 feet (60 to 90 cm) in front of and faces the client - Asks the client to cover 1 eye - Examiner covers eye opposite to the eye covered by the client - The examiner brings in an object gradually from periphery - Asks the client to report when object is first noted

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve?

Ask the client to shrug the shoulders against the nurse's resistance.

The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)?

Elevate the shoulders.

The nurse would perform which action to assess for a pulse deficit?

Auscultate the apical heart beat while palpating the radial artery.

The clinic nurse is preparing to assess the client's apical pulse. The nurse correctly palpates over which area? Click on the image to indicate your answer.

Apical pulse

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?

"I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward."

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply.

- Tongue - Nail beds - Mucous membranes

The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data?

Client reports difficulty sleeping at night.

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds?

Pleural friction rub

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II?

Snellen chart

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?

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

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?

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

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?

"You can read at a distance of 20 feet (6 meters) what a person with normal vision can read at 30 feet (9 meters)."

The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions on breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which information should the nurse give to the client?

"You need to perform BSE on the same day every month."

The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test?

A tuning fork

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve?

A wisp of cotton

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data?

Ask the client to follow the flashlight through the 6 cardinal positions of gaze.

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?

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 planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test?

Cloves, peppermint, and soap

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?

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

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site?

Mitral area

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take?

Page an interpreter from the hospital's interpreter services.

The nurse is preparing to perform a Weber test on a client who reports a loss of hearing in one ear. To perform the test, the nurse places the tuning fork in which area? Click on the image to indicate your answer.

Rationale:The Weber test is a valuable assessment test when a client reports hearing that is better with 1 ear than the other. In this test, a vibrating tuning fork is placed on the client's head over the midline of the client's skull. The client is then asked whether the tone sounds the same in both ears or better in one. The client should hear the tone by bone conduction through the skull, and it should sound equally loud in both ears.

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?

The client has a rash on the chest and arms.

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test?

The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field. Rationale:The confrontational method assumes that the examiner has normal peripheral vision. The client sits facing the examiner, approximately 2 feet (60 cm) away. The eyes of the client and the examiner should be at the same level. Both the examiner and the client cover the eyes directly opposite each other and stare at each other's uncovered eye. A small object is brought from the peripheral visual field and tests the superior, temporal, inferior, and nasal field. The client states when he or she sees the object.

The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if one of the students states that which action should be performed?

Roll the testicle between the thumb and forefinger.

A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the nurse include in the client's focused assessment?

Self-care needs such as toileting, feeding, and ambulating

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?

Separate the client's jaw by pushing down on the chin.

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?

Stroking the foot from the heel to the toe

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination?

Supine with the head raised slightly and the knees slightly flexed

The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction?

"It is best to do TSE first thing in the morning before a bath or shower."

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.

10 packs-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.

In what area of the chest would the nurse expect to auscultate these breath sounds? ( play sound )

Anteriorly and posteriorly over the major bronchi

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?

At a specific day of the month and on that same day every month thereafter

A clinic nurse is performing a cardiovascular assessment on a client and auscultates the chest over the apex of the heart. The nurse should document this finding as which sound? (play sound ~*lub*)

First heart sound, S1

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action?

Identify an object placed in the client's hand. Rationale:Astereognosis is the inability to discern the form or configuration of common objects using the sense of touch. Agraphesthesia is the inability to recognize the form of written symbols. The remaining options test for extinction phenomena and 2-point stimulation, respectively.

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client?

Intolerance for sound levels that do not bother other people

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?

Left shoulder

The nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment technique should the nurse perform next?

Listen to bowel sounds in all 4 quadrants.

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for?

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 performing a physical examination on a hospitalized client. On abdominal assessment, the nurse listens to the bowel sounds and hears these sounds. The nurse documents that which sound is heard?

Normal bowel sounds Rationale:Normal bowel sounds are high-pitched, gurgling, cascading sounds occurring irregularly between 5 and 30 times a minute. A bruit is a pulsatile blowing sound and occurs with stenosis or occlusion of an artery. Hyperactive bowel sounds are loud, high-pitched, rushing, tinkling sounds that signal increased motility. Hypoactive bowel sounds are either diminished or absent, signal decreased motility, and occur after surgery or with inflammation of the peritoneum.

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area?

Oral mucosa Rationale:In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Jaundice would be best noted in the sclerae of the eye. Cyanosis would be best noted in the palms of the hands and soles of the feet.

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?

Over the fifth intercostal space in the left midclavicular line

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition?

Pronator drift

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client?

Redness and swelling in the ear canal

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?

Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply.

- Muscle strength graded 5/5 - Symmetrical movements bilaterally - Increased muscle size on the dominant arm - A 1-cm hypertrophy of the right upper arm

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test?

"I will tell you when the small object is in my visual field." Rationale:The confrontational method assumes that the examiner has normal peripheral vision. The client sits facing the examiner approximately 2 feet (60 cm) away. The eyes of the client and the examiner should be at the same level. Both the examiner and the client cover the eyes directly opposite to one another and stare at each other's uncovered eye. A small object is brought in from the peripheral visual field, and the superior, temporal, inferior, and nasal fields are evaluated. The client states when he or she sees the object.

The nurse is conducting a health screening clinic and is preparing to test the visual acuity of a client using a Snellen chart. The nurse educates the client about the procedure. Which statement by the client indicates that the teaching has been effective?

"Stand 20 feet (6 meters) from the chart and cover 1 eye."

A 52-year-old male client is seen in the health care provider's (HCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet, 8 inches (173 cm) and his weight is 220 pounds (99.8 kg). Vital signs are as follows: temperature, 98.6°F (37°C) orally; pulse, 86 beats/minute; and respirations, 18 breaths/minute. 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?

"When was the last time you had your blood pressure checked?"

The clinic nurse prepares to perform a focused assessment 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 assessment? Select all that apply.

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

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.

- History of headaches - Previous back injury - History of hypertension - History of diabetes mellitus

In what area of the chest would the nurse expect to auscultate these breath sounds? (play sound)

Over the peripheral lung fields Rationale:Breath sounds are noises resulting from the transmission of vibrations produced by the movement of air in the respiratory passages. Normal breath sounds include bronchovesicular sounds, vesicular breath sounds, and bronchial breath sounds. The sounds that the nurse hears are vesicular breath sounds. Vesicular breath sounds are normally heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low pitched and resemble a sighing or gentle rustling; the inspiration phase is longer than the expiration phase. Bronchovesicular breath sounds are normally heard over the first and second intercostal spaces at the sternal border anteriorly and at the T4 level medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are moderately pitched with a medium intensity. The inspiration and expiration phases are equal. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and there is a distinct pause between the inspiration and expiration phases. Bronchial breath sounds are normally heard over the manubrium.

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?

Palpate for increased skin temperature around the wound edges.

A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching?

Palpating over the breast tissue to assess and compare vibrations from 1 side to the other Rationale:When assessing for tactile fremitus, the nurse should begin palpating over the lung apices in the supraclavicular area. The nurse should compare vibrations from one side to the other as the client repeats the word ninety-nine. The nurse should avoid palpating over female breast tissue because breast tissue usually blocks the sound.

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.

- Provide sufficient lighting. - Set the room temperature at a comfortable level. - 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 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 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.