exam 3 HA (REVIEW QUESTIONS)

A man seeks treatment for "recent breast enlargement." On examination the nurse notes bilateral enlargement of the breasts. Which question asked by the nurse is most appropriate based on this finding? 1. "What medications are you currently taking?" 2. "Have you recently been lifting weights?" 3. "Did your mother have large breasts?" 4. "Have you ever had cancer?"

. "What medications are you currently taking?"

Which patient's description of pain is consistent with injury to a bone? 1. "Deep, dull, and boring" 2. "Cramping even when not moving" 3. "Intermittent, sharp, and radiating" 4. "Tingling with pins and needles sensation with movement"

1. "Deep, dull, and boring"

4. Which question gives the nurse additional information about a patient's report of his hands shaking for the last 2 months? 1. "Does the shaking occur when your hands are at rest or when you are picking up an item?" 2. "Do you experience any abnormal sensations, such as tingling or coldness, at the same time?" 3. "What actions do you take to relieve the shaking when it occurs?" 4. "Have you ever experienced this shaking before?"

1. "Does the shaking occur when your hands are at rest or when you are picking up an item?"

A nurse is obtaining a health history from a 52-year-old male patient with a red lesion at the base of the tongue. What additional data does the nurse specifically collect about this patient? 1. Alcohol and tobacco use 2. Date of his last dental examination 3. Use of dentures 4. A history of pyorrhea

1. Alcohol and tobacco use

The nurse asks a patient to stand with her feet together, her arms placed at her sides, and her eyes closed. The nurse then observes the patient moving her foot to maintain balance and opening her eyes. Based on this finding, which additional assessment does the nurse perform to confirm an abnormality with balance? 1. Ask the patient to walk in tandem, putting the heel of one foot directly against the toes of the other foot. 2. Ask the patient to sit down and alternatively tap the thighs with your hands using rapid supination and pronation movements. 3. Place a vibrating tuning fork in the patient's ankle and ask when she no longer detects the vibration. 4. With the patient in a seated position, support one lower leg while sharply dorsiflexing the foot and maintain it in flexion.

1. Ask the patient to walk in tandem, putting the heel of one foot directly against the toes of the other foot.

How does a nurse respond to parents of a 5-year-old who are worried that their child has a protruding abdomen? 1. Assesses the child to differentiate a normal "potbelly" from a hernia 2. Suggests that the parents administer an appropriate dose of a laxative at bedtime 3. Refers the parents to a nutritionist to develop an appropriate weight-loss diet for the child 4. Informs the parents that a protruding abdomen is always an abnormal finding in this age group

1. Assesses the child to differentiate a normal "potbelly" from a hernia

What does the nurse assess for during each prenatal visit? 1. Blood pressure 2. Hemorrhoids 3. Personal habits (smoking, alcohol consumption) 4. Visual acuity

1. Blood pressure

A patient describes a recent onset of frequent and severe unilateral headaches that last about 1 hour. Based on these symptoms, the nurse suspects which type of headache? 1. Cluster headache 2. Migraine headache 3. Tension headache 4. Sinus headache

1. Cluster headache

A 22-year-old white male comes to the emergency department with a concern about a mass in his testicle. In addition to his age and race, which fact is a known risk factor for testicular cancer? 1. He had an undescended testicle at birth. 2. His mother had breast cancer. 3. He was treated for gonorrhea 18 months ago. 4. He had a hydrocele during infancy.

1. He had an undescended testicle at birth.

A patient reports joint pain interfering with sleep and morning joint stiffness for the first hour after getting out of bed. Considering this report, what abnormal findings does the nurse anticipate during the examination? 1. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally 2. Decreased range of motion of one hip and knee, with pain on flexion and crepitus during movement of these joints 3. Erythema in one great toe, ankle, and lower leg that is painful to the touch 4. Abrupt onset of local tenderness, edema, and decreased range of motion of the shoulder and hip bilaterally

1. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally

A patient with darkly pigmented skin has been admitted to the hospital with hepatitis. How does the nurse assess for jaundice in this patient? 1. Inspect the color of the sclera. 2. Inspect genitalia for color. 3. Blanch the fingernails. 4. Jaundice cannot be assessed in patients with darkly pigmented skin.

1. Inspect the color of the sclera.

During a physical examination, the nurse is unable to feel the patient's thyroid gland with palpation from an anterior approach. What is the appropriate action of the nurse at this time? 1. Recognize that this is an expected finding. 2. Auscultate the thyroid area. 3. Palpate the thyroid using a posterior approach. 4. Refer the patient for follow-up with an endocrinologist.

1. Recognize that this is an expected finding.

Which finding on a 2-month-old baby is considered abnormal and requires further follow-up? 1. The anterior fontanelle is not palpable. 2. The thyroid gland cannot be palpated. 3. The head circumference is slightly greater than the chest circumference. 4. Head lag is observed when the shoulders are lifted off the examination table.

1. The anterior fontanelle is not palpable.

Which finding is expected during a rectal exam? 1. The rectal wall is smooth. 2. Severe pain is reported when the finger is introduced through the anus. 3. Hard stool is present in the rectum. 4. The anus is surrounded by white flat lesions.

1. The rectal wall is smooth.

What are the characteristics of lymph nodes in patients who have an acute infection? 1. They are enlarged and tender. 2. They are round, rubbery, and mobile. 3. They are hard, fixed, and painless. 4. They are soft, mobile, and painless.

1. They are enlarged and tender.

A nurse is palpating the lymph nodes of an 18-month-old toddler and finds enlarged postauricular and occipital nodes. What is the significance of this finding? 1. This is a normal finding for a toddler. 2. The toddler may have an ear infection. 3. The toddler may have an inflammation of the scalp. 4. The toddler needs to be referred to a pediatrician.

1. This is a normal finding for a toddler.

Which finding is considered abnormal during late pregnancy? 1. Watery vaginal discharge 2. Hemorrhoids 3. Lordosis 4. Abdominal striae

1. Watery vaginal discharge

A patient has a herpes lesion on her vulva. While examining her, the nurse should take which measures? 1. Wear examination gloves while in contact with the genitalia. 2. Place the patient in an isolation room. 3. Wash the genitalia with alcohol or povidone-iodine (Betadine) before the examination. 4. Inspect the genitalia only; reschedule the patient for a full examination after the lesion has healed.

1. Wear examination gloves while in contact with the genitalia.

A patient has multiple solid, red, raised lesions on her legs and groin that she describes as "itchy insect bites." How does the nurse document these lesions? 1. Wheals 2. Bulla 3. Tumors 4. Plaques

1. Wheals

What is the earliest and most sensitive indication of altered cerebral function? 1. Memory impairment 2. Loss of deep tendon reflexes 3. Inability to communicate 4. Change in level of consciousness

4. Change in level of consciousness

A 32-year-old woman has a 4-day history of sore throat and difficulty swallowing. The nurse observes tonsils covered with yellow patches. The tonsils are so large that they fill the entire oropharynx and appear to be touching. How does the nurse document these findings? 1. "Tonsils yellow and edematous." 2. "Enlarged tonsils 4+ with yellow exudate." 3. "Strep infection to tonsils with 3+ swelling." 4. "1+ edema of tonsils with pus."

2. "Enlarged tonsils 4+ with yellow exudate."

You had to yell his name to get him to open his eyes; he could not tell you his name or location, and he could raise his hands when asked. Using the Glasgow Coma Scale (see Fig. 15.23), what score would you give to this patient? 1. 12 2. 13 3. 14 4. 15

2. 13

The nurse observes multiple red circular lesions with central clearing that are scattered all over the abdomen and thorax. How does the nurse document the shape and pattern of these lesions? 1. Gyrate and linear 2. Annular and generalized 3. Iris and discrete 4. Oval and clustered

2. Annular and generalized

Which finding does the nurse recognize as abnormal when examining a male patient? 1. Testes are palpable and firm within the scrotal sac bilaterally 2. Discharge observed from the penis when the glans is compressed 3. Foreskin lies loosely over the penis 4. Glans a lighter skin tone than the rest of the penis

2. Discharge observed from the penis when the glans is compressed

Which finding of a preschooler is abnormal during a cardiovascular system examination? 1. Heart rate of 106 beats/min 2. Failure to gain weight because of fatigue while eating 3. Continuous low-pitched vibration heard over the jugular vein 4. Pulse increasing on inspiration and decreasing on expiration

2. Failure to gain weight because of fatigue while eating

A 19-year-old college student comes to the student health center because she discovered a small, nontender, firm, rubbery lump in her right breast. What is the most common cause of breast lumps in women her age? 1. Breast cancer 2. Fibroadenoma 3. Ductal ectasia 4. Breast abscess

2. Fibroadenoma

While assessing a patient's bicep muscle strength, the nurse applies resistance and asks the patient to perform which motion? 1. Extension of the arm 2. Flexion of the arm 3. Adduction of the arm 4. Abduction of the arm

2. Flexion of the arm

A patient tells the nurse that her stools have bright red blood in them. The nurse suspects which problem? 1. Gallbladder disease 2. Hemorrhoids 3. Rectal polyps 4. Upper intestinal bleeding

2. Hemorrhoids

What is the expected patient response when assessing the function of CN XI (spinal accessory)? 1. Demonstrates full, active range of motion of the neck 2. Moves shoulders against resistance equally 3. Follows an object with eyes without nystagmus 4. Sticks out tongue without tremor or deviation

2. Moves shoulders against resistance equally

1.During a health history, a patient reports having difficulty swallowing. Based on this report, which assessment technique does the nurse use to collect more data about the patient's ability to swallow? 1. Ask the patient to puff out her cheeks, purse her lips, and blow out. 2. Observe the soft palate when the patient says "ahh." 3. Observe the patient while she swallows water from a paper cup. 4. Wearing gloves, grasp the patient's tongue and palpate all sides.

2. Observe the soft palate when the patient says "ahh."

A patient complains of her jaw popping when chewing. Which examination techniques are appropriate for the nurse to use with this patient? 1. Inspecting the musculature of the face and neck for symmetry 2. Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain 3. Asking the patient to move her chin to her chest, hyperextend her head, and move her head from the right side to the left side 4. Asking the patient to open her mouth as widely as possible and inspecting the lower jaw for redness, edema, or broken teeth

2. Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain

A patient with a missed menstrual period and nausea has which signs and symptoms of pregnancy? 1. Questionable 2. Presumptive 3. Probable 4. Positive

2. Presumptive

While taking the health history of a 23-year-old female patient, the nurse considers risk factors for STD. Which data from the patient suggest a need for patient education? 1. She has been in a monogamous sexual relationship for 2 years; she uses a condom to prevent pregnancy. 2. She has been sexually involved with one man for the last 2 weeks; she uses spermicidal gel to prevent pregnancy. 3. She has a Pap test each year, and the results have been negative. 4. She uses oral contraceptives to prevent pregnancy.

2. She has been sexually involved with one man for the last 2 weeks; she uses spermicidal gel to prevent pregnancy.

The nurse examines a patient's auditory canal and tympanic membrane with an otoscope. Which finding is considered abnormal? 1. Presence of cerumen 2. Yellow color to the tympanic membrane 3. Presence of a cone of light 4. Shiny, translucent tympanic membrane

2. Yellow color to the tympanic membrane

A 48-year-old woman asks the nurse how to best protect herself from excessive sun exposure while at the beach. Which response would be most appropriate? 1. "Limit your time in the sun to 5 minutes every hour." 2. "Wear a wet suit that covers your arms and legs." 3. "Apply a waterproof sunscreen (SPF 15 or higher) to exposed skin surfaces; reapply at least every 2 hours." 4. "Apply sunscreen with a minimum SPF 50 to all skin surfaces before leaving for the beach; this will provide all-day coverage."

3. "Apply a waterproof sunscreen (SPF 15 or higher) to exposed skin surfaces; reapply at least every 2 hours."

Which data from the health history of a 42-year-old man should be evaluated further as a possible risk for hearing loss? 1. "I watch TV in the evenings with my wife and children." 2. "When I was younger, I wore an earring." 3. "My primary hobby is carpentry work." 4. "I have been an accountant for 16 years for an insurance agency."

3. "My primary hobby is carpentry work."

With the patient in a supine position, how does a nurse assess the external rotation of the patient's right hip? 1. Asking the patient to move the right leg laterally with the right knee straight 2. Asking the patient to flex the right knee and turn medially toward the left side (inward) 3. Asking the patient to place the right heel on the left patella 4. Asking the patient to raise the right leg straight up and perpendicular to the body

3. Asking the patient to place the right heel on the left patella

How does the nurse assess a patient's consensual reaction? 1. By touching the cornea with a small piece of sterile cotton and observing the change in the pupil size 2. By observing the patient's pupil size when the patient looks at an object 2 to 3 feet away and then looks at an object 6 to 8 inches away 3. By shining a light into the patient's right eye and observing the pupillary reaction of the left eye 4. By covering one eye with a card and observing the pupillary reaction when the card is removed

3. By shining a light into the patient's right eye and observing the pupillary reaction of the left eye

Which disorder, if any, does a nurse screen for when examining a healthy adolescent? 1. Muscle weakness 2. Limited joint range of motion 3. Curvature of the spine 4. No screening is needed.

3. Curvature of the spine

While examining the ear of an infant with an otoscope, the nurse pulls down on the ear for which reason? 1. Increases the depth that the otoscope can be inserted 2. Stabilizes the ear to avoid injury if the infant moves the head suddenly 3. Enhances visualization of the tympanic membrane by straightening the ear canal 4. Facilitates drainage of cerumen from the ear canal, allowing better visualization of inner ear structures

3. Enhances visualization of the tympanic membrane by straightening the ear canal

During an examination, the nurse palpates the Skene glands. Which technique best describes this process? 1. Exerting pressure over the clitoris, slide the finger downward (posteriorly) toward the vaginal opening. 2. Palpate the fourchette and slide the finger forward (anteriorly) toward the vaginal opening. 3. Exert pressure on the anterior vaginal wall and slide the finger outward toward the vaginal opening. 4. Grasp the labia majora between the index finger and thumb and milk the labia outward.

3. Exert pressure on the anterior vaginal wall and slide the finger outward toward the vaginal opening.

A patient has edema and redness of the skin surrounding the nail on his right index finger. Which data elicited from his history best explains this condition? 1. He has a family history of fungal infections of the nails. 2. There has been a scabies outbreak among his family members. 3. He has a new full-time job as a dishwasher at a restaurant. 4. He recently had several warts removed from each of his hands

3. He has a new full-time job as a dishwasher at a restaurant.

The nurse is comparing the right and left legs of a patient and notices that they are asymmetric. Which additional data does the nurse collect at this time? 1. Passively moves each leg through range of motion and compares the findings 2. Observes the patient's gait and legs as he or she walks across the room 3. Measures the length of each leg and compares the findings 4. Palpates the joints and muscles of each leg and compares the findings

3. Measures the length of each leg and compares the findings

Which finding is considered abnormal when conducting a breast examination on a 68-year-old woman? 1. Dark pink areola 2. Pendulous breasts 3. Serous nipple drainage 4. Granular textur

3. Serous nipple drainage

What is the reason for palpating axillary lymph nodes during a clinical breast examination? 1. Axillary nodes fluctuate during the month in response to the menstrual cycle. 2. Axillary node tenderness is the most common initial symptom of breast cancer. 3. The lymph network in the breast primarily drains toward the axillary lymph nodes. 4. This is a matter of convenience because of the close proximity of the axillae to the breasts.

3. The lymph network in the breast primarily drains toward the axillary lymph nodes.

Which patient behavior indicates to the nurse that the patient's facial cranial nerve (CN VII) is intact? 1. The patient's eyes move to the left, right, up, down, and obliquely. 2. The patient moistens the lips with the tongue. 3. The sides of the mouth are symmetric when the patient smiles. 4. The patient's eyelids blink periodically.

3. The sides of the mouth are symmetric when the patient smiles.

To inspect the glans penis of the uncircumcised male, the nurse retracts the foreskin. After inspection, she is unable to replace the foreskin over the glans. The nurse recognizes that this situation could potentially lead to which complication? 1. Decreased sperm production 2. Urinary tract infection 3. Tissue necrosis of the penis 4. Testicular cancer

3. Tissue necrosis of the penis

The nurse recognizes which symptom as commonly associated with prostate enlargement? 1. Constipation 2. Rectal bleeding 3. Weak urinary stream 4. Penile discharge

3. Weak urinary stream

A 24-year-old female patient has a 2-day history of clear nasal drainage. Based on these data, which question is the most logical for the nurse to ask? 1. "Is there a foul odor coming from your nose?" 2. "Have you recently had nosebleeds?" 3. "Do you snore when sleeping?" 4. "Do you have allergies?"

4. "Do you have allergies?"

2.As a patient is walking into the exam room, the nurse notices his unsteady gait. What findings does the nurse anticipate during the neurologic exam? 1. When the patient stands with his feet together and eyes closed, his upright posture is maintained. 2. The nurse notices no patient response after striking the right patellar tendon with a reflex hammer. 3. The patient is able to move the heel of one foot down the shin of the other leg while lying supine. 4. A tremor is observed in his hands while he touches his finger to his thumb on the same hand.

4. A tremor is observed in his hands while he touches his finger to his thumb on the same hand.

Which technique is used for palpating lymph nodes? 1. Apply firm pressure over the nodes with the pads of the fingers. 2. Apply gentle pressure over the nodes with the tips of the fingers. 3. Apply firm pressure anterior to the nodes with the tips of the fingers. 4. Apply gentle pressure over the nodes with the pads of the fingers.

4. Apply gentle pressure over the nodes with the pads of the fingers.

Which is an expected finding of a newborn's respiratory assessment? 1. Thoracic breathing 2. A 1:2 ratio of anteroposterior-to-lateral diameter 3. Flaring of the nares noted on inspiration 4. Bronchovesicular breath sounds in peripheral lung fields

4. Bronchovesicular breath sounds in peripheral lung fields

How does the nurse determine if a patient's musculoskeletal examination is normal? 1. By reading the examination findings documented in the patient's chart 2. By comparing findings from other patients in the same age group 3. By reading descriptions in health assessment books 4. By comparing the patient's left side with the right side

4. By comparing the patient's left side with the right side

When a nurse asks a patient to place the right arm behind the head, the nurse is assessing for which range of motion? 1. Flexion of the elbow 2. Hyperextension of the shoulder 3. Internal rotation and adduction of the shoulder 4. External rotation and abduction of the shoulder

4. External rotation and abduction of the shoulder

While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to perform which movements? 1. Flexion, extension, and hyperextension 2. Circumduction, internal rotation, and external rotation 3. Adduction, abduction, and rotation 4. Flexion, pronation, and supination

4. Flexion, pronation, and supination

What is the nurse assessing when measuring from the patient's symphysis pubis to the top of the fundus? 1. Fetal development 2. Fetal lie and position 3. Attitude of the fetus 4. Gestational age

4. Gestational age

Which data collected from the history of a 32-year-old female patient should be followed with a symptom analysis? 1. Has never had a mammogram. 2. Experiences light to moderate bleeding during the menstrual cycle. 3. Periods began at age 12; has never been pregnant. 4. Has pelvic pain and vaginal discharge.

4. Has pelvic pain and vaginal discharge.

5. Which technique does the nurse use to assess the triceps reflex? 1. Holds the patient's relaxed arm with the elbow extended while striking the appropriate tendon with a reflex hammer 2. Holds the patient's relaxed forearm with the hand slightly pronated while striking the appropriate tendon with a reflex hammer 3. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon, and strikes the thumb with the reflex hammer 4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes the appropriate tendon just above the elbow with a reflex hammer

4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes the appropriate tendon just above the elbow with a reflex hammer

During an initial prenatal visit, the nurse identifies which factor as consistent with a high-risk pregnancy? 1. Patient is 18 years old. 2. Patient height is 5 feet 4 inches. 3. Birth weight of infant with last pregnancy was 2800 g. 4. Patient smokes one-half pack of cigarettes a day.

4. Patient smokes one-half pack of cigarettes a day.

Which disorder is an example of a vascular lesion? 1. Dermatofibroma 2. Vitiligo 3. Sebaceous cyst 4. Port wine stain

4. Port wine stain

When examining a 16-year-old male patient, the nurse notes multiple pustules and comedones on the face. The nurse recognizes that increased activity of which cells or glands produce these manifestations? 1. Epidermal cells 2. Eccrine glands 3. Apocrine glands 4. Sebaceous glands

4. Sebaceous glands

A 51-year-old woman has found a small lump in her breast. Which data from her history are risk factors for breast cancer? 1. Her husband's mother died from breast cancer at age 43. 2. She drinks a glass of wine each night with dinner. 3. Menarche occurred at age 14; menopause occurred at age 46. 4. She underwent radiation treatment for Hodgkin disease at age 17.

4. She underwent radiation treatment for Hodgkin disease at age 17.

Which position is ideal when examining the genitalia of a 3-year-old boy? 1. Prone position with legs flexed in a frog-leg position 2. Supine position with knees spread and ankles spread apart 3. Lithotomy position with knees and ankles spread apart 4. Sitting position with knees spread and ankles crossed

4. Sitting position with knees spread and ankles crossed

A 60-year-old male patient states that he has a sore above his lip that has not healed and is getting bigger. The nurse observes a red scaly patch with an ulcerated center and sharp margins. These findings are commonly associated with which malignancy? 1. Kaposi's sarcoma 2. Malignant melanoma 3. Basal cell carcinoma 4. Squamous cell carcinoma

4. Squamous cell carcinoma

While talking with a patient, the nurse suspects that he has hearing loss. Which examination technique is most accurate for assessing hearing loss? 1. Whispered voice test 2. Rinne test 3. Weber test 4. Test using audioscope

4. Test using audioscope

On assessment of the neurologic status of a 4-month-old infant, the nurse notes which finding as abnormal? 1. The infant abducts and extends arms and legs when startled. 2. When the infant's sole is touched, the toes flex tightly in an attempt to grasp. 3. When stroking the infant's foot from sole to great toes, there is fanning of the toes. 4. The infant steps in place when held upright with feet on a flat surface.

4. The infant steps in place when held upright with feet on a flat surface.

What is an expected finding of the newborn's vision that the nurse teaches the parents? 1. Binocular vision is normally achieved at this age. 2. Peripheral sight does not develop until age 3 or 4 months. 3. The newborn can only distinguish the colors of blue and green. 4. The newborn is nearsighted and cannot see items unless they are close.

4. The newborn is nearsighted and cannot see items unless they are close.

During an eye examination, how does a nurse recognize normal accommodation? 1. The patient has peripheral vision of 90 degrees left and right. 2. The patient's eyes move up and down, side to side, and obliquely. 3. The right pupil constricts when a light is shown in the left pupil. 4. The patient's pupils dilate when looking toward a distant object.

4. The patient's pupils dilate when looking toward a distant object.

A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client in order to obtain a focused health history of the ears?Select all that apply. A. "Have you had trouble hearing?" B. "Do you ever lose your balance?" C. "Do you have problems with nasal drainage?" D. "Do you have ringing in your ears?" E. "Have you ever used hearing aids?"

A. "Have you had trouble hearing?" (The nurse should ask the client about difficulties hearing when obtaining a focused health history of the ears. The function of the ears is hearing and equilibrium. Asking the client about their hearing is an appropriate question for the nurse to ask for a focused ear history) B. "Do you ever lose your balance?" (The nurse should ask the client if they ever lose their balance when obtaining a focused health history of the ears. The function of the ears is hearing and equilibrium. Loss of balance could indicate an inner ear disorder.) D. "Do you have ringing in your ears?" (The nurse should ask the client if they have ringing in their ears, or tinnitus, when obtaining a focused health history of the ears. The function of the ears is hearing and equilibrium. Ringing in the ears, or tinnitus, could indicate an inner ear disturbance.) E. "Have you ever used hearing aids?" (The nurse should ask the client if they have ever used hearing aids when obtaining a focused health history of the ears. The function of the ears is hearing and equilibrium. The use of hearing aids is important for the nurse to know and document as part of the focused ear history.)

A nurse is assessing a client who has a lump on their neck. Which of the following questions should the nurse ask the client? Select all that apply. A. "How long has the lump been on your neck?" B. "Have you started taking a new medication?" C. "Are you having difficulty swallowing?" D. "Are you experiencing difficulty breathing?" E. "Is the lump causing you discomfort?"

A. "How long has the lump been on your neck?" The nurse should ask the client how long the lump has been on their neck. A persistent lump can be an indication that it is malignant. C. "Are you having difficulty swallowing?" The nurse should ask the client if they are having difficulty swallowing as a result of the lump on their neck. Dysphagia can lead to aspiration when trying to swallow, eat, or drink fluids. D. "Are you experiencing difficulty breathing?" The nurse should ask the client if they are having difficulty breathing as a result of the lump on their neck. This can lead to a medical emergency if the client's airway becomes closed. E. "Is the lump causing you discomfort?" The nurse should ask the client if the lump is causing discomfort. The amount, description, and location of the discomfort will provide information for diagnostic purposes.

A nurse is performing range-of-motion exercises on a client's feet. The nurse should provide which of the following instructions to the client to assess plantar flexion of the feet? A. "Point your toes toward the floor." B. "Turn the soles of your feet out, away from the body." C. "Point your toes up, toward your nose." D. "Turn the bottoms of your feet in, toward the midline."

A. "Point your toes toward the floor." (To assess plantar flexion, the nurse should instruct the client to point their toes toward the floor.)

A nurse is assessing the range of motion of a client's hands. Which of the following instructions should the nurse provide to assess abduction and adduction of the client's fingers? A. "Spread your fingers apart and then move them back together." B. "Make a fist and then straighten your fingers." C. "Bend your thumb in toward the palm of the hand and then move it back out." D. "Bend your thumb to touch the tip of each finger."

A. "Spread your fingers apart and then move them back together." To assess abduction and adduction of the fingers, the nurse should instruct the client to spread their fingers apart (abduction) then move them back together (adduction).

A nurse is assessing a client's head. Which of the following should the nurse identify as an unexpected finding?Select all that apply. A. A lesion on the client's scalp B. Protrusions on the client's head C. Oval white patches in the client's hair D. Protrusion of the client's mastoid bone E. Edema around the client's eyes

A. A lesion on the client's scalp (The nurse should identify that a lesion on the client's scalp can indicate a skin disorder or infection.) B. Protrusions on the client's head (The nurse should identify that protrusions on the client's head can indicate recent trauma to the head.) C. Oval white patches in the client's hair (The nurse should identify that oval white patches in the client's hair can indicate head lice, or pediculus human capitis.) E. Edema around the client's eyes (The nurse should identify that edema around the client's eyes, cheeks, or face can indicate infection, trauma, or a heart disorder.)

A nurse is preparing to perform a skin assessment on a client. Which of the following tools should the nurse plan to use? A. Penlight B. Otoscope with a pneumatic bulb attachment C. Wide-tipped speculum D. Tongue blade

A. Penlight The nurse should plan to perform a skin assessment in an area with strong lighting for general visualization. A penlight is used to illuminate suspicious areas of the skin

A nurse is caring for a client with a suspected stroke. Which of the following actions should the nurse take?Select all that apply. A. Assess muscle strength B. Obtain vital signs C. Make the client NPO D. Assess for strabismus E. Assess orientation

A. Assess muscle strength (The nurse should assess the client's muscle strength. The client who has had a stroke may have hemiparesis or hemiplegia, leading to decreased muscle strength on one or both sides.) B. Obtain vital signs (The nurse should obtain vital signs at the time of the suspected stroke for a baseline reference and comparison. The vital signs will indicate heart function, blood pressure which are contributors to stroke events.) C. Make the client NPO (The nurse should make the client NPO and have the client's swallowing ability tested to prevent the risk of aspiration due to impaired swallowing.) E. Assess orientation ( The nurse should assess the client's baseline orientation at the time of the suspected stroke to allow for a comparison to previous orientation and future changes.)

A nurse is recommending sources of food rich in calcium content to a client. Which of the following foods should the nurse recommend? (Select all that apply.) A. Broccoli B. Milk C. Corn D. Apples E. Legumes

A. Broccoli B. Milk E. Legumes

A nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a result of vomiting. Which of the following findings should the nurse expect? A. Defined reddened area of the sclera B. Drooping of the eyelid C. Cloudy pupil D. Bulging eyes

A. Defined reddened area of the sclera The nurse should identify that a client who has experienced a subconjunctival hemorrhage will have a defined reddened area of the sclera. This results from leakage of blood outside the blood vessels due to increased pressure within the eye during vomiting.

A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Which of the following interventions should the nurse plan to include? A. Limit elevation of the head of the bed to 30º or less. B. Massage the area every 2 hr. C. Reposition the client every 4 hr. D. Ensure that the client uses a donut-shaped cushion when sitting in a chair.

A. Limit elevation of the head of the bed to 30º or less. Raising the head of the bed more than 30º increases the risk for skin damage due to shearing forces. Shearing occurs when the client slides downward in the bed. The outer layer of skin sticks to the bed linens while the deeper skin layers move downward. This results in twisting of blood vessels and can lead to skin damage.

A nurse is caring for a client who has a stage 1 pressure injury. Which of the following information should the nurse include when documenting the characteristics of the wound? (Select all that apply.) A. Location of the pressure injury B. Size of the injury in centimeters C. Depth of the injury in centimeters D. Color and odor of drainage from the wound E. Integrity of the skin surrounding the wound

A. Location of the pressure injury (The nurse should document the location of the pressure injury in relation to the adjacent bony prominence.) B. Size of the injury in centimeters (The nurse should document the length and width of the pressure injury in centimeters.) E. Integrity of the skin surrounding the wound (The nurse should assess and document the condition of the wound edges and the area of skin surrounding the pressure injury. The nurse should also note any changes in temperature, sensation, or firmness in the area. )

A nurse is preparing a community program about injury prevention for a group of adults. Which of the following information should the nurse include? (select all) A. Maintain good posture when working at a desk. B. Do not text and drive. C. Use back muscles when lifting objects. D. Remove loose rugs from the home. E. Wear a helmet when riding a bicycle.

A. Maintain good posture when working at a desk. B. Do not text and drive. D. Remove loose rugs from the home. E. Wear a helmet when riding a bicycle.

A nurse is assessing a client's wrist and hands. Which of the following findings indicates the client might have arthritis? (Select all that apply.) A. Nodules on the joints B. Slight extension of the wrist C. A large mound below the thumb D. Fingers are linear in shape E. Fingers deviate toward the ulnar

A. Nodules on the joints (arthritis) E. Fingers deviate toward the ulnar (Ulnar deviation, in which the fingers are not in alignment with the wrist and forearm but instead deviate toward the ulnar side of the arm, is an indication of arthritis.)

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect? A. Pale mucosa B. Bright red mucosa C. Green discharge D. Yellow discharge

A. Pale mucosa

A nurse is palpating a client's extremities and notes the lower left leg is cooler to the touch than the client's right leg or arms. How should the nurse interpret this finding? A. The client might have a blood clot. B. The client might have an infection. C. The client is experiencing complications of kidney failure. D. The client's blood oxygen levels are lower than expected.

A. The client might have a blood clot. Unilateral coolness is associated with decreased blood flow to the extremity. This can occur when the client is experiencing a blood clot that is blocking the flow of blood. Additional causes of unilateral coolness of an extremity include chronic disease of the blood vessels or a physical obstruction of blood flow, such as from a cast that is too tight.

A nurse is performing a head and neck assessment on a client. The client reports a high-pitched ringing in their ears. Which of the following terms should the nurse use when documenting what the client is experiencing? A. Tinnitus B. Strabismus C. Bell's palsy D. Hirsutism

A. Tinnitus This is ringing of the ears.

A nurse is collecting data from a client about their skin and nails. Which of the following statements by the clients should the nurse identify as needing further assessment? A. "When I was a child, I developed a rash after taking amoxicillin." B. "I noticed that my fingernails have changed recently." C. "I used to take baths, but I recently switched to showering." D. "In my family, one cousin had basal cell carcinoma."

B. "I noticed that my fingernails have changed recently." The nurse should follow up with additional questions for the client to obtain specific information about nail changes the client has observed.

A nurse is assessing flexion of a client's elbows. The nurse should provide which of the following instructions to the client? A. "Start with your arms straight out in front of you with palms facing the floor. Then twist your arms at your elbows so your palms are facing up toward the ceiling." B. "Start with your arms straight out in front of you. Then bend your elbows up and bring your fingers toward your shoulders." C. "Start with your arms straight out in front of you with palms facing the ceiling. Then twist at your elbows so your palms are facing down toward the floor." D. "Start with your elbows bent and your fingers at your shoulders. Then straighten your arms out in front of you."

B. "Start with your arms straight out in front of you. Then bend your elbows up and bring your fingers toward your shoulders." (To test flexion, the nurse should instruct the client to bend their elbows in front of them.)

A nurse is providing teaching to a client who has osteoporosis about the adequate intake of calcium. Which of following intake amounts should the nurse recommend? A. 500 to 1,000 mg daily B. 1,000 to 1,200 mg daily C. 1,500 to 2,000 mg daily D. 2,000 to 2,200 mg daily

B. 1,000 to 1,200 mg daily (The nurse should recommend that the client consume 1,000 to 1,200 mg of calcium daily. This amount can decrease the risk of bone loss and protect bones against fractures.)

A nurse is providing teaching to a client about adequate daily intake of vitamin D. Which of the following intake amounts should the nurse recommend? A. 500 IU daily B. 800 IU daily C. 1,500 IU daily D. 1,800 IU daily

B. 800 IU daily (The nurse should recommend that the client consume 600 to 800 IU of vitamin D daily. Vitamin D protects bones by assisting with the absorption of calcium. Sources of vitamin D include egg yolks, fatty fish, and fortified foods. Exposure to sunlight triggers vitamin D synthesis.)

A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration. In which of the following locations should the nurse perform the assessment? A. Lateral to the umbilicus B. Inferior to the collar bone C. Dorsal side of the hand D. Anterior aspect of the neck

B. Inferior to the collar bone Assessing skin turgor is performed by pinching a large fold of skin just below the clavicle. Other reliable sites to assess skin turgor include over the sternum and on the back of the forearm. In older adults, a natural loss of skin elasticity may slow the recoil time of the skin.

A nurse is assessing a client's skin color. Which of the following findings should the nurse report to the provider? (Select all that apply.) A. Patches of increased pigmentation on the client's cheeks B. Pinpoint areas of purplish-red coloration across the abdomen C. Pale-colored nailbeds D. Darkly pigmented area across the client's sacral area E. Light-colored jagged lines

B. Pinpoint areas of purplish-red coloration across the abdomen (Areas of purplish-red discoloration that are smaller than 3 mm in diameter are termed petechia. This is an unexpected finding. Petechia can indicate a bleeding disorder and should be reported to the provider.) C. Pale-colored nailbeds (Pale nailbeds is an unexpected finding. This can be an indication of low oxygen levels and should be reported to the provider.)

A nurse is performing a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has difficulty reading fine print. In which of the following sections of the client's electronic health record (HER) should the nurse document this finding? A. Vital signs B. Review of systems C. Allergies and home medications D. Patient information

B. Review of systems (The nurse should include the client's report of "vision changes, especially when reading fine print" as part of the review of systems section of the client's EHR. This is subjective data the nurse is obtaining from the client and the purpose of the client's visit.)

A nurse is evaluating assessment findings of a client's skin. The nurse should identify that which of the following findings is associated with a possible infection? A. Wheals B. Vesicles C. Papules D. Bulla

B. Vesicles Vesicles are small, serous, raised, fluid-filled skin lesions. The nurse should identify that they are associated with both chickenpox and shingles infections and should be reported to the provider.

A nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash. The nurse should identify that which of the following findings indicates the client might have a skull fracture? A. Edema around the ear B. Watery, clear drainage C. Yellow drainage D. Crusted skin

B. Watery, clear drainage The nurse should identify that clear, watery, or bloody drainage can indicate that the client has a skull fracture. The nurse should notify the provider immediately.

A nurse is performing a skin assessment on a client. Which of the following findings should the nurse report to the provider? A. Skin tags on the neck B. Yellow discoloration of the palms C. Birthmark on the thigh D. Absent tenting of the skin

B. Yellow discoloration of the palms Yellow discoloration of the skin, or jaundice, should be reported to the provider. It is caused by an elevated level of bilirubin, which is a by-product of the breakdown of red blood cells. Jaundice can occur with disorders of the blood or liver. Jaundice is visible throughout the body of clients who have light skin and is visible on the palms and soles of clients who have darker skin tones. The color change can also be seen on all clients in the sclera and on the hard palate.

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect? A. Ptosis of an eyelid B. Yellow sclera C. Edema of the eyelids D. Reddened conjunctiva

B. Yellow sclera The nurse should identify that yellowing of the sclera can indicate that the client has liver disease.

A nurse is taking a health history from a client. Which of the following statements by the client requires further questioning by the nurse? A. "The bruise on my leg is from running into the base of a chair." B. "I'm sleeping better since I gave up caffeine in the afternoon." C. "For some reason, I have been falling recently." D. "I no longer have back pain since I started walking 2 miles every day."

C. "For some reason, I have been falling recently." (This statement by the client is an unexpected finding and requires further questioning. Frequent falling can indicate that the client is experiencing a musculoskeletal or neurological disorder that requires investigation.)

A nurse is providing teaching to a client who reports acne on their face and chest. Which of the following client statements indicates an understanding of the teaching? A. "Exposing these areas to a tanning bed twice a month will decrease the outbreaks." B. "Opening the acne lesions will make them drain and go away faster." C. "I should wash the areas frequently with warm water and soap." D. "Keeping the skin moist with oil-based creams will prevent acne outbreaks."

C. "I should wash the areas frequently with warm water and soap." Frequent washing of the affected areas with warm water and soap will remove oil and dirt from the skin. This will reduce the risk of a secondary infection occurring in the lesions.

A nurse is providing teaching to a client who reports extremely dry skin. Which of the following interventions should the nurse recommend? A. Increase the frequency of bathing. B. Use a dehumidifier to reduce air moisture. C. Apply an alcohol-free lotion. D. Cover the dry areas with a thin coating of powder.

C. Apply an alcohol-free lotion. The nurse should recommend an alcohol-free lotion that creates a film on the skin to decrease moisture evaporation and dryness. Lanolin, cocoa butter, and petroleum-based lotions are products that retain skin moisture.

A nurse is caring for a client who has a traumatic injury to a lower extremity. Which of the following actions should the nurse take? A. Apply heat therapy after the first 24 hr following the injury. B. Place an ice pack directly on the injured area. C. Apply compression to the injured area of the extremity. D. Encourage the client to use the extremity as much as possible.

C. Apply compression to the injured area of the extremity. (The nurse should apply prescribed compression to the injured area to limit edema, provide support, and ease discomfort.)

A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect? A. White patches on the tongue B. Bleeding of the gums C. Beefy red tongue D. Petechiae of the hard palate

C. Beefy red tongue The nurse should identify that a client who has a vitamin B12 insufficiency can have a smooth, dark, or swollen tongue.

A nurse is performing range-of-motion exercises on a client's hips. The nurse assesses which of the following motions by instructing the client to bend the knee and bring it up toward the chest? A. External rotation of the hip B. Adduction of the hip C. Flexion of the hip D. Hyperextension of the hip

C. Flexion of the hip (To test flexion of the hip, the nurse should instruct the client to bend their knee and bring it up toward their chest.)

A nurse is examining a lesion on a client's back. Which of the following characteristics should the nurse identify as a possible indication of a malignant skin lesion? A. Smooth, defined border B. Uniform color C. Greater than 6 mm in diameter D. Symmetrical appearance

C. Greater than 6 mm in diameter Lesions that are greater than 6 mm, or the size of a pencil eraser, in diameter should be recognized as possible malignant skin lesions and reported to the provider.

A nurse is performing a head-to-toe assessment on a client. Which of the following assessment findings may indicate that the client has a thyroid disorder? A. Beefy red tongue B. Swollen lymph nodes C. Lump on the anterior portion of their neck D. Lip color is darker than surrounding skin

C. Lump on the anterior portion of their neck The nurse should identify that an anterior lump on the client's neck can indicate that the client has a thyroid disorder

A nurse is inspecting the fingernails of an older adult client. Which of the following findings should the nurse report to the provider? A. Yellowed nail color B. White horizontal lines C. Spongy nail base D. Capillary refill time of 2 seconds

C. Spongy nail base The base of the nail should be firm to palpation. Spongy nail bases are associated with clubbing of the nails, which is a manifestation of chronic hypoxia. The nurse should report this finding to the provider.

A nurse is performing an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye? A. Outer layer of the eyeball B. Mucous membrane that lines the eyeball C. Transparent layer that covers the iris and pupil D. Colored portion in the center of the eye

C. Transparent layer that covers the iris and pupil This is the cornea.

A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect? A. Overgrowth of gum tissue B. Beefy red tongue C. Petechiae on hard palate D. White patches on the tongue

D. White patches on the tongue The nurse should expect white patches on the client's tongue. This is an indication of candidiasis, an oral infection known as thrush.

A nurse is teaching a client about risk factors for developing melanoma. Which of the following client statements indicates an understanding of the teaching? A. "The fact that I have five moles increases my risk for developing melanoma." B. "My cousin had squamous cell carcinoma, which increases my risk for melanoma." C. "Having a light complexion decreases my risk for developing melanoma." D. "The blistering sunburns I had as a child increase my risk for melanoma as an adult."

D. "The blistering sunburns I had as a child increase my risk for melanoma as an adult." Excessive sun exposure and severe or blistering sunburns in childhood increase the risk for developing melanoma as an adult.

A nurse is assessing the range of motion of a client's head and neck. Which of the following instruction should the nurse provide to assess hyperextension. A. "Turn your head from side to side and look back over your shoulders." B. "Bend your neck to the side and bring your ear close to your shoulder." C. "Lower your chin to your chest and raise it back up." D. "Tilt your head back and look up at the ceiling."

D. "Tilt your head back and look up at the ceiling." (To assess for hyperextension of the head, the nurse should instruct the client to tilt their head back and look up at the ceiling.)

A nurse is assessing a client's spinal range of motion. Which of the following motions is the nurse assessing by asking the client to bend backward as far as they can go? A. Flexion B. Rotation C. Lateral flexion D. Hyperextension

D. Hyperextension (ask the client to bend backwards as far as they can go.)

A nurse is performing a musculoskeletal and neurological assessment. Which of the following actions should the nurse take? A. Perform the assessment from the toes to the head. B. Assess the extremities from distal to proximal. C. Perform passive range-of-motion before active range-of-motion movements. D. Inspect both sides of the body for symmetry.

D. Inspect both sides of the body for symmetry. (The nurse should inspect the client for symmetry of range of motion, gait, muscle tone, and strength.)

A nurse is admitting a client who has had a stroke. Which of the following actions should the nurse take? A. Keep the bedside table at the end of the client's bed. B. Place a towel on the client's bathroom floor. C. Raise the four side rails of the client's bed. D. Keep the client's bed in the lowest position.

D. Keep the client's bed in the lowest position. (The nurse should keep the client's bed in the lowest position closest to the floor. This allows the client to get out of bed more easily with assistance.)

A nurse is assessing a client's mouth. The nurse should identify that which of the following is an expected finding? A. Yellowing of the hard palate B. Red spots on the hard palate C. White patches on the tongue D. Large vein on the ventral surface of the tongue

D. Large vein on the ventral surface of the tongue This is an expected finding.

A nurse is assessing a client's head and neck. Which of the following findings should the nurse report to the provider? A. Prominent C-7 vertebra B. Clicking in the temporomandibular joint C. Firm neck muscles D. Locking of the jaw joint

D. Locking of the jaw joint (It is an unexpected finding for the temporomandibular joint, or jaw, to have decreased range of motion or to lock during assessment. This finding should be reported to the provider)

A nurse is assessing a client's skin color. Which of the following areas should the nurse check to determine the presence of pallor? A. Anterior chest B. Palms of the hands C. Auricle of the ear D. Mucous membranes

D. Mucous membranes Pallor is a pale or lighter skin color than usual that can be caused by anemia or a circulatory problem. It is best observed by inspecting the color of the lips, mucus membranes, and nail beds.

A nurse is assessing the spine of a client. Which of the following findings requires further investigation? A. The client's spinous process protrudes slightly. B. The spine is concave at the cervical and lumbar areas C. The spine is convex at the thoracic area. D. The client walks with a shuffling gait.

D. The client walks with a shuffling gait. (It is an unexpected finding for an adult client to walk with a shuffling gait. This finding could indicate a musculoskeletal or neurological disorder and should be reported to the provider for further investigation.)

A nurse is examining the texture of an older adult client's skin. Which of the following findings should the nurse report to the provider? A. Thin skin B. Hyperpigmentation on the back of the hands C. Silver-white depressed scars on the abdomen D. Velvety skin

D. Velvety skin Skin that feels smoother and softer than expected, similar to velvet, is associated with thyroid disorders. This is an unexpected finding that should be reported to the provider.