health assessment final

An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize? A) "Are you currently taking any diuretic medications?" B) "Are you familiar with the USDA's MyPlate recommendations?" C) Do you use any over-the-counter dietary supplements? D) "Have you ever been diagnosed with heart disease?"

A) "Are you currently taking any diuretic medications?"

An obese teenage boy from a culture that values increased body mass has been referred to the clinic. The nurse is assessing him for malnutrition based on his electronic health record and current health complaints. His mother questions the nurse's rationale, stating, "Anyone can see he's not malnourished. Just look at the size of him!" How should the nurse best respond? A) "It's actually very possible for a person to be overweight but have inadequate nutrition." B) "People can become obese because their bodies are storing up nutrients that they often lack." C) "Actually, there's very little relationship between body mass and nutritional state." D) "Assessment for malnutrition is a standard component of a larger nutritional assessment."

A) "It's actually very possible for a person to be overweight but have inadequate nutrition."

A male client who is 6 feet tall with a medium frame weighs 175 lb. The nurse calculates his ideal body weight to be which of the following? A) 178 lbs B) 160 lbs C) 190 lbs D) 184 lbs

A) 178 lbs

A client has sought care because of a sudden increase in the size of his scrotum. The nurse's assessment reveals the presence of a large scrotal mass. How can the nurse best assess for a scrotal hernia? A) Auscultate the mass for bowel sounds. B) See if the mass disappears when the client stands. C) Palpate the mass for pain. D) Percuss the mass for dullness.

A) Auscultate the mass for bowel sounds.

The nurse is assessing a client's eye muscle strength and cranial nerve function. Which test would be most appropriate for the nurse to perform? A) Cardinal fields of gaze test B) Visual fields test C) Cover test D) Corneal light reflex test

A) Cardinal fields of gaze test

While the nurse is assessing a client's coordination, the client exhibits uncoordinated, jerky movements and is unable to touch either finger to the nose. Which condition should the nurse suspect? A) Cerebellar disease B) Lower motor neuron disease C) Extrapyramidal tract abnormalities D) Vestibular dysfunction

A) Cerebellar disease

While the nurse is performing as assessment of the eyes for a client, the nurse notes that one of the client's pupils is dilated and unresponsive to light. Which condition should the nurse suspect? A) Cranial nerve III (oculomotor) damage B) Central nervous system dysfunction C) Cranial nerve V (trigeminal) injury D) Lesions of the sympathetic nervous system

A) Cranial nerve III (oculomotor) damage

Which characteristic of the first heart sound would the nurse expect to hear in a client with mitral insufficiency? A) Diminished B) Split C) Varying D) Accentuated

A) Diminished

An older adult client has a body mass index of 15.5 and is consequently considered to be underweight. The client lives alone and states that she has "never been a heavy eater." How can the nurse most accurately assess the client's nutritional habits? A) Elicit the client's 24-hour food recall. B) Assess the client's waist circumference and waist-to-hip ratio. C) Measure the client's mid-arm circumference. D) Have the client describe an "ideal" meal.

A) Elicit the client's 24-hour food recall.

A group of students is reviewing material related to the role of religion and spirituality in health care choices. The students demonstrate understanding when they identify which situation as the most prominent ethical dilemma that involves religion? A) Failure to seek timely medical care B) Implementing spiritual care C) Treating clients' psychological needs D) Providing life-saving therapy

A) Failure to seek timely medical care

While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. What would the nurse include? A) Flexion B) Abduction C) Circumduction D) Internal rotation

A) Flexion

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. What would the nurse suspect? A) Gouty arthritis B) Rheumatoid arthritis C) Plantar fasciitis D) Degenerative joint disease

A) Gouty arthritis

Which question would be most important to ask obtaining the nursing health history of a male client with extensive peripheral vascular disease? A) Have you experienced a change in your usual sexual activity? B) When was your last prostate exam for cancer? C) Have you had an electrocardiogram recently? D) Do your parents have trouble with circulation?

A) Have you experienced a change in your usual sexual activity?

A client has a sensorineural hearing loss. Which condition would the nurse most likely identify as a cause? A) Inner ear problem B) Otitis media C) Otosclerosis D) Perforated eardrum

A) Inner ear problem

When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. What would the nurse suspect? A) Meningitis B) Cervical strain C) Compression fracture D) Cervical disc degeneration

A) Meningitis

A woman reports a sudden onset of spontaneous nipple discharge. What would the nurse do next? A) Refer the client for cytologic study of the discharge. B) Reassure the woman that this is a result of hormonal fluctuations. C) Observe the breast for eversion of the nipples. D) Collect a sample for culture and sensitivity testing.

A) Refer the client for cytologic study of the discharge.

The nurse is obtaining the health history of a young adult client. During the interview, the client tells the nurse, "I banged my head pretty good when I was snowboarding last weekend." The client states that he did not subsequently seek care. What is the nurse's most appropriate action? A) Refer the client for medical assessment and possible treatment. B) Teach the client about the importance of wearing head protection during sports. C) Promptly assess the client's balance and coordination. D) Teach the client about the warning signs of increased intracranial pressure.

A) Refer the client for medical assessment and possible treatment.

A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate understanding of the waveforms when they identify which component as indicating ventricular repolarization? A) T wave B) P wave C) QRS complex D) ST segment

A) T wave

The nurse is assessing an older adult client's heart and neck vessels. When attempting to palpate the client's apical impulse, what principle should guide the nurse's actions? A) The apical impulse may be more difficult to palpate than in a younger client. B) The apical impulse will be irregular due to normal, age-related physiological changes. C) The apical impulse will be easier to palpate if the client is in a standing position. D) The apical impulse will be found in a more medial location than in a younger client.

A) The apical impulse may be more difficult to palpate than in a younger client.

A hospital nurse is performing a nutritional assessment of a 39-year-old obese client who has been recently diagnosed with type 2 diabetes. The nurse has completed the collection of subjective data and is preparing to proceed with objective data collection. Which principle should guide the nurse's subsequent actions? A) The nurse should be aware that the client may find assessment embarrassing. B) The assessment should be performed over a series of brief sessions. C) The nurse should avoid performing anthropometric measurements due to the client's obesity. D) There are likely to be inconsistencies between subjective data and objective data.

A) The nurse should be aware that the client may find assessment embarrassing.

The nurse reads in a client's electronic health record that her most recent ankle-brachial index (ABI) was 0.42. How should this assessment finding inform the nurse's care? A) The nurse should implement interventions to address severe arterial insufficiency. B) The nurse should assess the client's extremities for pitting edema at least once per shift. C) The nurse should inspect the client's feet and ankles for venous ulcers once per shift. D) The nurse should position the client to promote venous return.

A) The nurse should implement interventions to address severe arterial insufficiency.

The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following? A) The pattern is expected with this condition B) Client may have overdosed on narcotics C) Client is hypoventilating D) These are normal Kussmaul's respirations

A) The pattern is expected with this condition

The nurse is performing a skin assessment on a client and notes the presence of a rash in a butterfly pattern across the bridge of the nose and cheeks. Which consideration should the nurse take into account based on this finding? A) This is characteristic of systemic lupus erythematosus (SLE). B) Poor hygiene may cause this type of rash. C) Yellowing of the sclera due to jaundice may also be present. D) Decreased melanin production due to aging may be a potential cause.

A) This is characteristic of systemic lupus erythematosus (SLE).

A nurse is testing a client's deep tendon reflex. The nurse taps the tendon above the olecranon process. The nurse is assessing which reflex? A) Triceps B) Brachioradialis C) Achilles D) Biceps

A) Triceps

A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client? A) Trigeminal neuralgia B) Cluster headache C) Migraine headache D) Tension headache

A) Trigeminal neuralgia

When assessing cranial nerves IX and X, what would the nurse consider as a normal finding? A) Uvula and soft palate rising bilaterally on phonation B) Asymmetrical soft palate C) Deviation of uvula when client says "ah" D) Stationary soft palate on phonation

A) Uvula and soft palate rising bilaterally on phonation

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor? A) Vitamin D deficiency B) Personal history of fractures C) Age D) Small-boned, thin frame

A) Vitamin D deficiency

The nurse is performing the bulge test during the assessment of a client's knee. This test will allow the nurse to make what determination? A) Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation B) Whether the size of the client's knee changes throughout the joint's range of motion C) Whether the client's knee joint is capable of adduction and abduction D) Whether swelling in the knee joint is a normal age-related change or a pathological finding

A) Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation

To provide a high-quality spiritual assessment, the nurse understands that the focus must be on which of the following? A) Objectivity in assessment B) Collaboration in an open dialogue C) Absolute appropriate timing D) A specific religious affiliation

A) objectivity in assessment

When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Which sensations are carried by this tract? Select all that apply. A) Light touch B) Position C) Pain D) Temperature E) Vibration

A, C, E

A client's recent complaints of polyuria have prompted a full diagnostic work-up for diabetes mellitus, including a nutritional assessment. To determine the client's body mass index (BMI), the nurse must know which assessment parameters? Select all that apply. A) Age B) Height C) Weight D) Waist circumference E) Gender

B and C

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate? A) "You don't need to worry about anything. I will make sure to be very gentle during the exam." B) "Before I get ready to examine the painful area, I will let you know in plenty of time." C) "I'm going to examine the area where you're having pain first to get a better picture of what's going on." D) "Since you're having pain in a certain area, I won't have to do a very thorough exam there."

B) "Before I get ready to examine the painful area, I will let you know in plenty of time."

Which question by the nurse would best facilitate discussion of sexual concerns while minimizing the client's anxiety or embarrassment? A) "Do you reach orgasm with each intercourse?" B) "Do you have any problems with your sexual performance?" C) "Do you have more than one sexual partner?" D) "Do you and your partner communicate about sex?"

B) "Do you have any problems with your sexual performance?"

During a routine follow up visit, an older adult client asks the nurse, "I've noticed that my sense of smell has decreased over the years and I'm concerned about the cause." What is the nurse's best response? A) "Congenital problems may sometimes cause a loss of smell." B) "Over time the sense of smell decreases in some people, and this is normal." C) "Injury of the nerve tissue at the top of the nose may be the cause." D) "There may be a tumor or lesion present in the frontal lobe."

B) "Over time the sense of smell decreases in some people, and this is normal."

When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting which of the following? A) Right ventricular failure B) A narrowed vessel C) Decreased cardiac output D) Increased central venous pressure

B) A narrowed vessel

A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. What bowel sound would the nurse expect to assess in this client? A) Hyperactive B) Absent C) Normoactive D) Hypoactive

B) Absent

The nurse has had a client place the backs of both her hands against each other while flexing her wrists 90 degrees with fingers pointed downward and wrists dangling. The presence of pain or tingling during this test suggests what health problem to the nurse? A) Gouty arthritis B) Carpal tunnel syndrome C) Diabetic neuropathy D) Osteoarthritis

B) Carpal tunnel syndrome

While inspecting the penis of a client, the nurse suspects herpes progenitalis based on which assessment finding? A) Hardened nodules on the glans B) Clear vesicles that erupt C) Red, oval ulcerations D) Painless fleshy papules

B) Clear vesicles that erupt

The nurse is performing an assessment on an adolescent client and notes a 45-degree flexion of the cervical spine. What should the nurse do next? A) Assess the thoracic and lumbar spine. B) Continue the exam because this curve is normal. C) Perform the Lasegue test. D) Palpate the spinous processes.

B) Continue the exam because this curve is normal.

A nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion? A) Tympany on percussion B) Cullen sign C) Tenderness on palpation D) Diastasis recti

B) Cullen sign

A nurse is assessing a client for possible fluid overload. Which assessment finding is most consistent with this diagnosis? A) Moist, plump tongue B) Distended neck veins with head elevated at 45 degrees C) Boggy eyeball D) Venous filling of 3 seconds

B) Distended neck veins with head elevated at 45 degrees

What would the nurse expect to find when examining a client with a herniated lumbar disc? A) Lumbar lordosis B) Flattened lumbar curve C) Rounded thoracic convexity D) Lateral curvature of the spine

B) Flattened lumbar curve

During a client's genitourinary exam, the nurse notes that the client's scrotum is enlarged and easily transilluminates. What should the nurse suspect? A) Hernia B) Hydrocele C) Tumor D) Varicocele

B) Hydrocele

The nurse is assessing a female client's genitourinary system. What finding would lead the nurse to suspect a problem with the ovaries during palpation? A) Walnut-sized ovaries B) Immobile ovaries C) Slight tenderness on palpation D) Smooth ovarian surface

B) Immobile ovaries

The nurse notes limitation in active range of motion of a client's right shoulder. What would the nurse to do next? A) Ask the client which is the dominant side. B) Measure range of motion with a goniometer. C) Test muscle strength. D) Perform passive range of motion test.

B) Measure range of motion with a goniometer.

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack? A) Nail beds B) Oral mucosa C) Sclera D) Palms

B) Oral mucosa

Which of the following would lead the nurse to suspect meningeal irritation? A) Discomfort behind the knee with full extension of the leg B) Pain and flexion of the hips and knees with neck flexion C) Hips and knees remain relaxed and motionless when neck is flexed D) Reports of decreased pain with flexion of the hips and knees

B) Pain and flexion of the hips and knees with neck flexion

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding? A) Obturator sign positive B) Positive Rovsing sign C) Psoas sign present D) Positive skin hypersensitivity test

B) Positive Rovsing sign

The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next? A) Assess for foreign body impaction. B) Refer the client immediately for further evaluation. C) Position the client to facilitate drainage. D) Examine for postauricular cysts.

B) Refer the client immediately for further evaluation.

What would a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration? A) Intestinal air B) Splenomegaly C) Hepatomegaly D) Abdominal mass

B) Splenomegaly

The nurse is conducting a focused neurological assessment of an 81-year-old client. When analyzing the assessment data, the nurse should be aware of what age-related neurological change? A) Impaired judgment B) Tremors accompanying intentional movements C) Loss of sensation in distal extremities D) Loss of remote memory

B) Tremors accompanying intentional movements

A group of students is reviewing information related to the major bones of the skeleton. The students demonstrate understanding of the material when they identify which of the following as part of the axial skeleton? A) Humerus B) Vertebral column C) Carpals D) Femur

B) Vertebral column

During the history, a young adult woman asks the nurse, "My mother has osteoporosis. What can I do to help reduce my risk?" Which response by the nurse would be most appropriate? A) "Keep your calcium intake at about 800 milligrams each day." B) "Increase the amount of non-weight-bearing physical activity that you do." C) "Avoid smoking and using alcohol." D) "Avoid being out in the sun for long periods of time."

C) "Avoid smoking and using alcohol."

The nurse is preparing to perform a nutritional assessment for a client. Which of the following questions would be most appropriate to use when initiating the assessment? A) "How many meals do you eat each day?" B) "How often do you eat out?" C) "Can you tell me what you've eaten in the last 24 hours?" D) Did you eat breakfast today?

C) "Can you tell me what you've eaten in the last 24 hours?"

A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers? A) A nutritional health program B) Teaching about genetic screening C) A smoking cessation program D) Teaching about monthly self-examination

C) A smoking cessation program

When assessing the external genitalia of a female client, the nurse notes several parasites crawling on the skin with nits attached to the pubic hair. Which action by the nurse would be most appropriate? A) Evacuate the living quarters for 1 month. B) Scrub the pubic area with soap to remove all the nits. C) Advise the client to obtain over-the-counter pediculosis treatment. D) Instruct the client to wash and shave the pubic hair.

C) Advise the client to obtain over-the-counter pediculosis treatment.

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next? A) Assess the client for signs and symptoms of fluid volume overload. B) Assess the client's nutritional status. C) Assess the client for other signs and symptoms of liver disease. D) Review the client's blood work for low platelets and hemoglobin.

C) Assess the client for other signs and symptoms of liver disease.

A client complains of excessive tearing of the eyes. Which assessment would the nurse do next? A) Inspect the palpebral conjunctiva B) Test pupillary reaction to light C) Assess the nasolacrimal sac D) Perform the eye positions test

C) Assess the nasolacrimal sac

A client's bladder is found to be distended. At which location would the nurse begin palpating? A) In the left lower quadrant B) In the right lower quadrant C) At the symphysis pubis D) At the umbilicus

C) At the symphysis pubis

The nurse would assess for which of the following after noting circumoral cyanosis in a client? A) Ketoacidosis B) Allergic reaction C) Changes in vital signs D) Carbon monoxide poisoning

C) Changes in vital signs

The nurse is analyzing the data from the assessment of a client's heart and neck vessels. The client's first heart sound corresponds with what event in the cardiac cycle? A) Beginning of diastole B) Isometric contraction C) Closure of the atrioventricular valves D) Closure of the semilunar valves

C) Closure of the atrioventricular valves

A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following? A) Optic chiasm B) Direct reflex C) Consensual response D) Accommodation

C) Consensual response

When palpating the axillae, which finding would the nurse document as normal? A) Hard B) Fixed C) Discrete D) Node size: 1.2 cm

C) Discrete

An 18-year-old woman complains because one breast is larger than the other. Which of the following would the nurse do next? A) Ask if she has a family history of breast cancer. B) Reassure the woman that this finding is normal. C) Find out whether this is a new problem. D) Ask whether she has any other symptoms.

C) Find out whether this is a new problem.

When talking to a client before starting the physical exam, the nurse notes that the client's head is tilted to one side. Which of the following would the nurse examine first? A)Thyroid gland B) Lymph nodes C) Hearing acuity D) Mental status

C) Hearing acuity

During a scrotal exam, the nurse notes an enlarged scrotal sac that easily transilluminates. Which of the following would the nurse suspect? A) Varicocele B) Tumor C) Hydrocele D) Hernia

C) Hydrocele

Inspection of a client's penis reveals that the urethral meatus is located on the ventral side of the penis. The nurse documents this finding as which of the following? A) Paraphimosis B) Epispadias C) Hypospadias D) Phimosis

C) Hypospadias

A nurse is teaching an older adult female client who has chosen to perform regular breast self-examinations. The nurse includes teaching on expected changes in the client's breasts due to aging. Which information will the nurse include? A) Less "granular" in texture B) Larger nipple area C) Increase in fatty tissue D) Increase in glandular tissue

C) Increase in fatty tissue

Which of the following would indicate to the nurse that a client is at nutritional risk? A) Is physically able to shop for food B) Has gained 3 lbs in the last 6 months C) Ingests 4 servings of beer per day D) Takes one prescription drug daily

C) Ingests 4 servings of beer per day

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment? A) Palpate the client's abdomen to stimulate bowel motility. B) Repeat auscultation in four to six hours. C) Listen for five minutes before documenting an absence of bowel sounds. D) Perform abdominal percussion, and then repeat auscultation.

C) Listen for five minutes before documenting an absence of bowel sounds.

A client whose ideal body weight is 150 lbs. currently weighs 115 lbs. How should the nurse classify this client's nutritional status? A) Lean B) Mild malnutrition C) Moderate malnutrition D) Severe malnutrition

C) Moderate malnutrition

A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor? A) Obesity B) Inadequate abdominal muscle tone C) Overuse of laxatives D) Excessive fat and sugar intake

C) Overuse of laxatives

The nurse identifies a collaborative problem related to spirituality. When planning the client's care, the nurse would direct interventions toward which of the following? A) Impact of spirituality on the client's health B) The problem that results from clustering the data C) Psychological or physiologic response of the body to stress D) Client response to being referred to a primary care provider

C) Psychological or physiologic response of the body to stress

When asked to touch the ear to the shoulder, a client reports pain. Which of the following would the nurse do next? A) Palpate the paravertebral muscles for pain. B) Flex and then hyperextend the neck. C) Refer the client for further evaluation. D) Perform muscle strength against resistance.

C) Refer the client for further evaluation.

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer? A) Stage III B) Stage IV C) Stage II D) Stage I

C) Stage II

A client is scheduled for an MRI of the left knee. What assessment finding could cause the client to experience discomfort while having the diagnostic test? A) Dry skin B) Male-pattern baldness C) Tattoo on the left lower leg D) Spoon-shaped nails

C) Tattoo on the left lower leg

A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort? A) There is an increased level of carbon dioxide in the blood. B) The client will respond negatively to increased stimuli. C) There is loss of involuntary respiratory control. D) The client's oxygen levels in the blood will be increased.

C) There is loss of involuntary respiratory control.

A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area? A) Posterior neck B) Axillary area C) Upper arm D) Inguinal area

C) Upper arm

The nurse examines a client and assesses a temporal artery that is hard, thick, and tender. The nurse would gather additional information related to which area? A) Hearing B) Mental status C) Vision D) Neurologic status

C) Vision

A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following statements would the nurse include in the teaching? A) "Make sure to get lots of vitamin D from the sun." B) "Use a humidifier to increase the moisture in the environment." C) "Increase your intake of foods high in iron and zinc." D) "Avoid smoking and alcohol use."

D) "Avoid smoking and alcohol use."

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis? A) An audible S3 sound at the site of the thyroid B) Irregular S1 and S2 rhythms in the thyroid C) Audible referred breath sounds at the site of the thyroid D) A sound of turbulent blood flow in the thyroid

D) A sound of turbulent blood flow in the thyroid

The nurse is assessing a 39-year-old woman who has a 20-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the woman's risk of stroke? A) A beta-adrenergic blocker B) ASA C) Acetaminophen D) An oral contraceptive

D) An oral contraceptive

A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. What would the nurse do next? A) Inspect for a lift. B) Palpate for a thrill. C) Listen for a ventricular gallop. D) Auscultate for pulse rate deficit.

D) Auscultate for pulse rate deficit.

While inspecting the vagina, the nurse observes a thin, grayish-white vaginal discharge with a fishy odor. What would the nurse suspect? A) Trichomoniasis B) Moniliasis C) Atropic vaginitis D) Bacterial vaginosis

D) Bacterial vaginosis

The nurse has positioned a client supine and asked her to perform the heel-to-shin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain? A) Leg strength B) Light touch sensation C) Deep tendon reflexes D) Balance and coordination

D) Balance and coordination

The nurse is inspecting the client's vaginal musculature and asks the client to bear down. Which finding would lead the nurse to suspect that the client has a cystocele? A) Protrusion at the back of the wall B) Urine leakage C) Protrusion of the cervix D) Bulging of the anterior wall

D) Bulging of the anterior wall

During deep palpation of the client's abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which nursing action would be most appropriate? A) Evaluate further for a problem with the spleen. B) Assess urinary output. C) Refer the client for medical follow-up. D) Document the position of the liver.

D) Document the position of the liver.

The nurse would be especially alert for an increased risk for overhydration for a client experiencing which of the following? A) Chronic emphysema B) Adult respiratory distress syndrome C) Newly diagnosed hepatitis C virus infection D) Early congestive heart failure

D) Early congestive heart failure

The nurse is preparing to auscultate the breaths sounds of a client's anterior chest. The nurse notes that the client's chest has a large amount of hair on it. Which of the following would the nurse do? A) Give the client a razor and soap and ask him to shave the hair on his chest B) Omit this part of the assessment and document this C) Have the client breath more forcibly during the exam and listen with the bell D) Have the client put his T-shirt back on and auscultate through the shirt

D) Have the client put his T-shirt back on and auscultate through the shirt

After teaching a group of students about malnutrition, the instructor determines that the teaching was successful when the students identify which of the following statements as true? A) Height-weight charts are the best determinant of malnutrition. B) An equal volume of fat weighs more than muscle. C) Thin clients have a low percentage of fat. D) Malnutrition includes overnutrition and undernutrition.

D) Malnutrition includes overnutrition and undernutrition.

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What would the nurse do next? A) Ask the client about a family history of cancer. B) Refer the client for medical follow-up. C) Document the benign findings. D) Perform a random blood sugar test.

D) Perform a random blood sugar test.

The nurse analyzes the data to develop a care plan for a client based on an actual client concern for a 24-year-old client's nutritional status. For which client concern should the nurse create the care plan? A) Opportunity to improve knowledge associated with client request to learn more about testing blood glucose level B) Risk for malnutrition associated with decreased caloric intake C) Risk for dehydration associated with ongoing nausea and vomiting D) Poor body image associated with significant recent weight loss

D) Poor body image associated with significant recent weight loss

The nurse is examining a client's breasts and notes the presence of pronounced dimpling. How should the nurse best respond to this assessment finding? A) Confirm whether the client has breast implants in place. B) Explain to the client that this is a normal, age-related change. C) Ask the client about any history of mastitis (breast infection). D) Promptly refer the client for further medical assessment.

D) Promptly refer the client for further medical assessment.

When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. The nurse is testing which of the following? A) Rotation B) Flexion C) Supination D) Pronation

D) Pronation

An adult client states that his mother has been living with peptic ulcer disease, and he is motivated to ensure that he does not develop the disease as he ages. What health promotion advice should the nurse provide? A) Eat several small meals a day rather than three larger meals. B) Exercise for at least 30 minutes, three times per week. C) Attend screening clinics at least twice per year. D) Quit smoking as soon as possible.

D) Quit smoking as soon as possible.

A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect? A) Renal failure B) Narcotic overdose C) Diabetic ketoacidosis D) Severe brain damage

D) Severe brain damage

When assessing the ear, which finding would be cause for concern? A) Red, flaky cerumen B) Darwin tubercle C) Pearly gray tympanic membrane D) Tender tragus

D) Tender tragus

The nurse is providing care for a client with a history of chronic heart failure. The client is in bed with the head of her bed at 45 degrees, and the nurse is assessing the client's neck veins. What assessment finding would be most consistent with a nursing diagnosis of fluid volume excess related to chronic heart failure? A) The client's carotid pulses are asymmetrical and difficult to palpate. B) The client's carotid arteries are not palpable. C) The client's carotid pulses are easier to palpate than the jugular pulses. D) The client's jugular veins are clearly visible and firm to palpation.

D) The client's jugular veins are clearly visible and firm to palpation.

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? A) VI B) III C) VIII D) XII

D) XII

A nursing student is preparing to demonstrate how to test the range of motion for the elbow. Which of the following would the student include? Select all that apply. A) Supination B) Flexion C) Rotation D) Extension E) Abduction F) Circumduction

a,b,c,d,e,f