Health Assessment Hesi Practice

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. "Numbness and tingling with movement"

1. "Deep, dull, and boring"

A nurse performing a neck assessment of a client is testing the status of cranial nerve XI. What does the nurse ask the client to do to enable assessment of this nerve? 1. Smile 2. Lift the eyebrows 3. Stick out the tongue 4. Shrug the shoulders against resistance

4. Shrug the shoulders against resistance Cranial nerve XI (spinal accessory nerve) is tested by asking the client to shrug the shoulders against the resistance of the nurse's hand and to turn the head to each side as the nurse tries to resist the client's movement.

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

A patient reports nausea and vomiting; and the nurse observes hand tremors, agitation, and sweating. In view of these findings, which additional data would the nurse need to collect? 1. Which fears or stressors the patient has been experiencing 2. When the patient last took illegal drugs and which one was taken 3. Which kinds of obsessions or compulsions the patient has been experiencing 4. When the patient last drank alcohol and how much was consumed

4. When the patient last drank alcohol and how much was consumed

How does the nurse palpate the chest for tenderness, bulges, and symmetry? 1. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another 2. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another 3. With the tips of the fingers, palpates the skin over the chest and the alignment of vertebrae 4. With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and the alignment of vertebrae

4. With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and the alignment of vertebrae

Loud, low-pitched bubbling and gurgling sounds heard on inspiration (may be present on expiration); may decrease with coughing or suctioning but reappear

Coarse Crackles

A complete health history and full physical examination and forms a baseline database.

Complete database

Indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or in the presence of a tumor.

Dull note on percussion of the lungs

Rapid collection of data, often during the provision of lifesaving measures.

Emergency database

Discontinuous high-pitched crackling sounds heard during inspiration that do not clear with coughing

Fine Crackles

Focused on a limited or short-term problem, such as one problem or body system.

Focused database

Evaluation of a client's progress.

Follow-up database

When too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse.

Hyperresonance

Physical assessment includes:

Inspection, palpation, percussion, and auscultation; these skills are performed one at a time in this order, except for the abdominal assessment.

Tool used to assess color vision, reveals the client's ability to distinguish a pattern of color (a number) in a series of color plates.

Ishihara chart

Exaggeration of the posterior curvature of the thoracic spine

Kyphosis (hunchback)

Increased lumbar curvature

Lordosis (Swayback)

Things a client says about himself or herself or what a family member or significant other says about the client during history-taking.

Subjective data

Low-pitched rustling; heard over the peripheral lung fields

Vesicular sounds

High-pitched, continuous musical sounds heard during inspiration or expiration

Wheezing

An inappropriate appearance and poor hygiene may be indicative of

depression manic disorder dementia organic brain disease.

What the nurse observes while inspecting, palpating, percussing, and auscultating during the physical examination, as well as information from the client's health record and the results of laboratory and diagnostic studies.

Objective data

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 headaches 2. Migraine headaches 3. Tension headache 4. Sinus headache

1. Cluster headaches

Narrowing of the bronchi creates which adventitious sound? 1. Wheeze 2. Crackles 3. Rhonchi 4. Pleural friction rub

1. Wheeze

Auscultation is a component of which examination technique? 1. Blood pressure measurement 2. Visual acuity 3. Examination of the ears 4. Measurement of oxygen saturation

1. Blood pressure measurement

Which breath sounds are expected over the posterior chest of an adult? 1. Vesicular 2. Bronchovesicular 3. Bronchial 4. Bronchoalveolar

1. Vesicular

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. Bullae 3. Tumors 4. Plaques

1. Wheals

During a history the patient says that she is so uncomfortable with her life that she wishes that it were over. Which is an appropriate follow-up question from the nurse? 1. "Have you thought of hurting yourself?" 2. "Oh, I've felt that way many times." 3. "That feeling will go away; just give it some time." 4. "In which ways has your life been uncomfortable?"

1. "Have you thought of hurting yourself?"

During a sports physical of a 16-year-old girl, the nurse asks which questions to collect data about drug use? 1. "Many teenagers have tried street drugs. Have you tried any?" 2. "Tell me which street drugs your friends have offered you." 3. "Do your friends tell you about the street drugs they use? 4. "Your high school has a reputation for students using street drugs. Do you use these drugs?"

1. "Many teenagers have tried street drugs. Have you tried any?"

A nurse is conducting an interview with a client who has come to the clinic after finding a lump in her right breast during breast self-examination. The client says, "I am so worried. I know that this must be breast cancer. What am I going to do?" Which response should the nurse give the client? 1. "Tell me what worries you." 2. "Most lumps found in the breast aren't cancer." 3. "Let's talk again after the doctor examines you." 4. "You shouldn't be so worried. After all, if it is cancer, you found it at an early stage."

1. "Tell me what worries you."

A patient complains of leg pain. Which question is pertinent to ask to gain additional information? 1. "What were you doing when the pain first occurred?" 2. "How do you feel about having this pain?" 3. "Do you think the pain is caused by a cramp?" 4. "Has anyone in your family ever had similar pain?"

1. "What were you doing when the pain first occurred?"

The nurse is teaching a patient how to evaluate the percentage of fat in a serving of food. She explains that the label on a package of a toaster pastry states that there are 6 g of fat and 210 calories per serving. What is the percentage of fat per serving? 1. 26% 2. 35% 3. 54% 4. 72%

1. 26%

A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse conducts which type of assessment on his admission? 1. A comprehensive assessment 2. A problem-based health assessment 3. An episodic assessment 4. A screening assessment for colorectal cancer

1. A comprehensive assessment

Which communication technique conveys genuine interest in what the patient has to say? 1. Active listening 2. Sitting close to the patient 3. Maintaining professional dress and conduct 4. Holding the patient's hand during the interview

1. Active listening

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

A clinic nurse is performing a mental status examination of a client. Which action should the nurse take to test the client's remote memory? 1. Asking about the client's first job 2. Asking what time the client left home to come to the clinic 3. Asking what method of transportation the client used to get to the clinic 4. Reciting four unrelated words and asking the client to repeat them at various points later in the assessment

1. Asking about the client's first job Remote memory involves past events, whereas recent memory involves day-to-day experiences. Asking about the client's first job requires the client to recall a past event.

A nurse is assessing a woman whose religious beliefs do not allow blood transfusions. She has severe anemia, is very weak, and has altered mental status. What should the nurse do to provide culturally competent care to this woman? 1. Examine his or her feelings about the role of religious beliefs in making decisions about life. 2. Recognize that he or she cannot provide care to patients whose religious beliefs endanger their lives. 3. Try to convince the patient to have a blood transfusion to save her own life. 4. Determine whether the patient is competent to make her own decisions about health care.

1. Examine his or her feelings about the role of religious beliefs in making decisions about life.

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

1. Flexion, extension, and hyperextension

The nurse records the following general inspection findings on a patient: "41-year-old Hispanic male in no distress; very thin, skin tone slightly jaundiced, disheveled appearance, and appears older than his stated age. Patient with flat affect and makes minimal eye contact." What additional information should be added to this general inspection? 1. His body movement 2. The family history 3. The estimated size of his liver 4. His pulse rate

1. His body movement

A patient with darkly pigmented skin has been admitted to the hospital with hepatitis. What is the best way for the nurse to 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.

While examining a patient with an infected abdominal incision, the nurse notices that it is very malodorous. Which technique does this represent? 1. Inspection 2. Palpation 3. Auscultation 4. Percussion

1. Inspection

The nurse palpates the abdomen to gather data about which organs located in the right upper quadrant? 1. Liver and gallbladder 2. Stomach and spleen 3. Uterus, if enlarged, and right ovary 4. Right ureter and ascending colon

1. Liver and gallbladder

A nurse is performing an abdominal assessment of a client who complains of right upper quadrant pain. Which technique should the nurse use to palpate the abdomen? 1. Palpating tender or painful areas last 2. Tapping the client's skin with short, sharp strokes 3. Using both hands and knead deeply into the abdomen 4. Starting with deep palpation, then performing light palpation

1. Palpating tender or painful areas last

The nurse is interviewing a patient with a history of flank pain, fever, chills, and pain radiating to the groin. Which examination technique is most appropriate for this patient? 1. Percussion of the costovertebral angle 2. Deep palpation of the lower abdomen 3. Inspection of a urine specimen 4. Auscultation of the lower quadrants of the abdomen

1. Percussion of the costovertebral angle

A nurse performing a neurological assessment of a client who has sustained a stroke (brain attack) is preparing to check for stereognosis. Which action should the nurse take to perform this assessment? 1. Placing an object in the client's hand and asking the client to identify it 2. Tracing a number on the client's hand and asking the client to identify it 3. Moving the client's finger up and down and asking the client which way it is being moved 4. Making two simultaneous pinpricks on the skin and asking the client to distinguish them

1. Placing an object in the client's hand and asking the client to identify it Stereognosis is the client's ability to recognize objects placed in his or her hand.

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.

On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding? 1. Rhonchi 2. Wheeze 3. Crackles 4. Pleural friction rub

1. Rhonchi

Select the example given below that represents information a nurse collects from a patient during a physical examination. 1. Shiny skin and lack of hair found on lower legs 2. Concerned about lack of money to pay for prescriptions 3. Complains of tingling in both feet while sleeping 4. Family history of colon and breast cancer

1. Shiny skin and lack of hair found on lower legs

A nurse collects subjective and objective data from a client who underwent surgery after sustaining a leg fracture in a motor vehicle accident and is now in skeletal traction. The nurse identifies which findings as objective data? Select all that apply. 1. Temperature is 99.9° F (37.2°C). 2. The client complains of leg pain. 3. Blood pressure is 128/86 mm Hg. 4. Pin sites are red but without drainage. 5. The client tells the nurse that he feels warm. Submit

1. Temperature is 99.9° F (37.2°C). 3. Blood pressure is 128/86 mm Hg. 4. Pin sites are red but without drainage. Objective data are the findings collected by the nurse while inspecting, percussing, palpating, and auscultating. Objective data also include information from the client's health record and the results of laboratory and diagnostic studies. The client's temperature and blood pressure readings are objective data, as is the nurse's observation of the pin sites.

A nurse preparing to perform a respiratory assessment of an adult client is reading the client's medical record. The nurse sees that the health care provider noted resonance on percussion of the client's posterior chest. What interpretation does the nurse make of this finding? 1. The client has normal, healthy lungs. 2. The client may have a pneumothorax. 3. The client most likely has a lung tumor. 4. An excessive amount of air is present in the lungs.

1. The client has normal, healthy lungs. Resonance on percussion predominates in healthy adult lung tissue.

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 patient complains of pain in the calf when walking. Which question should the nurse ask for further data? 1. "Does your calf also swell when this pain occurs?" 2. "Does the pain go away when you stop walking?" 3. "Do you become short of breath when you're walking?" 4. "Do you feel dizzy when the pain occurs?"

2. "Does the pain go away when you stop walking?"

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 swollen." 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."

Which question is appropriate for a nurse to ask at the beginning of a mental health history? 1. "Have you been feeling anxious or sad?" 2. "How have you been feeling about yourself?" 3. "Are you alone a lot, or do you socialize with friends?" 4. "How are you dealing with the stressors in your life?"

2. "How have you been feeling about yourself?"

A nurse is teaching a family from Guatemala about the importance of exercise to reduce body weight. The husband asks, "What exercise should we do?" Considering the time orientation of this family, what is the most effective way for the nurse to respond? 1. "Research has shown that walking 30 minutes most days of the week is best." 2. "Is there an exercise that you can do today for 30 minutes and add it to your daily routine?" 3. "If you exercise 30 minutes most days of the week, you can lose weight by your next visit." 4. "I have always found that resistance weight training each day for 30 minutes is effective."

2. "Is there an exercise that you can do today for 30 minutes and add it to your daily routine?"

A 50-year-old patient asks how he can reduce his risk of colon cancer. What is the most appropriate response by the nurse? 1. "A diet high in animal protein reduces the risk." 2. "Regular exercise to reduce body fat helps prevent colon cancer." 3. "Taking antacids for heartburn can help prevent colon cancer." 4. "Taking vitamin C daily helps reduce the risk."

2. "Regular exercise to reduce body fat helps prevent colon cancer."

The nurse is interviewing an adult Navajo woman. Which statement demonstrates cultural sensitivity and acceptance of the patient? 1. "How often do you visit the medicine man for your health care?" 2. "Tell me about your health care beliefs and practices." 3. "Many Navajo people are afraid of hospitals. Are you afraid?" 4. "Have you ever had a physical examination with a physician or a nurse practitioner?"

2. "Tell me about your health care beliefs and practices."

When a patient complains of chest pain, which question is pertinent to ask to gain additional data? 1. "What were you doing when the pain first occurred?" 2. "What does the pain feel like?" 3. "Do you have episodes of shortness of breath?" 4. "Has anyone in your family ever had a similar pain?"

2. "What does the pain feel like?"

A nurse performing a skin assessment of a client with heart failure notes that the client's ankles are swollen. To assess the severity of the edema, the nurse presses the skin at the ankle. Moderate pitting is present, but the indentation subsides rapidly. How should the nurse document this finding? 1. 1+ edema 2. 2+ edema 3. 3+ edema 4. 4+ edema

2. 2+ edema

Which situation illustrates a screening assessment? 1. A patient visits a clinic for the first time and the nurse completes a history and physical examination. 2. A hospital sponsors a health fair in a community to measure blood pressure as well as cholesterol levels. 3. A nurse at an urgent care center checks the blood pressure, pulse, temperature, and respirations of a patient reporting leg pain. 4. A patient with diabetes mellitus comes to the laboratory to get her blood glucose tested prior to a visit with a health care provider.

2. A hospital sponsors a health fair in a community to measure blood pressure as well as cholesterol levels.

The nurse is caring for a patient with a femur fracture. An immobilization device is used to maintain the alignment of the femur. The nurse palpates the top of the foot to make which determination? 1. Amount of drainage from the wound 2. Adequacy of blood perfusion to the foot 3. Presence of air in the underlying tissue 4. Range of motion to the foot

2. Adequacy of blood perfusion to the foot

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

A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? 1. Make sure the bell of the stethoscope is used rather than the diaphragm. 2. Ask the patient to cough then repeat the auscultation. 3. Ask the patient not to talk while the nurse is listening to the lungs. 4. Change the patient's position to ensure accurate sounds.

2. Ask the patient to cough then repeat the auscultation.

A school nurse notices a boy with a bandage on his arm and black fluid under the edge of the bandage. She asks the teen what happened to his arm. He replies that his mother applied axle grease to a boil. What is the nurse's most appropriate response to this boy? 1. Tell the teen to remove the bandage and wash his arm. 2. Ask the teen what the boil looks like and feels like and if the axle grease is healing the boil. 3. Advise the teen to tell his mother to use antibiotic cream rather than axle grease. 4. Suggest that the teen see a health care provider because the axle grease will infect the boil.

2. Ask the teen what the boil looks like and feels like and if the axle grease is healing the boil

A patient states that he has experienced "a lot" of unintentional weight loss over the past 4 months. The nurse measures his height and weight (5 feet 11 inches, 170 pounds) and determines that his body mass index is 22.7. Which of the following is the most appropriate action to better evaluate his recent weight loss? 1. Calculate his desirable body weight. 2. Ask, "What is your usual body weight?" 3. Record what he ate in the last 24 hours. 4. Determine his hip-to-waist ratio.

2. Ask, "What is your usual body weight?"

A man weighs 265 pounds and is 6 feet 4 inches tall. Based on these data, how does the nurse classify his weight? 1. Overweight 2. Class I obesity 3. Class II obesity 4. Class III obesity

2. Class I obesity

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? 1. White 2. Clear 3. Yellow 4. Pink tinged

2. Clear

While testing 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 female has been admitted to the emergency department with severe abdominal pain. She is lying on a stretcher quietly, with very little movement. Which patient response should the nurse anticipate when palpating this patient's abdomen? 1. Flushing of the face and neck 2. Guarding over the abdomen 3. Redness on the lower abdominal quadrants 4. Decreased peristalsis

2. Guarding over the abdomen

Which technique does a nurse use to assess the mental status of patients? 1. Ask them about any of their relatives who have mental health disorders. 2. Have them calculate the change to expect after making a purchase. 3. Ask them to recall how they cope with stress on a daily basis. 4. Have them describe the moods and emotions they experience on a usual day.

2. Have them calculate the change to expect after making a purchase.

When assessing a patient's abdomen, the nurse uses assessment techniques in which order? 1. Inspection, palpation, and auscultation 2. Inspection, auscultation, and palpation 3. Auscultation, inspection, and palpation 4. Palpation, auscultation, and inspection

2. Inspection, auscultation, and palpation

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

After collecting data, the nurse begins data analysis with which activity? 1. Documenting information from the history 2. Organizing the data collected 3. Reporting data to other care providers 4. Recording data from the physical examination

2. Organizing the data collected

A patient had a knee replaced because of arthritis. He reports that he has not slept well for several nights. He states that he can't get comfortable. Today he is asking for pain medication more often. What could be a reason for this increase in pain? 1. Arthritis pain is variable; it can be mild one day and severe the next. 2. Pain tolerance decreases with sleep deprivation. 3. The anesthesia from surgery is wearing off. 4. The patient is using the pain medication to help him sleep during the day.

2. Pain tolerance decreases with sleep deprivation.

What is the most reliable way to assess pain in a patient who is cognitively intact? 1. Type and frequency of analgesic medications the patient takes 2. Patient's most recent vital signs (e.g., blood pressure and pulse rate) 3. Extent of tissue damage the patient has experienced 4. Report by the patient describing the pain experienced

4. Report by the patient describing the pain experienced

The nurse obtains vital signs on a 42-year-old man having his annual physical examination. He has no medical conditions and states that his health is excellent. Using an automated blood pressure device, his blood pressure is measured as 62/40. Which action by the nurse is most appropriate? 1. Obtain a different cuff and take the blood pressure again. 2. Take the blood pressure again using the auscultation method. 3. Place the patient in a supine position and take the pressure on the leg. 4. Record the blood pressure and continue with the examination.

2. Take the blood pressure again using the auscultation method.

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 or amber color to the tympanic membrane 3. Presence of a cone of light 4. Shiny, translucent tympanic membrane

2. Yellow or amber 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."

An older man who is near death has been admitted to the hospital, and his family members are at his bedside. Which question or statement should the nurse use during the admission assessment to address the spiritual needs of the patient and his family appropriately? 1. "What is your religion? I'll make the appropriate spiritual arrangements." 2. "Tell me what death means to people from your culture." 3. "Are there any special needs that you and your family request at this time?" 4. "I'll call the hospital priest so he can administer last rites."

3. "Are there any special needs that you and your family request at this time?"

A patient reports a gnawing, burning pain in the midepigastric area that is aggravated by bending over or lying down. Which additional question does the nurse ask for the symptom analysis? 1. "Do you have a family history of this type of pain?" 2. "How long ago did you eat?" 3. "Do you have any symptoms such as nausea with this pain?" 4. "Have you noticed any yellow coloring in your eyes or on your skin?"

3. "Do you have any symptoms such as nausea with this pain?"

During the history the patient indicates that her eyes have been red and itching. Which additional question does the nurse ask? 1. "Have you ever had a detached retina?" 2. "Have you had the pressure in your eyes checked? 3. "Do you have seasonal allergies?" 4. "Do you also have double vision?"

3. "Do you have seasonal allergies?"

Which question gives the nurse further information about the patient's complaint of chest pain? 1. "Have you had your influenza immunization this year?" 2. "Are there environmental conditions that may affect your breathing at home?" 3. "How would you describe the chest pain?" 4. "Has the chest pain been interrupting your sleep?"

3. "How would you describe the chest pain?"

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."

A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? 1. "Has there been a change in the amount of the distention?" 2. "Did you have heartburn before the vomiting?" 3. "What did the vomitus look like?" 4. "Have you noticed a change in the color of your urine or stools?"

3. "What did the vomitus look like?"

A patient complains of chest pain. Which question has the highest priority to obtain additional information? 1. "What were you doing when the pain first occurred?" 2. "Do you have shortness of breath with the chest pain?" 3. "What does the pain feel like?" 4. "Has anyone in your family ever had similar pain?"

3. "What does the pain feel like?"

A nurse is caring for a woman who has just been pronounced dead. Her adult children are in the room. Which statement by the nurse indicates culturally competent care? 1. "Which funeral home would you like notified of your mother's death?" 2. "We will be moving her to the morgue in about 30 minutes." 3. "Would you like some time alone with your mother for any specific ceremonies?" 4. "Here are some of her personal belongings that were in the drawer."

3. "Would you like some time alone with your mother for any specific ceremonies?"

Which set of vital signs should the nurse recognize as out of the expected range? 1. 42-year-old man: BP, 114/82; pulse, 74 beats/min; respiration, 16 breaths/min; temperature, 36.8° C 2. 11-year-old girl: pulse, 88 beats/min; respiration, 22 breaths/min; temperature, 36.7° C 3. 3-year-old boy: pulse, 130 beats/min; respiration, 44 breaths/min; temperature, 36.7° C 4. 1-month-old girl: pulse, 120 beats/min; respiration, 42 breaths/min; temperature, 36.7° C

3. 3-year-old boy: pulse, 130 beats/min; respiration, 44 breaths/min; temperature, 36.7° C

During an interview, an elderly patient tells the nurse that she has periodic problems in keeping her balance. The nurse asks her what she is doing when the episodes occur. Which area of the symptom analysis is the nurse pursuing with this question? 1. Severity 2. Frequency 3. Aggravating factors 4. Location

3. Aggravating factors

Which patient has the greatest risk for hypertension? 1. An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his forehead and eyes 2. A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw 3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner 4. A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a deep breath

3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner

With the patient in a supine position, how does a nurse test 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

A nurse performing an abdominal examination on a 37-year-old woman would document which finding as abnormal? 1. No aortic pulsations to light or deep palpation 2. Bowel sounds every 15 seconds in the lower quadrants 3. Bulges observed when coughing 4. Silver-white striae and a faint vascular network

3. Bulges observed when coughing

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 she or he 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

A nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate? 1. Bronchial breath sounds in the posterior thorax 2. Decrease in respiratory rate 3. Decreased breath sounds on auscultation 4. Complaint of sharp chest pain on inspiration

3. Decreased breath sounds on auscultation

How does a nurse determine jugular vein pulsations? 1. Elevates the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the head of the bed is slowly lowered 2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle 4. Positions the patient supine and asks him or her to cough; looks for jugular vein pulsations during the cough

3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle

A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? 1. Dyspnea with diminished breath sounds bilaterally 2. Asymmetric chest expansion on the right side 3. Fever and tachypnea with crackles over the right lower lobe 4. Prolonged expiration with an occasional wheeze in the right lower lobe

3. Fever and tachypnea with crackles over the right lower lobe

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 liver disease. 2. There has been a scabies outbreak among his family members. 3. He has a new full-time position as a dishwasher at a local restaurant. 4. He had several warts removed from his hands 2 years ago.

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

Which is an expected finding of an abdominal examination of an adult? 1. Abdomen has a rounded contour 2. Venus hum over the epigastrium 3. High-pitched gurgles every 5 to 15 seconds 4. Swishing sounds over the abdominal aorta

3. High-pitched gurgles every 5 to 15 seconds

A nurse performing a musculoskeletal assessment is inspecting the posterior aspect of the client's posture as the client stands. After noting an exaggeration of the posterior curvature of the client's thoracic spine, how does the nurse interpret this finding? 1. Lordosis 2. Scoliosis 3. Kyphosis 4. Osteoporosis

3. Kyphosis Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine.

Which assessment data are determined by the use of a goniometer? 1. Auscultation of fetal heart tones 2. Inspection of the cervix 3. Measurement of joint flexion 4. Assessment of hearing

3. Measurement of joint flexion

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

While inspecting the legs of a male patient, the nurse notes that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease? 1. Pitting edema of one or both feet or legs 2. Increased circumference in the thighs bilaterally 3. Pale, cool legs with diminished-to-absent dorsalis pulses 4. Pain when legs are dependent that is relieved when legs are elevated

3. Pale, cool legs with diminished-to-absent dorsalis pulses

During a health history a patient says, "Stressors? Oh, yeah, I have stressors. I got a promotion at work; and, with the extra income I'm going to move into a new house, but that has been delayed because my mother is in the hospital and my son is going off to college. To get through this time I just keep using my support systems, exercising, and meditating." How does a nurse interpret these comments by this patient? 1. Flight of ideas 2. Moderate anxiety 3. Positive coping strategies 4. Rationalization and denial

3. Positive coping strategies

A nurse performing a physical assessment of a client is checking the client's mouth and throat. As part of the assessment, the nurse plans to assess the function of cranial nerve XII. What should the nurse ask the client to do as a means of assessing this nerve? 1. Frown 2. Show the teeth 3. Stick out the tongue 4. Say "ah" as the tongue is depressed with a tongue blade

3. Stick out the tongue To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the client to stick out the tongue. The nurse then notes the forward thrust in the midline as the client protrudes the tongue. The nurse also asks the client to verbalize certain words and then listen for clear, distinct speech.

A patient is brought to the emergency department in severe respiratory distress. Which method of temperature measurement would be the most appropriate? 1. Oral temperature 2. Axillary temperature 3. Temporal artery 4. Rectal temperature

3. Temporal artery

Why does the nurse ask a patient which medications he takes as part of a nutritional assessment? 1. Medications must be taken with food to avoid irritation to the gastrointestinal system. 2. Many drugs affect nutritional intake requirements; thus adjustments to the diet must be made. 3. The absorption and bioavailability of some medications are affected by food. 4. Some medications taste bad and may interfere with the appetite.

3. The absorption and bioavailability of some medications are affected by food.

The nurse documents which information in the patient's history? 1. The patient is scratching his left arm. 2. The patient's skin feels warm. 3. The patient reports itching of her eyes. 4. The patient's temperature is 100°F.

3. The patient reports itching of her eyes.

An older woman is 5 feet 2 inches tall and weighs 100 pounds. To best understand her dietary intake, which question is most appropriate? 1. "Who prepares your meals on a daily basis?" 2. "What are your favorite foods?" 3. "How do you get to the grocery store each week?" 4. "Could you describe what you eat on a typical day?"

4. "Could you describe what you eat on a typical day?"

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?"

A 62-year-old patient tells the nurse that he is in excellent health and does not take any medications. What is the most appropriate response by the nurse to follow up on the patient's statement? 1. "Do you avoid taking drugs because of bad experiences?" 2. "Which medications have you taken in the past?" 3. "That is hard to believe. Most men your age take medications." 4. "Do you use over-the-counter medications or herbal preparations?"

4. "Do you use over-the-counter medications or herbal preparations?"

What question does a nurse ask a patient with a history of pancreatitis who is complaining of abdominal pain? 1. "Which foods aggravate the pain?" 2. "Have you recently traveled outside the United States?" 3. "Have you noticed a change in your bowel habits?" 4. "How severe is the pain on a scale of 0 to 10?"

4. "How severe is the pain on a scale of 0 to 10?"

The nurse is conducting an interview with Jeremy, a 17-year-old accompanied by his mother. Which statement made by the nurse is an age-appropriate adjustment when conducting a health history with an adolescent? 1. "Jeremy, do you have a girlfriend, and if so are you sexually active yet?" 2. "Mrs. Williams, is your son sexually active yet?" 3. "Jeremy, how do you incorporate safe sex practices into your daily life?" 4. "Mrs. Williams, would you wait outside while I discuss a few things with Jeremy?"

4. "Mrs. Williams, would you wait outside while I discuss a few things with Jeremy?"

A nurse performing an abdominal assessment of a client is preparing to auscultate for bowel sounds. In which part of the abdomen should the nurse place the stethoscope first? 1. Left upper quadrant 2. Left lower quadrant 3. Right upper quadrant 4. Right lower quadrant

4. Right lower quadrant To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope lightly against the skin, then begins to auscultate in the right lower abdominal quadrant, in the area of the ileocecal valve, because bowel sounds are always present there normally.

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 nurse performing a breast examination is preparing to palpate the client's breasts. Into which position should the nurse assist the client to perform palpation? 1. A standing position, with the client holding both arms above her head 2. A standing position, with the client holding her hands firmly on her hips 3. A supine position, with the arm on the side being examined positioned across the chest 4. A supine position, with the arm on the side being examined positioned behind the head and a small pillow placed under the shoulder on the same side

4. A supine position, with the arm on the side being examined positioned behind the head and a small pillow placed under the shoulder on the same side To palpate the breasts, the nurse assists the client into a supine position and positions the client's arm on the side being examined behind the head. A small pillow is placed under the shoulder on the same side. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall and notes tissue consistency. Palpation is performed systematically, with care taken to ensure that the entire breast and tail are palpated.

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.

During an assessment of a young adult, the nurse notes that the patient's shoulders are uneven. Which examination would the nurse perform for further data? 1. Ask the patient to rotate each shoulder to assess for range of motion. 2. Ask the patient to push against the nurse's hands with his or her forearm to test muscle strength. 3. Ask the patient to shrug his or her shoulders while the nurse pushes them down to test the muscle strength. 4. Ask the patient to bend forward at the waist while the nurse checks the alignment of the patient's vertebrae.

4. Ask the patient to bend forward at the waist while the nurse checks the alignment of the patient's vertebrae.

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. Audiometry test

4. Audiometry test

A nurse is preparing an ambulatory male client for a rectal examination. After the examination has been explained to the client, into what position should the nurse assist the client? 1. Sims 2. Supine 3. Left lateral 4. Bending forward resting upper body on exam table

4. Bending forward resting upper body on exam table

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

A nurse conducting a physical assessment is observing the client's balance and performing tests to determine the client's sense of equilibrium. Which cranial nerve is the nurse assessing? 1. Cranial nerve II 2. Cranial nerve IX 3. Cranial nerve VII 4. Cranial nerve VIII

4. Cranial nerve VIII Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the client's balance when the client is walking or standing, involve the vestibular portion.

Which technique does the nurse use to palpate a patient's abdomen? 1. Asks the patient to breath slowly though the mouth 2. Uses the heel of the hand to perform deep palpation 3. Uses the left hand to lift the rib cage away from the abdominal organs 4. Depresses the abdomen 1 cm for light palpation

4. Depresses the abdomen 1 cm for light palpation

When a nurse asks a patient to place the right arm behind the head, the nurse is testing 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

Which infection control intervention is most frequently applied? 1. Wearing gloves 2. Using masks 3. Wearing eye protection 4. Hand hygiene

4. Hand hygiene

What is the most accurate technique for detecting a venous thrombosis at the bedside? 1. Dorsiflex the calf and note if the patient complains of pain. 2. Elevate one leg above the level of the heart to determine if the veins empty. 244 3. Palpate the pulses distal to the areas of the suspected thrombosis. 4. Measure the thigh circumference to detect an increase from the baseline.

4. Measure the thigh circumference to detect an increase from the baseline.

The nurse testing the patient's muscle strength finds that the patient has full resistance to opposition. Using Table 14-3, how would this finding be documented? 1. Poor or 2/5 2. Fair or 3/5 3. Good or 4/5 4. Normal or 5/5

4. Normal or 5/5

A 62-year-old patient tells the nurse that he has recently had frequent fainting spells. After palpating the radial pulse, 13 pulsations are counted in 15 seconds with a regularly irregular rhythm. What is the most appropriate action for the nurse to take at this time? 1. Reassess the pulse rate after he walks around the room for several minutes. 2. Reassess the pulse rate for 15 seconds using the carotid artery. 3. Take an apical pulse for 5 full minutes, counting the number of skipped beats. 4. Palpate the pulse for one l minute and determine the pattern to the irregularity.

4. Palpate the pulse for one l minute and determine the pattern to the irregularity.

During inspection of the respiratory system the nurse documents which finding as abnormal? 1. Skin color consistent with patient's ethnicity 2. 1:2 ratio of anteroposterior to lateral diameter 3. Respiratory rate is 20 breaths per minute 4. Patient leaning forward with arms braced on the knees

4. Patient leaning forward with arms braced on the knees

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

4. Port wine stain

High-pitched, with a harsh, hollow, tubular quality heard over the trachea and larynx

Bronchial sounds

Moderately pitched; heard over the major bronchi

Bronchovesicular sounds

Dry, grating quality sounds heard best during inspiration; does not clear with coughing

Pleural Friction Rub

Loud, low-pitched, coarse rumbling sounds heard during inspiration or expiration; may be cleared by coughing

Rhonchi

Lateral spinal curvature

Scoliosis

Order of vital signs

Temperature Radial pulse (apical pulse may be measured during the cardiovascular assessment) Respirations Blood pressure Height and weight