Module 6 Practice Quizzes

Swollen labia minora

The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding?

a client in the Intensive Care Unit for acute pancreatitis asking for pain medications

The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for?

Auscultation of a bruit

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider?

Translators may need additional explanations of medical terms.

The client, Mrs. Rodrigquez, has requested a translator so that she can understand the questions that the nurse is asking during the client interview. What is important when working with a client translator?

Ask the boy to sit cross-legged.

The nurse is examining the testicles of a 6-year-old boy. How can the nurse prevent a retractile testis from slipping back up the inguinal canal?

objective data.

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of:

This is a normal and transient condition of adolescent males.

A 14-year-old male is brought to the clinic by his father with concerns that he is developing an excessive amount of breast tissue. The examination confirms that he has slight enlargement of the breast tissue. What information should be relayed to the teen and his parent?

"There are some things I may need to share with your parents or physician."

A 15-year-old female is being seen for an annual physical examination. The teen asks the nurse if what they talk about will be kept private. What is the appropriate response by the nurse?

The client makes noises when he breathes.

A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse?

Measure the pulse oximetry.

A 56-year-old client with Mexican heritage has a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32. The nurse notices that the client is restless, and his skin has an ashen appearance. Which nursing action is the priority intervention?

Palpation

A 57-year-old male client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last?

Pain is 4 out of 10 on a pain scale.

A client has been reporting persistent headaches. Which is an example of subjective data?

Patency of airway

A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to have a neuroma removed from the left leg. Which assessment should receive the highest priority?

Evaluate the blood pressure and pulse

A client is admitted to the emergency department. He is bleeding from a cut on his head and his skin color is pale, with diaphoresis. What nursing action should be performed first?

Crepitus

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

1. Soft, low-pitched, whispering sounds heard over most of the lung fields 2. Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly 3. Blowing, hollow sounds auscultated over the larynx and trachea

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply.

Redness of the cheeks and lips

A nurse assesses the skin of a child and documents evidence of plethora. Which finding did the nurse observe?

It is distended.

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean?

Standing at the bedside

A nurse conducted a health history with a 5-year-old child admitted with abdominal pain. The nurse stood at the bedside while talking to the parent and child. The client was in a private room. The nurse made sure the door was closed and referred to the parent as "Mrs. Smith" whenever asking a question. Which action by the nurse was not conducive to the health history?

Tuning fork

A nurse has explained her intention to conduct a Weber test and Rinne test. Which pieces of equipment will the nurse require?

Document normal breath sounds.

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action?

Inspect the area of itchy skin.

A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." Which action should the nurse take first?

1. inspecting the abdominal incision 2. taking the client's blood pressure 3. reviewing morning lab results

A nurse is caring for a post-operative client 1 day after coronary artery bypass surgery. Which nursing interventions demonstrate the skill of assessment? (Select all that apply.)

"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)."

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, "What does that mean?" How should the nurse respond?

oriented to person, place, and time

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"?

A very dark mole with an uneven border

A nurse is examining the skin of a 15-year-old girl. Which finding would most warrant concern on the part of the nurse?

Axillary temperature, femoral pulse, head circumference

A nurse is performing a physical examination on a newborn. Which assessment should she include?

Bruits

A nurse is performing auscultation. The nurse would use the bell of the stethoscope to auscultate which sounds?

1. Position the client supine and drape appropriately. 2. Inspect the skin of thorax and abdomen. 3. Palpate the thorax. 4. Auscultate the thorax. 5. Auscultate the abdomen. 6. Palpate the abdomen.

A nurse is preparing to assess the thorax and abdomen of a client using the head-to-toe physical assessment method. Place the assessment techniques in the order in which they should be performed.

Warm the diaphragm of the stethoscope.

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Down and back

A nurse is preparing to examine the ear of a 2-year-old child. The nurse would pull the pinna in which direction?

"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that."

A nurse is teaching a young female client about breast cancer prevention. The client asks at what age does she need to begin having mammograms. What is the nurse's best response?

observe the client's body language.

A nurse is using the assistance of an interpreter. When interviewing a client who does not speak English, the nurse should:

skin turgor.

A nurse performing an integumentary inspection on a client gently pinches the skin under the clavicle. This nurse is assessing:

whose skin is a dusky, bluish color.

A nurse uses observation to examine a client's skin. The nurse would document cyanosis for the client:

peripheral pulses.

A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's:

Parents will not always reveal their most important concern in the initial minutes of the interview.

After eliciting a chief concern from a client, a nurse continues gathering information about related and other health concerns. Why is it important for the nurse to ask a second time at the end of the interview if there are other concerns?

Cranial nerve I

Cranial nerve function is important for normal sensory functioning. Which cranial nerve is important for the sense of smell?

Salmon nevus

The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark?

The nurse places the stethoscope over the popliteal artery

Due to casts on both arms, the nurse must measure an 11-year-old client's blood pressure in the thigh. After placing the blood pressure cuff on the thigh, which action by the nurse demonstrates understanding of the procedure?

2+ pitting edema noted on bilateral lower extremities

During assessment of the lower extremities, the nurse notes the bilateral lower extremities are pink, intact, warm, and soft to touch, as well as normal in contour with a 4 mm depression in the skin after pressing that returns after 2 seconds. Which is the correct interpretation and documentation of this result?

1. Cardiovascular: radial pulses 90, bounding, and equal 2. Skin: warm and dry 3. Gastrointestinal: abdominal pain with rebound tenderness in RLQ

Mr. Martinez is a 55-year-old male who was brought to the emergency department (ED). He reports abdominal pain in his right lower quadrant (RLQ) and nausea without vomiting. The nurse performs a physical assessment on the client and documents the following: Neurologic status: awake and alert; Cardiovascular: radial pulses 90, bounding, and equal; Skin: warm and dry; Respirations: 24 and regular; Gastrointestinal: abdominal pain with rebound tenderness in RLQ; Musculoskeletal: sitting up in bed with knees bent. Identify which findings involved the assessment technique of palpation. Select all that apply.

A child who has suffered a head injury and is comatose

On what client would it be appropriate for the nurse to perform a rectal temperature?

The dorsum

Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature?

1. The nurse visually inspects the child's thorax. 2. The nurse palpates the child's thorax. 3. The nurse percusses over the child's lungs. 4. The nurse auscultates the child's lungs.

The experienced nurse is assessing the child's lungs. Rank the following steps in the proper order of assessment.

"Take your blood pressure medications exactly as your doctor prescribed them."

The nurse at the neighborhood family clinic is teaching a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client?

"This is common for newborns up to several days of age. It happens because of the immature circulatory system trying to get used to being outside the uterus."

The nurse brings a 2-day-old infant into the mother's room in the postpartum unit. The mother voices concern that her newborn's hands and feet "look a little blue." How should the nurse respond?

This information is part of the legal record and should be treated as confidential.

The nurse collects a client history including biographical data regarding the child being admitted. Which responsibiltiy is the most important related to the data collected?

Decreased cardiac output

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing?

1. Decreased near vision 2. Increased systolic and diastolic blood pressure 3. Decreased tissue elasticity

The nurse enters the room of an older adult client diagnosed with Alzheimer disease to perform a head-to-toe assessment. What assessment findings by the nurse are reflective of the normal signs of aging? Select all that apply.

"Do you have any concerns about your daughter?"

The nurse examines a 3-year-old girl in a health maintenance setting. What is the first question the nurse would ask her mother to obtain a health history?

Wheezing on auscultation

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse?

1. The nurse waits to measure the child's temperature 30 minutes after a nebulizer treatment 2. The nurse encourages the child to keep the mouth closed during temperature measurement 3. The nurse asks the mother if the child has had anything to drink recently

The nurse is assessing a 5-year-old's oral temperature. Which actions by the nurse indicate knowledge of the procedure?

Palpation

The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use?

Auscultation of short, high-pitched popping sounds during inspiration

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

It's called a salmon nevi or a stork bite. They typically fade over time but may never go away totally."

The nurse is assessing a newborn. The child's mother asks about small pink area on the bridge of the child's nose. What would be the appropriate response by the nurse?

The tympanic membrane is translucent, shiny, and gray.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal?

In the crib facing the mom

The nurse is beginning the examination of a 4-month-old infant. She takes the infant from the mother's arms to do the exam. Where should the nurse place the infant for the exam?

Inspect the left lower leg for areas of redness.

The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first?

Check the client's ear canals for cerumen.

The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate?

These lesions will normally fade as the child ages.

The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct?

VIII

The nurse is conducting a physical examination of a 10-year-old child. The nurse whispers the child's name from behind the child so that the child does not see the nurse's lips moving. Which cranial nerve is the nurse assessing?

1. Color 2. Location 3. Size 4. Distribution

The nurse is examining a child's skin for lesions and rashes. When documenting the findings, which would the nurse include? Select all that apply.

1. Delivery information (type of delivery and complications) 2. Chronic diseases 3. Immunization status

The nurse is gathering data for a child's chart. What data needs to be collected as part of the child's health history? Select all that apply.

"What brings you here today?"

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first?

Palpable pulsation over the mitral area

The nurse is palpating a client's precordium. Which result is an expected clinical finding?

Assess the client for dehydration.

The nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding?

Ask the client if the scrotal skin has always been lighter in pigment than the rest of the patient's skin

The nurse is performing an assessment of the genitalia of a 15-year-old male. The nurse notes that the pigment of the skin of the scrotum is much lighter than the rest of the client's skin color. What is the nurse's best action?

Verify that the procedural consent form is signed.

The nurse is preparing a client for an emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action?

1. Inspection 2.Auscultation 3. Percussion 4. Palpation

The nurse is preparing to assess a client's abdomen. Arrange the steps of the assessment in the correct order.

Blood pressure recording

The nurse is preparing to conduct a physical examination of a 3-year-old child. Which assessment will the nurse introduce for the first time to this client?

Ask the client to empty her bladder.

The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment?

Pull the child's earlobe back and down and point the sensor beam toward the center of the tympanic membrane.

The nurse is preparing to measure an infant's temperature with a tympanic thermometer. Which is the correct way to position the device?

With the child seated on the caregiver's lap.

The nurse is preparing to perform a physical examination of a toddler. Which is the preferred location to complete the assessment?

Heart rate 60, respiratory rate 31

The nurse is reviewing vital signs taken by the unlicensed assistive personnel on a group of toddlers. Which warrants follow up by the nurse?

Help the family design a genogram. (shows the relationship between family illnesses and diseases in a visual manner)

The nurse is taking a family history of a 10-year-old with asthma. What would be a helpful tool to obtain a family history of illness and disease?

Heart rate of 120 beats per minute

The nurse is taking vital signs on a group of assigned preschool children. Which assessment finding would indicate the need for further action?

A bubble behind the tympanic membrane

The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation?

The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.

The nurse is weighing a 20-month-old who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child?

Examine the child's head and work down to the child's toes.

The nurse prepares to examine a 4-year-old boy. How would the nurse proceed?

Ask the parents for a day history.

The nurse seeks to know how much time a preschooler's parents spend playing with the child every day. Which is the best way to obtain this kind of information?

a client's heart murmur.

The nurse should use the bell of the stethoscope during auscultation of:

Palpation

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment?

23 ((Weight in pounds X 703) ÷ (height in inches X height in inches))

The student nurse is caring for a child who weighs 48 pounds and is 38 inches tall. Which is the child's body mass index (BMI)?

look at a close object, then at a distant object.

To assess a client's visual accommodation, the nurse has the client:

mastoid process.

To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the:

"Has anything changed your sexual performance?"

To obtain data about an adult client's sexuality and reproductive pattern, what question is best for the nurse to ask?

chief concern.

Upon admission to the hospital, the client states, "I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy." This statement reflects the client's:

ptosis.

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:

Wheezes

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

Respirations

When doing a health assessment on a child, the nurse should include a physical assessment. What is the most important thing to assess first when performing the physical assessment?

provide privacy and confidentiality.

When examining a client upon admission to the hospital, it is important to:

The chief complaint of the child

When obtaining a child's health history the child's biological data is assessed. What is the next thing to assess in the child's history?

The fourth intercostal space.

Where is the point of maximal impulse (PMI) found in a 5-year-old girl?

Percussion

Which assessment measure would the nurse use to assess the location, shape, size, and density of a tumor?

Body systems framework

Which framework is used during the focused assessment?

Stridor

Which respiratory sound indicates an upper airway obstruction?

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

Which technique should the nurse use to assess the pupillary light reflex on a client?

blurred.

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is:

Assessing vision

While at school, the client is called to the school nurse's office. The school nurse is performing secondary prevention interventions. Which would the nusre most likely be performing?