Physical Assessment Study Questions
While assessing the client, the nurse notes that the client has a moist cough. The nurse would include which of the following questions in the focused interview?
"Are you coughing up any mucus or phlegm?"
The mother of a 9-year-old girl voices concern to the nurse regarding her daughter's breast development and breast tenderness. The nurse's best response to the mother is:
"Breast enlargement and tenderness is common between the ages of 9 to 13, but I will inform her primary care provider of your concerns."
The nurse is interviewing a client who has recently been diagnosed with atherosclerosis in the client's coronary arteries. Which of the following questions by the nurse has the highest priority to help the nurse determine the client's most important risk factor for this condition?
"Do you smoke or are you exposed to secondhand smoke?"
The nurse who works on a cardiac unit is teaching the student nurse about heart sounds. The student nurse asks how the S1 heart sound is produced. Which of the following is the nurse's best response?
"It results from the closure of the atrioventricular valves."
The nurse is performing the Weber test. The nurse documents that the sound lateralized to the client's right ear. The student nurse observing the assessment asks the nurse about the meaning of this documentation. Which of the following is the nurse's best response?
"The client is able to hear bone-conducted sound better through the impaired ear."
The nurse is caring for a client who had abdominal surgery several months ago. The client has verbalized concern that the scar from the surgery is purplish in color. Which of the following statements is the nurse's best response?
"The color is normal and will fade with time."
A 4-year-old child's respiratory rate is 30 per minute. The mother states, "That seems like a really high number. My healthcare provider told me my respiratory rate is only 16 per minute." Which of the following is the nurse's best response?
"This is a normal finding for your child's age."
The nurse is assessing a client with a severe left pleural effusion. Which of the following findings are expected?
- Absent breath sounds on the left side -Tracheal shift to the right -Pleural friction rub auscultated.
A[1][2] 31-year-old female client wishes to begin taking oral contraceptives. The medical history indicates that the client had a deep vein thrombosis three years ago. After reviewing the objectives set forth in Healthy People 2020, which of the following is the best response by the nurse?
. "Taking oral contraceptives increases your risk of developing clots."
During the focused interview, the client admits to regularly abusing cocaine. Which of the following findings does the nurse expect to discover during the physical assessment of the client's nose?
1. The nurse notes that the nasal septum has perforated. 3. The septum is noted to be very pale in color.
A client's blood pressure is 138/86 mm Hg. The nurse classifies this client's blood pressure as which of the following categories?
2. Prehypertension
The client's stroke volume is 72 The client's heart rate is 82 beats per minute. What is the client's cardiac output?____________
5904 mL per minute.
The nurse is assessing a 1-month-old infant's respiratory system and sees that the infant is primarily using abdominal muscles to breathe and has an irregular breathing pattern. The nurse recognizes that this finding is:
A normal finding.
During the assessment of a client's integumentary status the nurse notes "vitiligo present bilateral hands." This documentation indicates which of the following information?
Abnormal loss of melanin in patches
The nurse is caring for a client who may have an arterial obstruction in her right ulnar artery. Which of the following tests may be used to help determine the patency of this artery?
Allen's test
The nurse is performing a breast assessment of an Asian adult female. Which of the following should the nurse do first?
Ask the client if she has noticed any changes in her breasts such as lumps, thickening, or discharge from the nipples.
The nurse is preparing to assess an elderly client with emphysema. Which of the following anatomical changes would the nurse expect to find in this client?
Barrel chest
The nurse is unable to palpate a client's pedal pulses. Which of the following items will the nurse use to help locate this client's pedal pulses?
Doppler
The nurse is assessing a client's right lower extremity and during inspection notes an area of redness. In order to assess the temperature of the client's skin, the nurse should use which part of the hand?
Dorsal surface
The nurse is inspecting a client's chest and upper extremities. Which of the following would be the appropriate method for the nurse to assess these body areas?
Examine the left arm, the right arm, and then the chest.
The nurse is about to perform a physical assessment on an adult client. Before beginning this phase of the client's health assessment, the nurse should first:
Explain to the client what will happen during the examination.
The nurse is assessing the client's eyes. Which of the following findings is most consistent with glaucoma?
Eyeballs are firm to palpation.
Which of the following structures attaches the tongue to the floor of the mouth?
Frenulum
The nursing instructor is observing a student nurse assess the client's respiratory system. The student demonstrates proper technique for auscultation when moving the stethoscope:
From side to side.
The nurse is demonstrating palpation of the lymph nodes to a nursing student. Which of the following methods would be correct for the nurse to use during this examination?
Gentle, circular pressure
The nurse is assessing a newborn infant and notes that the infant's head is enlarged with prominent scalp veins visible. The nurse would correctly document this finding as which of the following?
Hydrocephalus
The nurse is assessing the fundus of the elderly client's eye with an ophthalmoscope. The nurse determines that there is a cyst within the macula. Which of the following client symptoms may be associated with this finding
Impaired central vision
The nurse is preparing to assess a client's abdomen. Which of the following sequences will the nurse use to assess this body area?
Inspection, Auscultation, Percussion, Palpation
A menopausal woman comes to the clinic with complaints of thin, watery nipple discharge with blood present. The nurse would suspect which of the following disorders in this client?
Intraductal papillomas
The nurse is teaching a client with benign breast disease about symptom relief. Which of the following topics would the nurse include in this session?
Limiting salt intake
During the assessment of a client's voice sounds, the nurse hears louder sounds over the client's right lower lobe. This finding would be consistent with:
Lobar Pneumonia
A client with a fever is also complaining of difficulty hearing. The nurse realizes this client might be experiencing which of the following disorders?
Otitis media
An elderly client says, "I can't seem to hear as well as I could when I was younger." The nurse suspects this client is experiencing which of the following disorders?
Presbycusis
During the assessment of an elderly client's skin, the nurse notes small areas of hyperpigmentation on the dorsal aspect of the client's hands. The client states, "I've been getting more of these big freckles as I get older." The nurse realizes this finding is due to:
Senile lentigines
The nurse is assessing an infant diagnosed with Down syndrome. Which of the following characteristics would the nurse expect to find during the examination?
Slanted eyes 2. Cleft palate and lip 4. Shortened neck
The nurse is percussing the client's anterior chest and notes a dull sound over an area where lung tissue is normally found. Which of the following would the nurse associate with this finding?
The client's heart may be enlarged.
During the assessment of a client's eyes, the nurse suspects that the client has ptosis. Which of the following did the nurse most likely find?
The eyelid is drooping.
As the nurse assesses the pregnant client she states that she sometimes feels like she has difficulty breathing. The client has reached the 36th week of her pregnancy. The nurse realizes that the client's difficulty is related to:
The fetus pushing the diaphragm upwards.
The nurse is assessing a client's visual fields by confrontation. Which of the following nursing actions indicates that the nurse requires further education regarding this test?
The nurse asks the client to sit 20 feet away.
During the cardiac assessment of a client, the nurse hears a loud rumbling during diastole that increases toward the end of the sound. This sound is heard with the bell of the stethoscope over the lower left sternal border. The nurse would suspect which of the following in this client?
Tricuspid stenosis
The nurse educates the client about the major functions of the nose and sinuses. Which of the following structures is specifically responsible for filtering, moistening, and warming air that enters the lower portion of the respiratory tract?
Turbinates
Which of the following countries have decreased their population's risk of developing thyroid disease by adding iodine to salt?
United States
The nurse has assessed the client's skin. The nurse is preparing to document the appearance of herpetic lesions found over a client's nose and mouth region. The healthcare provider diagnosed the client with herpes simplex. Which of the following are common words that are used to describe these types of lesions?
Vesicular Pustular Crusty
The nurse is preparing to assess an adult client who presents to the emergency room after falling down some steps at home. The client complains of left ankle pain and has open abrasions to the left knee and shin. Which of the following should the nurse incorporate into the physical assessment of this client?
Wash hands in the presence of the client Put on nonsterile gloves to examine the client.
A client was referred to the clinic with complaints of blurred vision. The initial question for the nurse to ask the client would be which of the following?
Would you please tell me about your vision today?"
During an eye assessment, a 24-year-old client reports difficulty seeing items well at close range. The nurse realizes this finding is consistent with:
hyperopia.
The nurse is completing a focused interview to assess the skin, hair, and nails of a pregnant client. Which of the following questions would be most important for the nurse to include in the interview?
"Do you use any skin creams?"
The client is 36 weeks pregnant. The nurse is assessing the client's respiratory system and finds that her respiratory rate is 24 breaths per minute. The client states that she sometimes experiences shortness of breath. Which of the following is the nurse's best response?
"During your last trimester, it is normal for you to feel short of breath and to have a faster respiratory rate."
During the focused assessment of a female client, she reports breast tenderness, swelling, and lymph node enlargement around the time of her period. The nurse's best response to this finding is:
"Fluctuating hormone levels around the time of your period frequently causes these symptoms. I will note this in your chart and notify your primary care provider."
The nurse is conducting a focused interview on the client's integumentary system and prepares to obtain data related to risk factors for the development of integumentary disorders. Which of the following questions by the nurse would be unexpected based on the specific data the nurse is attempting to gain during the interview?
"Have you noticed any drainage from your skin?"
The nurse is assessing an adult African American client who is experiencing visual changes. Which of the following questions would be the most important to ask this client?
"Have you or anyone in your family ever been diagnosed with diabetes?"
The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the tongue. Which of the following questions would be appropriate for the nurse to include when obtaining further assessment data?
"Have you recently taken antibiotics?"
The nurse is asking a client questions regarding lifestyle patterns. Which of the following statements by the client would alert the nurse to possible risk for breast cancer?
"I drink two glasses of wine each night."
The nurse is teaching a group of high school males about self-breast examination. The nurse knows the teaching has been effective when one of the males makes which of the following comments regarding breast cancer in males?
"I know that I need to do monthly self-breast exams."
During the focused interview, the client makes the following statements. Which of the following statements indicates that the client has an increased risk of developing cardiovascular disease?
"I was diagnosed with hypothyroidism about 5 years ago."
The nurse is preparing to assess the client's eye with an ophthalmoscope while a student nurse is observing. Which of the following statements by the nurse to the student nurse is accurate regarding this portion of the assessment?
"I'm going to begin with the lens set to the 0 diopter."
The client has been admitted to the Coronary Care Unit with a myocardial infarction. Which of the following statements by the client indicate that adequate learning has occurred?
"I've been breathing fast and my heart's been racing because my heart's not working right."
A female client asks the nurse when the best time is to perform self-breast examination (SBE). The nurse's best response is:
"If you are still menstruating the best time is about 5 days after your period begins each month."
The nurse is performing a focused interview with the client. The nurse asks the client if the client has noticed any drainage from the ears, and the client states, "Yes." Which of the following statements indicate that the client may have developed acute otitis media?
"It is kind of yellowish-reddish color."
A pregnant client expresses concern about performing breast self-examination during pregnancy since her breasts are tender. Which of the following would be the best response by the nurse in this situation?
"It's very important for you to be familiar with the changes in your breasts."
The nurse is interviewing the mother of a three-week-old Caucasian infant. Which statement by the mother indicates she requires further education about her infant's eyes?
"My baby's eyes are blue and definitely will stay blue."
The nurse is performing a focused interview with an adult male client who recently experienced a myocardial infarction. The nurse requests information about how he felt during the time of the myocardial infarction. Which of the following client statements would be unexpected?
"My chest didn't actually ever hurt."
The nurse examines the peripheral vascular system of a client diagnosed with chronic bronchitis 22 years ago. The nurse examines the client's hand. Which of the following statements by the client is consistent with the client's diagnosis?
"My nails always look a little bluish."
The nurse is planning to assess an African American's integumentary status. Which of the following statements by the client is most consistent with the presence of cyanosis?
"My nails look a little bit bluish."
The African American middle-aged client has been diagnosed with glaucoma. Which of the following statements by the client indicate that further education is required?
"My race doesn't have anything to do with this diagnosis."
The nurse is performing an assessment of the client's head and neck. The client requests information about the assessment of her lymph nodes. Which of the following is the best response?
"Sometimes, enlarged lymph nodes indicate an infection."
A female client being examined by the nurse exhibits 2+ pitting edema in the right arm, while the left arm is normal in size. Which of the following responses by the nurses is most important at this time?
"Tell me about your past surgical procedures."
While the nurse is counseling a client about fibrocystic breast disease, the client asks if having this disorder will lead to cancer. The nurse's best response is:
"There is no direct link between this disease and breast cancer."
The nurse is assessing the skin of a newborn infant and notes a bright red, raised lesion on the lateral aspect of the thigh. The lesion is 4.5 centimeters in diameter. When light pressure is applied to the lesion, the site does not blanch. The mother expresses concern about the appearance of this site, and asks the nurse if it should be removed. Which of the following would be the best response for the nurse in this situation?
"These types of lesions usually disappear by the time a child turns 10 years old."
The nurse is performing a physical examination on a 2-day-old infant and notes flattened areas on each side of the head. The mother expresses concern about the infant's appearance. Which of the following responses would be appropriate for the nurse?
"This is normal and will resolve in a few days."
The nurse is teaching self-breast examination to a client and demonstrates inspecting the breasts with arms over the head. The client asks the nurse why this is necessary. The nurse would respond with which of the following?
"This is the best position to look for skin dimpling."
The nurse finds the client's thyroid gland is enlarged during the physical assessment. The client states that she has had a history of a goiter in the past. Which of the following questions is a priority to ask during the focused interview?
"What type of salt do you use in your diet?"
The nurse is assessing the oral mucosa of a pregnant female and notes enlargement of the gums. The client states that regular oral hygiene is performed and that she does not understand why this has occurred. Which of the following is the nurse's best response?
"You are experiencing a normal change during pregnancy."
The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse, "Why did this happen to me?" Which of the following statements is the nurse's best response?
"You may have some hormone imbalances."
A client is found to need corrective lenses for myopia. Which of the following explanations would the nurse provide to this client?
"Your glasses will help you to see objects in the distance."
A client presents with an enlargement of several cervical lymph nodes and asks the nurse about the function of these structures. The nurse would respond with which of the following statements?
"Your lymph nodes help to remove infectious organisms."
While assessing a client with a laceration on the client's left third finger, the nurse notes the presence of inflammation and swelling of the finger. The nurse might expect to find which of the following?
- 2 cm, tender, firm, left epitrochlear node -cm, tender, firm, left axillary lymph node
The nurse is preparing to perform a cardiac assessment on a client. Rank the following pieces of the assessment in order of occurrence.
-Inspection of the client's head and neck, chest, abdomen, and extremities -Palpation of the precordium and pulses -Percussion of the client's chest -Auscultation of the client's heart, apical pulse, and carotid arteries
The student nurse is assessing the client's cardiovascular system while the experienced nurse observes. The employment of which of the following techniques by the student nurse indicate the need for further education?
-The client complains of discomfort while lying flat. The student nurse auscultates the client's chest quickly while the client continues to lie flat. - The student nurse gently palpates the client's carotid arteries simultaneously to determine pulse strength, rhythm, and rate.
The student nurse is speaking with a nurse regarding the objectives of Healthy People 2020. Which of the following statements by the student nurse indicates that the student nurse requires further education regarding these objectives?
. "African Americans really need to be educated about the symptoms associated with hypertension."
The nurse is interviewing a 37-year-old client for breast cancer risks. The nurse understands that the client knows the risks associated with breast cancer when which of the following comments is made?
. "I know my risk for breast cancer increases with age."
The nurse is preparing to discuss the cultural implications associated with eye diseases with a small group of nursing students. Which of the following statement indicates that the nurse requires further education about this subject?
. "Our diabetic clients should return every 2 years for an assessment of their vision and their retina."
The nurse is performing a visual examination on a client due to the client's complaints of black dots appearing in the visual field. Which of the following statement is the nurse's best response to the client?
. "The black dots are known as floaters and are usually normal."
During the focused interview, the client answers the nurse's questions. Which of the following statements by the client suggests that the client has an increased risk of developing cardiovascular disease?
1. "I have been stressed out since my divorce last year." 3. "I went on this new diet because I gained 30 pounds in the last 9 months." 4. "On my new diet, I can eat only grains and vegetables." 5. "I think about my job all of the time."
The student nurse is preparing to perform an assessment of the client's peripheral vascular system. The experienced nurse asks the student nurse questions to ensure the student nurse has prepared adequately. Which of the following statements by the student nurse indicate that further education is required?
1. "I need to take a blood pressure only in the client's right arm." 3. "It will be easier to assess the client's carotid pulses if the client is obese."
The client is 3 months pregnant. The nurse recently reviewed the objectives of Healthy People 2020 regarding pregnant women. Which of the following statements by the client indicates adequate education has occurred according to the objectives?
1. "I never got my rubella vaccination so I've been staying away from my niece who has rubella." 2. "I stopped taking Accutane for my acne before we started trying to get pregnant." 3. "I have been so careful about taking my insulin now that I'm pregnant." 5. "I had to change to a different medication to prevent my seizures before we got pregnant."
The nurse is preparing an educational program regarding Healthy People 2020. Which of the following pieces of information is important to include for caregivers of infants and young children?
1. "Infants should always be placed to sleep on their backs." 2. "Children should be taught to wash their hands." 3. "Caregivers should ensure that the children's toys are age-appropriate." 4. "Parents should be educated about the importance of immunizations." 5. "Caregivers should inspect the children's toys for small possibly inhalable parts."
The nurse is assessing a child previously diagnosed with fetal alcohol syndrome. Which of the following statements by the client's adoptive mother are consistent with the child's diagnosis?
1. "It seems as if one of his eyelids is droopy 3. "His eyes almost look cloudy. 4. "He has required glasses to see well since he was 2 years old."
The nurse is performing a focused interview with a client who was recently diagnosed with varicose veins. Which of the following statements by the client are associated with risk factors for varicose veins?
1. "My mother had big veins on her legs from the time I was little." "I'm a hair stylist." "I know I weigh a lot more than I should."
A client complains of daily headaches. Which of the following would the nurse include in the focused interview?
1. "Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst." 2. "Tell me exactly where the pain is located." 3. "Is there anything that relieves the pain, like resting or medication?" 4. "Is the pain sharp, dull, steady, or throbbing?" 5. "Have you had a recent cold or infection?"
The nurse is caring for a male client who is complaining of dizziness when standing. The client has been compliant with his antihypertensive medication. Which of the following statements by the client are commonly associated with antihypertensive medication use?
1. "Sometimes, I just feel so sick to my stomach." 2. "I have frequent headaches." 3. "My sex life hasn't been so good since I started taking this medication."
The nurse is teaching an older adult client about breast self-examination (BSE). Which of the following should the nurse provide during this instruction?
1. Additional lighting 2. Increased time 3. Opportunity for questions 4. Large-print handouts
The nurse is examining an African American client. When compared to Caucasians, which of the following conditions is this client at a higher risk for developing?
1. Asthma 2. Sarcoidosis 3. Tuberculosis 4. Obstructive sleep apnea
The Emergency Department nurse determines that the client may be having a myocardial infarction. Which of the following pieces of information indicate that the client is experiencing an acute cardiovascular problem?
1. Blood pressure has dropped from normal and is 90/52. 2. Apical heart rate is 114 beats per minute. 4. Respiratory rate is 28 per minute.
The nurse is assessing the client. The client is irritable, anxious, and has lost 12 pounds over the last 2 months. The client's eyes appear to bulge from their sockets. Which of the following pieces of information does the nurse expect to find during the assessment of this client?
1. Blood pressure: 162/92 2. Apical pulse: 120 5. Client complains of feeling very warm.
The nurse is compiling statistics for a breast cancer awareness presentation for a group of women. The nurse would correctly use which of the following facts about breast cancer?
1. Breast cancer is one of the most common cancers in females. 3.Associated mortality has declined. 5. 25% of females in Western countries are genetically predisposed.
The nurse is conducting a breast health workshop for a group of women. Which of the following would the nurse include in this workshop when outlining risk factors for breast cancer?
1. Caucasian race 2. Positive family history 3. Low socioeconomic status 4. Hormone replacement therapy
The client is a 38-year-old female client who developed a pulmonary embolism and is currently in the Intensive Care Unit. The nurse in the Intensive Care Unit is interviewing the client and reviewing her history. Which of the following statements by the client or assessment findings are consistent with the client's increased risk for developing a pulmonary embolism?
1. Client states, "I usually smoke two packs of cigarettes each day." 2. Client states, "The nurse on the surgical unit really wanted me to sit on the side of the bed after surgery and to start walking with him later that evening, but I was so nauseated and in so much pain that I couldn't." 3. Client states, "I had an open appendectomy 4 days ago." 4 cm incision noted to RLQ, staples intact, edges well-approximated 4. Client states, "I have taken oral contraceptives for the last 7 years." 5. Client states, "I had some muscle cramping and tenderness in my left leg before they moved me to Intensive Care."
The nurse is preparing to assess the client's cardiovascular system. Which of the following positions will the nurse need to place the client in during the assessment?
1. Dorsal recumbent 2. Leaning forward 4. Left lateral position 5. Sitting upright
The nurse is examining a client's ears and notes that right ear is occluded with wax. The nurse would choose which of the following to remove the earwax?
1. Irrigation with warm mineral oil, peroxide, followed by warm water 4. A cerumen spoon to remove the wax
The nurse is assessing a client who may have arterial insufficiency in the left lower leg. Which of the following are consistent with this diagnosis?
1. Left dorsalis pedis pulse +1, right dorsalis pedis pulse +3 2. Skin is cool, tight, and shiny 3. When left leg is dependent, erythema is present 4. When left leg is elevated, pallor is present
The nurse is examining a client's neck. Which of the following would the nurse use as the correct method to palpate the trachea?
1. Palpate while the client is swallowing. 2. Slide the thumb and index finger upward on each side of the trachea. 3. Palpate the midline of the neck to feel the cricoid cartilage.
The nurse is preparing to assess the female client's cardiovascular system during the client's visit to the healthcare provider's office. Which of the following items should the nurse have available in the room in order to complete the examination?
1. Ruler (metric) 2. Stethoscope 3. Lamp 4. Client gown and a drape 5. Doppler
The nurse is examining a client with a history of benign breast disease (sometimes referred to as fibrocystic breast disease). The nurse would expect which of the following findings during this assessment?
1. Straw-colored discharge from the nipples 2. Freely movable masses 4. Thickened breast tissue 5. Masses with well defined boundaries
During the focused interview, the client provides information to the nurse regarding her daughter's recent diagnosis with cancer. The client is exhibiting clinical manifestations associated with anxiety. During the physical assessment, which of the following findings might be expected?
1. The client complains of pain when the tragus is gently manipulated. 2. The client has several small ulcers on her lip. 4. Small sores are noted within the mouth
The nurse is assessing the client's eyes during a comprehensive health assessment. Which of the following pieces of information should the nurse also gather?
1. The client is 62 years old. 2. The client's parents were born in Spain. 3. The client's annual income is below the poverty level. 4. The client is a welder. 5. The client recently attempted to commit suicide after his wife died in an automobile accident.
The nurse is assessing a client who is 34 weeks pregnant. Which of the following visual changes are usually normal in this stage in pregnancy and should disappear at some point after delivery?
1. The client is complaining that her eyes feel very dry. 2. She states that she is experiencing blurry vision. 5. She has been unable to wear her contact lenses.
The nurse is performing a focused interview and eye assessment on a client. The nurse suspects that the client is experiencing problems associated with her vision based on which of the following pieces of data?
1. The client is frowning and squinting while she is reading the Snellen chart. 1. The client is frowning and squinting while she is reading the Snellen chart.
The nurse is preparing an educational seminar about Healthy People 2020. The inclusion of which of the following topics in this presentation are unexpected and indicate that the nurse requires further education?
1. The parents of a newborn should be educated about the clinical manifestations associated with hyperthyroidism. 2. Thyroid disease more frequently affects males than females. 5. The iodine added to some medications can be linked to hypothyroidism in the clients who use these medications.
The student nurse is performing an assessment of the client's peripheral vascular system with the experienced nurse's guidance. Which of the following actions by the student nurse indicate that the student nurse requires further education?
1. The student nurse continues to assess the client while the client is in a flat, supine position. The client's respiratory rate increases to 26 breaths per minute and the client becomes dusky around the mouth and lips. 2. The student nurse requests that the client remove all undergarments prior to putting the gown. 3. The client left her socks on and the student nurse assesses the client's pedal pulses over the socks. 4. The client is wearing multiple rings and bracelets. The student nurse states that she may leave them on during the examination.
The nurse is performing a cardiac assessment on a healthy elderly adult client. Which of the following findings may be expected when compared to when the client was middle-aged?
1.Systolic murmur 3. Increased systolic blood pressure 4. Increased stroke volume 5. Slight decrease in heart rate
The nurse is examining a client who has been diagnosed with a fracture of one floating rib. Of the following ribs, which does the nurse suspect to be fractured?
12
While performing a focused interview with a healthy adult client, the nurse notes frequent position changes, wringing of hands, lack of eye contact, incomplete sentences, and rapid speech. The vital signs are BP 160/88, apical pulse 102 beats per minute, respiratory rate 26 per minute. Which of the following are appropriate responses by the nurse?
2. "Have you ever experienced chest pain?" 3. "Are you feeling any anxiety right now?" 4. "Are you experiencing any pain at this time?"
The nurse presented a program regarding objectives related to the overall health of eyes that are addressed in Healthy People 2020. Which of the following statements made by an adult participant in the program indicates an adequate understanding of these objectives?
2. "I'm going to call my eye doctor and ask that she performs a dilated eye exam."
The nurse is discharging an 11-month-old child who was brought to the emergency room for the treatment of an ear infection and fever. The nurse would include which of the following statements in the discharge teaching to the parents?
2. "It is important not to prop the baby's bottle during feeding." 5. "The last bottle of the evening should not be given just before the baby goes to sleep."
The client was recently diagnosed with venous insufficiency. Which of the following statements by the client are consistent with this diagnosis?
2. "My ankles and feet are always swollen." 5. "I have an ulcer on my inner leg above my ankle that just bleeds and bleeds."
The nurse is assessing the ears, nose and mouth of an Asian client with a student nurse. Which of the following statements made by the nurse to the student nurse about cultural differences is accurate?
2. "Sometimes in Asians and Native Americans, their ear wax looks dry and dark."
The nurse is performing the assessment of an elderly client recently diagnosed with arterial insufficiency due to atherosclerosis. Which of the following findings are consistent with this condition?
2. Carotid bruit present 3. Blood pressure 180/94 4. Peripheral pulses 1+/4+ in dorsalis pedis bilaterally 5. A pea-sized ulcer noted on the client's right great toe, no drainage, well-defined edges
The nurse is assessing several children in a pediatric clinic. Which of the following children might be experiencing delayed development?
2. The 26-month-old child has one baby tooth.
During a health assessment, a male client voices concern that he is at risk for breast cancer. The nurse is aware that further evaluation of the client's history should focus on predisposing factors that increase the chance for breast cancer in males. The interview should include questions related to which of the following factors?
2. The client's mother having a history of breast cancer 3. History of cirrhosis of the liver 5. History of radiation treatment for lung cancer
While the nurse is performing an assessment of a male client, gynecomastia is noted. The nurse is aware that this condition is most frequently associated with:
2. infants following birth. 3. the onset of puberty. 4. older males that have undergone hormonal treatment.
The nursing student is learning about the appropriate method to use when assessing a client's blood pressure. The student nurse asks the nursing instructor why it is necessary to palpate the systolic pressure prior to the procedure. Which of the following is the nursing instructor's best response?
3. "You are more likely to get an accurate reading when you do it this way."
The nurse is thoroughly assessing the client for any peripheral vascular problems. The client requested the nurse to state exactly what the nurse was looking for during the assessment. Which of the following statements by the nurse are unexpected?
3. I am going to perform the Trendelenburg's test to see how well the radial and ulnar arteries are supplying blood to your hand." 4. I am going to test your ability to feel sensations by giving you an injection." 5. "I am going to perform the Allen's test to see if you have any varicose veins."
The nurse is performing a focused interview with a client who has been cleaning the ears with a cotton-tipped applicator. The nurse should educate the client about which of the following complications that can occur as a result of this practice?
3. The client could perforate the tympanic membrane. The client's cerumen might become impacted.
The nurse is assessing a 20-year-old client and notes the presence of bilateral earlobe creases. The nurse would choose which of the following actions?
3.Document the finding and notify the healthcare provider. 4. Ask the client about any history of injuries to his ears. 5. Assess the client's risk factors for coronary artery disease
The nursing student is learning about blood pressure assessment and asks the instructor about blood pressure values. Which of the following responses is an accurate response?
4. "A client with stage II hypertension has a blood pressure that is greater than 160/100."
The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test was positive. As the nurse plans to meet the client's elimination needs, the nurse would implement which of the following interventions?
4. Obtain a bedside commode.
The nurse is assessing the client's respiratory system. Which of the following methods will result in the most accurate assessment of the client's respiratory rate?
4. The nurse should count the respirations in an unobtrusive manner without informing the client.
The nurse is preparing to examine several clients in the clinic setting. Which of the following clients would need the greatest degree of special consideration during a physical examination?
68-year old with chronic lung disease
The nurse taught the client how to self-administer eye drops and the client was performing a return demonstration. During this time, the client inadvertently touched the applicator to their cornea, which caused the client to blink and produce tears. The nurse may document this response as which of the following?
A normal response
The nurse is educating a prenatal class about lactation when one of the clients asks how milk is produced. The nurse would correctly identify which of the following structures as responsible for milk production?
Acini cells
The nurse is planning care for a client with hypothyroidism. Which of the following would be the priority nursing diagnosis for this client?
Activity intolerance related to fatigue
The nurse is assessing a client's eyes during a comprehensive health assessment. The nurse knows that the client who demonstrates clinical manifestations of which of the following conditions will require immediate intervention?
Acute Glaucoma
The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Based on this finding, the nurse would implement which of the following actions first?
Administer oxygen.
The nurse is preparing an educational program regarding the objectives listed in Healthy People 2020. Which of the following are specifically related to these objectives?
African American females often require information regarding gentle hair and scalp care. Infants have difficulty regulating their own body temperatures. Clients with diabetes mellitus have an increased risk for skin breakdown. Clients should monitor their moles for any changes, regardless of their age.
The nurse is preparing a teaching plan regarding thyroid function for the older adult. Which of the following would the nurse include in this teaching?
Annual monitoring of hormone levels
The nurse documents that the client's respirations are shallow and rapid. The client's respiratory rate is 30 per minute. From this finding, the nurse is concerned the client is:
Anxious.
While the client sleeps, the nurse notes that the client's respirations periodically stop. This finding would be documented as:
Apnea
The nurse is completing an assessment on a client following a cardiac catheterization procedure. During the initial assessment, the nurse easily palpates the client's right dorsalis pedis and posterior tibial pulses. The pulses on the client's left leg are strong and easily palpable. During the next assessment, the nurse is unable to palpate or find these pulses on the right side with a Doppler. Which of the following would be the most appropriate action for the nurse at this time?
Assess for the client's right popliteal pulse.
The nurse is conducting an assessment of a client with right lower quadrant abdominal pain. Which of the following should the nurse do when palpating the abdomen of this client
Assess the painful area last using deep palpation
A client is brought to the emergency department by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which of the following findings would indicate, to the nurse, the need for a more detailed neurological assessment of this client?
Asymmetry of the client's smile
While palpating respiratory expansion on a client in the emergency room the nurse notes movement on only one side of the chest. Which of the following conditions may produce this finding?
Atlectasis Lobar Pneumonia Pleural effusion
The nurse is performing an abdominal assessment and has just completed inspection. Which of the following techniques would the nurse correctly choose to use next in this assessment?
Auscultation
The nurse is using an ophthalmoscope to assess the optic disc in a client. The nurse would suspect hemorrhage of the optic disc is present when which of the following colors is visualized through the red-free filter of the ophthalmoscope?
Black
The nurse is conducting a wellness presentation for a group of factory employees and notes a large number of African Americans present. Based on information included in Healthy People 2020, the nurse would choose which of the following topics as a priority for this setting?
Blood pressure screening
The nurse working in a predominately Hispanic community outlines a breast health screening. The nurse is aware that:
Breast cancer is the leading cause of cancer death in Hispanic women.
The nurse is performing a breast examination and is palpating into the tail of Spence. The nurse understands that this is necessary for which of the following reasons?
Breast cancer occurs more frequently in this area.
While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. What is the nurse's next step?
Bring in another examiner to assess the finding
The nurse is auscultating the temporal artery and hears a soft blowing sound. How would the nurse correctly document this finding?
Bruit
The nurse is performing a skin assessment on a client and notes an oval-shaped, elevated, fluid-filled mass that is approximately 1.5 centimeter in size. The nurse would correctly document this finding as which of the following?
Bulla
The nurse is using a Doppler ultrasonic stethoscope to assess a client's pulse in the lower extremity and is unable to locate the pulse. What is the nurse's next action?
Check the pressure applied to the probe
The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea. Which of the following terms would the nurse use to document this finding?
Cheyne-Stokes
The nurse is preparing to assess the client's respiratory system. Rank in order according to how the nurse should proceed.
Client Survey Inspection Palpation Percussion Ausculation
The client is visiting the healthcare provider's office for a head-to-toe assessment. During the nurse's assessment of the client's skin, the nurse notes that the client is pale. Which of the following findings may be related to the client's color?
Client's blood pressure is 96/62 The client states, "I just smoked a cigarette before I came in the office." The client's oxygen saturation level is 86% on room air, The client states"It is snowing again outside with a wind chill factor of -11 degrees Fahrenheit.
While auscultating a client's lungs, the nurse identifies more than one sound. Which of the following should the nurse do?
Close the eyes and focus on one sound at a time.
During a focused assessment and interview regarding the client's head and neck, the client states that she is currently suffering from a severe headache that has occurred intermittently over the course of 3 days. The client denies any aura. The pain is severe and unilateral over the right side of her face. Also, the client is complaining of nasal congestion. Which of the following is the most likely diagnosis?
Cluster headache
The nurse is teaching a childbirth education class. The nurse would be correct in stating that which of the following commonly leaks from the nipples during the last month of pregnancy?
Colostrum
The client has developed anosmia. The healthcare provider educates the client about the possible causes. The nurse recognizes that which of the following would be an unexpected explanation for this condition?
Commonly associated with gingivitis
The pregnant female has entered her third trimester. The client has developed hypertension and has been diagnosed with preeclampsia. Which of the following would the nurse also expect to find during the assessment of this client?
Complaints of increasing headaches
During the breast examination on a client, the nurse palpates a small, subclavicular node on the right side of the client's chest. The priority action at this time is for the nurse is to do which of the following?
Continue with the exam.
The nurse is preparing to auscultate a client's lungs. Which of the following breath sounds would be considered abnormal?
Crackles Wheezes
The nurse is assessing the client's pupillary responses. The client is found to have no consensual response. The finding indicates which of the following to the nurse?
Cranial nerve III may not be functioning appropriately.
The nurse is assessing the function of the client's cranial nerves. The nurse finds that the client is unable to demonstrate the ability to chew. The nurse suspects that which of the following cranial nerves is not functioning properly?
Cranial nerve V
The client is experiencing the effects of a recent cerebrovascular accident. The client is unable to hear out of the left ear. Which of the following cranial nerves was most likely affected?
Cranial nerve VIII
The nurse is inspecting the fingernails of a client with a diagnosis of polycythemia. Which of the following findings would be expected with this diagnosis?
Dark red nails
A client has a visible pulsation in the middle of his abdomen. The assessment technique the nurse should use to assess this pulsation is:
Deep palpation
The nurse is assessing the 1-month-old infant's fontanels. The infant's fontanels are sunken. What may this indicate to the nurse?
Dehydration
The nurse is admitting a newly admitted client and notes skin vitiligo, which is highly visible even from a distance. The client asks the nurse to place a "No Visitors" sign on the door the patient's room. The client states, "I hate the way my skin looks. Some people just stare at me." Which of the following nursing diagnoses should be incorporated into the client's plan of care?
Disturbed body image
The nurse notes the pregnant client's blood pressure has dropped from 122/70 taken during her second month of pregnancy to 118/64 during her fifth month of pregnancy. Which of the following actions by the nurse is most appropriate?
Document the blood pressure as a normal finding .
The nurse is performing a peripheral vascular assessment of a female client who is 7 months pregnant. The nurse notes mild peripheral edema, all other findings were normal. Which of the following actions by the nurse would be appropriate?
Document the findings as expected due to the client's pregnancy.
The nurse is performing an assessment on a healthy 5 year old and palpates two enlarged lymph nodes on the child's neck. The lymph nodes are soft, mobile, nontender, and each is less than 1 cm in diameter. The nurse would choose which of the following actions in this situation?
Document this as a normal finding.
The nurse is assessing an adult client when suddenly the client refuses to continue the examination. What is the nurse's next step?
Document what was done and what was refused
The nursing instructor is observing a student nurse who is performing abdominal palpation on an adult client. In order to assess organs that lie deep within the abdominal cavity (e.g., kidneys, spleen), the student nurse should press on the client's abdomen using which of the following techniques?
Downward pressure of 2-4 cm using the palmar surface of the fingers
The nurse is performing the cover test and notes inward turning of the eye. Which of the following ways will the nurse accurately document this finding?
Esophoria
The nurse is caring for a teenager recently hospitalized with asthma. Several peers are preparing to visit the client and have brought gifts for the client. The nurse intervenes and prevents which of the following items from being brought into the patient's room?
Fresh flowers
The client visits the outpatient clinic. During the assessment of the client's skin, the nurse notes the presence of several abdominal lesions that appear in distinct clusters. The nurse would document these lesions in which of the following ways?
Grouped
The nurse is assessing a full-term African American newborn that is 18 hours old. The nurse would document which of the following as a normal finding?
Heart rate 115-120
The adult client is visiting the outpatient clinic. The client states, "I have sores in my mouth and on my lips." The nurse notes the presence of crusted lesions on the lips and inside the client's mouth along the cheek. The client states that the lesions do not itch. These findings are most consistent with the development of which of the following conditions?
Herpes simplex
The nurse is percussing the anterior chest of an elderly client. Which of the following would the nurse expect to find in this client?
Hyperresonance
The nurse is assessing a client admitted to the hospital for congestive heart failure and notes 1+ pitting edema of the left arm, as well as bilateral 1+ pitting edema in the client's ankles. The client's history indicates that the client has had a myocardial infarction and a left mastectomy. The nurse would suspect which of the following causes for the edema in the left arm?
Impaired lymphatic drainage
A client is demonstrating a diminished ability to exhale. The nurse realizes this client is at risk for developing:
Increased carbon dioxide levels.
The nurse is auscultating the thyroid gland and notes a bruit. Which of the following would the nurse associate with this finding?
Indicates increased blood flow.
The nurse is caring for a client with dark skin and needs to assess the skin for jaundice. Which of the following actions would be appropriate for the nurse in this situation?
Inspect the lips, oral mucosa, sclera, conjunctivae, and palms
The nurse uses the otoscope in the physical assessment of a client. The nurse understands that this instrument is used to:
Inspect the nose, Funnel light into the ear canal.
The nurse is preparing to assess the client's skin, hair, and nails. Which of the following techniques will the nurse use initially during this assessment?
Inspection
The nurse is planning to perform a breast examination of a female client. In preparing the client, the nurse will inform the client to expect which of the following techniques?
Inspection, Palpation, Client Interview
During the assessment of a client's eyes, the nurse suspects the client has entropian. Which of the following did the nurse most likely find while assessing this client?
Inversion of the lid and eyelashes
The nurse noted that the client was unable to control the amount of light that came into her eye. The dysfunction of which of the following structures is the most likely cause of this problem?
Iris
The nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in color. The nurse would correctly document this finding as which of the following?
Jaundice
The nurse is performing a skin assessment on an African American client and notes an elevated, irregular band of jagged tissue on the client's left arm. The client states, "I had a burn here a long time ago, but it seemed to keep on getting bigger." The nurse would correctly document this finding in which of the following ways?
Keloid
The client admits to cleaning his ears with a cotton-tipped applicator. As a consequence, the client has developed impacted cerumen and unilateral hearing loss. As the nurse prepares the client's plan of care, which of the following nursing diagnoses is most applicable?
Knowledge deficit
The nurse is performing a cardiac assessment on a 70-year-old client admitted with hypertension. The nurse determines that the apical impulse can be palpated in an area 2 cm in diameter at the point of maximal impulse. The nurse suspects that the client may have developed which of the following problems?
Left ventricular hypertrophy
The nurse is examining the eye. The client asks about the specific structures within the eye that are responsible for refraction of light rays. The nurse accurately states that the following structures are involved in this process:
Lens Cornea
A client has a reddened area on the left forearm. Which of the following assessment techniques should the nurse use to assess this area?
Light palpation
The nurse is assessing a client with complaints of sudden, intermittent headaches for the past several months. The client states that the headaches come after seeing flashes of lights and experiencing nausea. The nurse would suspect which of the following disorders?
Migraine headaches
The nurse is caring for a client admitted with a grade 3 heart murmur heard during systole. The nurse would suspect which of the following cardiac conditions?
Mitral regurgitation Aortic stenosis Pulmonic stenosis
The nurse is assessing the client's eye with an ophthalmoscope. The nurse is preparing to focus on the fundus and rotates the lens diopter wheel into the negative numbers. Based on this information, which of the following conditions does the client most likely have?
Myopia
The client is preparing to examine the client's head. Which of the following clients may prohibit the nurse from performing this portion of the exam?
Native American Indian
The nurse wants to assess the apex of a client's right lung. Which of the following locations should the nurse place the stethoscope to assess this area on the client?
Near the right clavicle
During the assessment of a client's respiratory system, the nurse determines that the client's expiration phase is the same length as the inspiration phase. The client's respiratory rate is 14 per minute. The nurse would document this finding as:
Normal
The nurse is caring for a client complaining of a painful, hot area located on the client's leg. Erythema and edema are present in the localized area. Which of the following actions should the nurse perform next?
Notify the healthcare provider.
The nurse is examining a 14-month-old child when the mother tells the nurse that the child cries frequently, has a fever, and is pulling at both ears. The nurse suspects the child has which of the following disorders from this assessment data?
Otitis media
The nurse is assessing a client's skin and notes that the color of the skin, nails, and the client's mucous membranes are very light. Which of the following descriptions would the nurse use when documenting this finding?
Pallor
The nurse is documenting about an ulcer on the lateral aspect of the client's right great toe. The nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding. To help determine information about the origin of the client's ulcer, which of the following pieces of the assessment will be most useful for the nurse?
Peripheral pulses
The nurse is caring for a client who has smoked for many years and documents that "clubbing is present." Which of the following techniques is the best way for the nurse to determine the presence of clubbing?
Place two of the same fingers from each hand together.
The nurse percusses the lungs and determines that there is an area of hyperresonance. This finding is consistent with which of the following conditions?
Pneumothorax
The nurse is assessing a client who is 7 months pregnant. The nurse would document which of the following cardiac findings as normal in this client?
Point of maximal impulse palpated at fourth intercostal space and left of midclavicular line
The emergency room triage nurse is assessing a child who has a history of a cough and nasal congestion for the last three days. When assessing patency of the nares, the nurse notes that the child is unable to breathe through the right nostril. The nurse would interpret these assessment findings as which of the following?
Produced by severe nasal inflammation or obstruction
The nurse is preparing to perform a complete health assessment on a client. Which of the following activities should the nurse perform just prior to this examination?
Provide an opportunity for the client to void, Wash hands in the presence of the client.
The nursing is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane. The nurse should perform which of the following steps to better visualize this structure?
Pull the pinna up and back, then reinsert the otoscope
The client is visiting the healthcare provider's office with complaints of discoloration of her hands. The client states, "My fingertips turn whitish and then later they get really red." The nurse is not surprised to learn from the healthcare provider that the client has which of the following disorders?
Raynaud's disease
The nurse is assessing the skin of a teenage male client and notes the presence of a musky odor. The client states that this is embarrassing for him and that he showers daily. Which of the following actions should the nurse take in this situation?
Reassure the teen that this is normal.
The nurse is assessing the tympanic membrane of a client and notes the presence of a bluish color. The nurse would suspect which of the following?
Recent head trauma
A client arrives in the emergency room with complaints of intermittent nosebleeds for the past two days. Which of the following assessments would be a priority for the nurse is this situation?
Request information from the client regarding increased propensity for bruising or bleeding. Obtain a blood pressure. Request information from the client to determine if there was any recent thin, watery drainage from the nose.
The nurse is assessing the client's nasal mucosa and notes the presence of a thin, watery discharge. The client complains of sneezing and nasal congestion. The nurse would suspect which of the following in this situation?
Rhinitis
The nurse is assessing the client. The nurse hears low-pitched, continuous respiratory sounds that have a snoring quality while auscultating the client's lungs. The nurse would correctly document these findings as which of the following?
Rhonchi
The Intensive Care Unit nurse is performing a cardiac assessment on a newly admitted 72-year-old client and notes the following findings: peripheral edema, jugular venous distention of 5 cm above the sternal angle when the client is at a 45 degree angle, and an enlarged liver. These findings are most consistent with which of the following disorders?
Right-sided heart failure
The client has an enlarged lymph node in front of his right ear. In which of the following ways should the nurse accurately document this finding?
Right-sided preauricular lymph node enlarged
A client presents in the healthcare provider's office with complaints of headache and malaise. The nurse assesses the client and finds that the client has severe pain when the sinuses are palpated. The nurse would suspect which of the following disorders?
Sinusitis
The nurse is assessing a client for hepatomegaly by percussing over the liver. The nurse would expect to hear which of the following sounds when percussing the liver?
Soft, high-pitched
The nurse is conducting a hearing assessment on an older adult client with impacted cerumen noted in the right ear canal. When performing the Weber test, the nurse would expect to learn which of the following?
Sound lateralized to the right ear.
During the respiratory assessment of a client the nurse wishes to locate the angle of Louis. This structure can be identified by using which of the following landmarks?
Sternum
The client was given several medications during a recent hospital admission. The client has come to the medical office with complaints of tinnitus and bilateral hearing loss. The nurse understands that which of the following medications are associated with hearing loss or tinnitus?
Streptomycin Aspirin Neomycin
The nurse is assessing a client and notes a loud, blowing sound over the right carotid artery. The nurse would suspect the client has developed which of the following disorders?
Stricture of the carotid
A female client is hospitalized with injury and tissue destruction of the left pectoralis major and serratus anterior muscles due to a motor vehicle accident. The nurse would include which of the following information during the discharge teaching?
Support bras
The nurse is using inspection to assess the breasts of a female client. Which of the following findings might the nurse obtain using this assessment technique?
Symmetry
The client has been brought via ambulance to the emergency room following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. What is the nurse's priority nursing action?
Test the drainage for glucose.
The client is complaining of pain in his temporomandibular joint. During the nurse's assessment of this client, which of the following pieces of information does the nurse expect to find?
The client has been under a great deal of stress due to a recent divorce The client has lost tooth enamel due to nighttime teeth grinding The client has developed severe tension headaches.
The nurse is completing a focused interview with assessment of the eye. Which of the following is most helpful to the nurse during the focused interview?
The client interacts easily with the nurse.
During an eye examination, the nurse requests that the client read letters located on the Snellen E chart. The client's vision is determined to be 20/200. Which of the following is true regarding these findings?
The client is legally blind. The client is myopic.
The nurse is assessing the client's temporomandibular joint. The client complains of chronic pain at this site. Which of the following may have occurred as a result of this condition?
The client is unable to chew well and has lost weight since the pain began. The client exhibits difficulty speaking clearly and enunciating words The client has developed torticollis.
During a focused interview of a client, the nurse learns about an open lesion on theclient's head that hasn't healed in several months. What might this indicate to the nurse?
The client may have a malignancy.
The nurse is performing an assessment of the client's skin when the nurse notes that the client has become pale and diaphoretic. The client's vital signs have remained stable since the beginning of the examination: blood pressure 138/76, heart rate is 88 beats per minute, and respiratory rate is 18 breaths per minute. Which of the following actions should the nurse take first?
The nurse asks the client, "Are you feeling anxious during this assessment?"
While percussing a client's lung area the nurse notes a flat tone. This tone would indicate:
The nurse is percussing over a bone
Which of the following findings is normal regarding assessment of the fontanels?
The nurse notes that the 2-week-old infant's fontanels are slightly pulsing.
The client was brought to the Emergency Department. The nurse administered a breathing treatment for the client earlier. The nurse is preparing the client for a procedure. The nurse notes that the client is breathing in a shallow manner and the client's hands are trembling. Which of the following actions will help decrease the client's level of anxiety?
The nurse should explain all procedures in a calm and reassuring voice.
The client presents with unilateral facial paralysis and the nurse suspects Bell's palsy. Which of the following statement by the nurse to the client may indicate that the nurse requires further education about Bell's palsy?
The onset of Bell's palsy is very slow and the effects can linger for several months."
The student nurse assessed the client's skin. The student nurse documented "+1 edema right lower leg." The experienced nurse expects to find which of the following based on the student nurse's documentation?
The presence of slight pitting, no obvious distortion
The nurse is assessing the eyes of an 82-year-old client. Which of the following findings are expected by the nurse based on the client's age?
The pupillary light reflex is slower bilaterally.
The nurse is teaching a group of health assistants about the stethoscope. Which of the following statements about the stethoscope will the nurse include in this teaching session?
The stethoscope works by blocking out environmental sounds, Short tubing provides the listener with the most accurate sounds, The binaurals should fit snugly in the ears
A senior nursing student is working in an elementary school with the school nurse. The student cares for a child who fell on the school playground and sustained multiple abrasions to the lower extremities. Which action by the nursing student would require immediate intervention by the school nurse?
The student nurse disposes of blood-soaked gauze in the office trash bin
The nurse is assessing the client's neck. Which of the following findings is abnormal?
The tracheal cartilage does not move when the client swallows.
The nurse notices that a client's pupils constrict when reading the consent form for medical treatment. This observation would lead the nurse to consider which of the following?
This is a normal response.
Which of the following information is true regarding the assessment of the thyroid or thyroid function in an infant or child?
To accurately assess thyroid function, the nurse should assess the child's growth and development in comparison to others in the child's age group.
The nurse is assessing an anxious-appearing client who is experiencing abdominal pain. The nurse should use which of the following techniques to put the client at ease when assessing the client's abdomen?
Touch each area lightly before applying deeper palpation
The nurse is assessing the client's head and neck. The nurse provides the client with a glass of water. Which of the following structures will the nurse most likely need to assess as the client drinks?
Trachea
The nurse is educating a group of teenagers in high school about the risks of chewing tobacco. The nurse would include information about which of the following signs of oral cancer?
Ulcerations on the lip or under the tongue
The nurse is taking the blood pressure of a client. The nurse obtains the blood pressure in both of the client's arms. The nurse determines that there is a difference of 15 mm Hg in the systolic readings between the arms and repeats the assessment with the same results. The nurse suspects which of the following may have occurred in this situation?
Unilateral arterial obstruction
A client with chronic bronchitis has been admitted to the hospital. The nurse inspects the client while assessing the client's respiratory system. Which of the following would be an expected finding?
Use of accessory muscles
While performing the assessment of the client's peripheral vascular system, the nurse notes that there was a rapid filling of superficial veins during the Trendelenburg test. These findings would be most consistent with which of the following disorders?
Valve incompetence
The nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.4 cm in size. The nurse would correctly document this finding as which of the following?
Vesicle
During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which of the following would be the best action for the nurse to take next?
Wet the chest hair before auscultating the chest
The nurse received a phone call from a mother who was discharged with her newborn several days ago. The mother completed the infant care teaching prior to discharge. The nurse would determine that the teaching had been effective if the mother reported which of the following?
Yellow skin and mucous membrane color
The nurse is palpating an adult client's neck and does not note any palpable lymph nodes. The nurse understands that this is:
a normal finding in adults.
The nurse is performing an assessment on a newborn and notes a thin, milky discharge from the infant's nipple. The nurse knows this is a:
common finding in newborns
The nurse is preparing to assess the thorax of an infant using the assessment technique of direct percussion. To correctly perform this assessment the nurse will use the:
fingertips of the dominant hand.
The nurse is preparing to percuss the lower lobes of a client's lungs. The percussion technique appropriate for this body area would be:
indirect percussion.
A 39-year-old client has been admitted to the hospital with complaints of increasing fatigue. The history is remarkable for rheumatic fever as a child. The nurse hears a diastolic murmur at the apex when the client is in the left lateral position. The murmur is described as a rumble without radiation. This description is most consistent with:
mitral stenosis.
The nurse is assessing a client and confirms the presence of galactorrhea. The nurse understands that this finding is:
suggestive of endocrine disorders.
