Quiz health assessment chapters 12, 24, and 25
A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis? A) Caucasian B) African American C) South Asian D) Native American
A) Caucasian
A nurse is preparing a program on osteoporosis for a local women's group. Which of the following should the nurse cite as a risk factor? A) Obesity B) Multiparity (multiple pregnancies) C) History of smoking D) African-American ethnicity
C) History of smoking
The nurse is preparing to palpate the anatomic snuffbox. At which location would the nurse palpate? A) At the anterior area of the sternoclavicular joint B) At the posterior temporomandibular joint C) At the olecranon process of the elbow D) At the back of the wrist and extended thumb
D) At the back of the wrist and extended thumb
When taking the Daily Spiritual Experiences Scale, a client says the word "God" in the scale is bothersome. Which response by the nurse would be most helpful in encouraging a client to complete the scale? A) "Substitute whatever word you prefer that would represent the divine or holy." B) "You can skip those questions and answer only those you are comfortable with." C) "Don't be concerned about the wording; just answer the best way you know how." D) "It is perfectly fine to leave out any question that contains the word 'God.'"
A) "Substitute whatever word you prefer that would represent the divine or holy."
A nurse recognizes the need to assess a client's spirituality after the client has been admitted from the emergency department to the medical unit. How should the nurse best initiate this assessment? A) "Would you describe yourself as being a religious or spiritual type of person?" B) "What is the belief system that you most closely adhere to?" C) "What church do you attend at Christmas and Easter?" D) "Do you consider yourself to be a moral person with beliefs about the supernatural?"
A) "Would you describe yourself as being a religious or spiritual type of person?"
A nurse interviews a pregnant client and learns that her beliefs around health care do not involve participation in comprehensive prenatal care. To which religious view would the client most likely adhere? A) Faith Assembly of Indiana B) Buddhist C) Christian Scientist D) Jehovah's Witness
A) Faith Assembly of Indiana
A nurse is planning a spiritual assessment of a client who is experiencing intractable losses in function as a result of disease. Which of the following principles should inform the nurse's assessment? A) Knowledge of the most common spiritual practices in the community is a priority. B) Reviewing all religious denominations before approaching a client is important. C) It is of little importance for a nurse to understand his or her own spirituality. D) Spirituality is a complex phenomenon that is not normally describable.
A) Knowledge of the most common spiritual practices in the community is a priority.
A nurse is having difficulty eliciting a patellar reflex during a client's neurological assessment. Which of the following would be most appropriate for the nurse to have the client do? A) Lock the fingers together and pull against each other. B) Clench the jaw tightly. C) Squeeze a thigh with the opposite hand. D) Stretch the arms over head.
A) Lock the fingers together and pull against each other.
When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. Which of the following would the nurse suspect? A) Meningitis B) Cervical strain C) Compression fracture D) Cervical disc degeneration
A) Meningitis
The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply. A) Risk for injury related to osteoporosis B) Risk for infection related to osteoporosis C) Activity intolerance related to osteoporosis D) Impaired physical mobility related to osteoporosis E) Disturbed sensory perception related to osteoporosis
A) Risk for injury related to osteoporosis C) Activity intolerance related to osteoporosis D) Impaired physical mobility related to osteoporosis
The nurse chooses to use a formal assessment technique when doing a client's spiritual assessment. Which of the following techniques would be most appropriate? A) Self-response assessment instrument B) Acronyms related to spirituality C) Open-ended questions D) A systematic guide for question choices
A) Self-response assessment instrument
The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment? A) The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. B) The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time. C) The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. D) The nurse will briefly touch the client, and the client will identify where the touch occurred.
A) The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.
The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of assessment? A) ìClench your teeth together tightly.î B) ìClose your left eye and look at me with your right.î C) ìLook straight at me while I shine this light in your eye.î D) ìOpen your mouth wide and say 'ah.'î
A) ìClench your teeth together tightly.î
When evaluating a client's risk for cerebrovascular accident, which client should the nurse identify as being at highest risk? A) A 42-year-old Caucasian female who smokes B) A 68-year-old African-American male with hypertension C) A 70-year-old Caucasian male who has one to two beers a day D) A 35-year-old African-American male who has sleep apnea
B) A 68-year-old African-American male with hypertension
A nurse practitioner refers clients for osteoporosis screening according to the latest U.S. Preventive Services Task Force (USPSTF) recommendations. According to these recommendations, what client should be screen for osteoporosis? A) A 71-year-old man who has type 2 diabetes B) A 69-year-old woman with no major risk factors for osteoporosis C) A 37-year-old woman who takes oral contraceptives D) A 49-year-old African-American woman who is obese
B) A 69-year-old woman with no major risk factors for osteoporosis
While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. Which of the following would the nurse include? A) Circumduction B) Flexion C) Abduction D) Internal rotation
B) Flexion
The nurse has placed her hands behind the client's head and flexed the client's neck forward as far as the client can tolerate. During the test, the client experiences leg pain and bends his knees. This assessment finding is suggestive of what health problem? A) Ischemic stroke B) Meningitis C) Bell's palsy D) Brain stem lesion
B) Meningitis
Inspection of a client's foot reveals an enlarged, painful, inflamed bursa (bunion) on the medial side of the foot. The nurse should make a referral for what health problem? A) Osteomalacia B) Hallux valgus C) Pes planus D) Gouty arthritis
B) Hallux valgus
During a client's spiritual assessment, the client explains that the ultimate purpose of her existence is to achieve a state that she describes as nirvana. The nurse should recognize that this client ascribes to what religion? A) Islam B) Hinduism C) Buddhism D) Judaism
B) Hinduism
A nurse is testing the range of motion of the thoracic and lumbar spine. Which of the following would the nurse document as an abnormal finding? A) Flexion of 80 degrees B) Lateral bending of 35 degrees C) Hyperextension of 15 degrees D) Rotation of 30 degrees
C) Hyperextension of 15 degrees
The nurse is obtaining the health history of a young adult client. During the interview, the client tells the nurse, ìI banged my head pretty good when I was snowboarding last weekend.î The client states that he did not subsequently seek care. What is the nurse's most appropriate action? A) Promptly assess the client's balance and coordination. B) Teach the client about the warning signs of increased intracranial pressure. C) Refer the client for medical assessment and possible treatment. D) Teach the client about the importance of wearing head protection during sports.
C) Refer the client for medical assessment and possible treatment.
During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would interpret this finding as suggestive of which of the following? A) Spastic hemiparesis B) Parkinsonian gait C) Scissors gait D) Cerebellar ataxia
D) Cerebellar ataxia
The nurse is preparing a client for cancer chemotherapy treatment. While talking with the nurse, the client says, "Miracles do happen, and I'm praying for one." The nurse interprets this statement as suggesting which religious preference? A) Judaism B) Buddhism C) Islam D) Christianity
D) Christianity
A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment? A) Vital signs B) Respiratory status C) Cardiac function D) Coordination
D) Coordination
A nurse is preparing to assess a client's cerebellar function. Which of the following aspects of neurological function should the nurse address? A) Remote memory B) Sensation C) Judgment D) Balance
D. Balance
The nurse has positioned a client supine and asked her to perform the heel-to-shin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain? A) Balance and coordination B) Light touch sensation C) Deep tendon reflexes D) Leg strength
A) Balance and coordination
During the health history, a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve? A) CN I B) CN II C) CN VII D) CN IX
A) CN I
During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. Which of the following would the nurse suspect? A) Gouty arthritis B) Rheumatoid arthritis C) Degenerative joint disease D) Plantar fasciitis
A) Gouty arthritis
A nurse is preparing an in-service program about spirituality and religion for a group of colleagues. When describing the effects on clients of religion and spirituality, which of the following should the nurse include? Select all that apply. A) Improved client sense of well-being B) Enhanced coping with end-of-life issues C) Increased mortality levels D) Increased timely use of health care E) Increased adherence to medical regimens
A) Improved client sense of well-being B) Enhanced coping with end-of-life issues E) Increased adherence to medical regimens
A nurse assesses a client's spirituality and religious practices. During the assessment, the nurse notes that the client is very quiet and rarely asks any questions of the health care workers. The nurse recognizes that this behavior may be associated with which religion? A) Islam B) Buddhism C) Hinduism D) Christianity
A) Islam
A nurse is working with a client who has received a terminal diagnosis. To help the nurse identify the client's possible coping responses, which of the following would be most important for the nurse to understand about spirituality? A) It varies in different situations. B) It increases in significance with illness. C) It decreases in importance with age. D) It remains static throughout the lifespan.
A) It varies in different situations.
The nurse is caring for the family of a client who has just died. The family requests that the client's arms not be crossed and that any of the clothing and dressings containing blood be left and be prepared for burial with the client. The nurse understands this family's request as indicative of what religious beliefs? A) Judaism B) Buddhism C) Hinduism D) Christianity
A) Judaism
Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A) Numbness B) Atrophy of the thenar prominence C) No tingling D) Hard, painless Bouchard nodes
A) Numbness
A nurse is admitting a client to a long-term care facility. In order to elicit reliable and valid data during the spiritual assessment, the nurse understands that the focus must be on which of the following? A) Objectivity when performing the assessment B) Sharing a common religious affiliation with the client C) Repeating the assessment in several weeks D) Providing spiritual interventions prior to assessment
A) Objectivity when performing the assessment
When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Select all the sensations that are carried by this tract. A) Pain B) Temperature C) Position D) Vibration E) Light touch
A) Pain B) Temperature E) Light touch
Assessment reveals that an older adult client has osteomalacia. Which of the following would be most important to include in the client's teaching plan? A) Practice risk prevention for fractures. B) Keep exercise to a minimum to decrease pain. C) Minimize movements to maintain joint stability. D) Treat secondary arthritis proactively.
A) Practice risk prevention for fractures.
The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed, constricted pupils bilaterally. The nurse should consider what possible cause for this assessment finding? A) Recent narcotic use B) Hemorrhagic stroke C) Recent seizure activity D) Cerebellar lesion
A) Recent narcotic use
The nurse's assessment of a hospital client's spirituality reveals that the client will accept very few of the standard treatments for her health problems. How should the nurse follow up this assessment finding? A) Report the finding to the appropriate supervisors. B) Prioritize complementary interventions in the client's care. C) Consult the client's clergy to weigh options. D) Document the client's nonadherence to treatment.
A) Report the finding to the appropriate supervisors.
An adult client has asked the nurse about actions that she can take to reduce her future risk of stroke. What health promotion activity should the nurse prioritize? A) Smoking cessation B) Annual MRI screening C) Nutritional supplementation D) Improved coping skills
A) Smoking cessation
A nurse is preparing to begin work in a diverse, urban community with members of numerous different religious traditions. The nurse should identify which statement as best reflective of Buddhism? A) Some holy days include fasting from dawn to dusk. B) The soul has no beginning or end. C) Outcomes are predetermined. D) Beliefs focus around the Koran.
A) Some holy days include fasting from dawn to dusk.
Which test would be most appropriate for the nurse to perform when a client complains of low back pain? A) Straight leg test B) Muscle leg strength C) Lateral bending of cervical spine D) Internal rotation of the shoulders
A) Straight leg test
A nurse should conduct an assessment of a client's Risk for Complications after gathering data related to the client's spirituality. When planning the client's care, the nurse should be aware that complications are primarily due to the effect of spirituality on what phenomenon? A) Stress B) Pain C) Worry D) Emotional lability
A) Stress
The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test? A) The client moves her feet apart to prevent herself from falling. B) The client is unable to consistently touch her finger to her nose while her eyes are close. C) The client experiences pain during neck flexion and extension. D) The client experiences pain when clenching her teeth.
A) The client moves her feet apart to prevent herself from falling.
The nurse is performing the bulge test during the assessment of a client's knee. This test will allow the nurse to make what determination? A) Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation B) Whether the size of the client's knee changes throughout the joint's range of motion C) Whether swelling in the knee joint is a normal age-related change or a pathological finding D) Whether the client's knee joint is capable of adduction and abduction
A) Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation
When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding? A) Stationary soft palate on phonation B) Deviation of uvula when client says ìahî C) Asymmetrical soft palate D) Uvula and soft palate rising bilaterally
D) Uvula and soft palate rising bilaterally
After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following? A) Compact bone B) Red marrow C) Yellow marrow D) Spongy bone
B) Red marrow
When asked to touch her ear to her shoulder, a client reports pain. Which of the following should the nurse do next? A) Perform muscle strength against resistance. B) Refer the client for further evaluation. C) Flex and then hyperextend the neck. D) Palpate the paravertebral muscles for pain
B) Refer the client for further evaluation.
The nurse has had a client place the backs of both her hands against each other while flexing her wrists 90 degrees with fingers pointed downward and wrists dangling. The presence of pain or tingling during this test suggests what health problem to the nurse? A) Osteoarthritis B) Diabetic neuropathy C) Carpal tunnel syndrome D) Gouty arthritis
C) Carpal tunnel syndrome
A group of students is reviewing material related to the role of religion and spirituality in health care choices. The students demonstrate understanding when they identify which of the following situations as the most prominent ethical dilemma that involves religion? A) Providing life-saving therapy B) Failure to seek timely medical care C) Implementing spiritual care D) Treating clients' psychological needs
B) Failure to seek timely medical care
A client expresses frustration that the nurse is assessing his spirituality, stating, "I thought I was here to have my tumor removed, not to figure out what I believe or don't believe about God." How should the nurse best justify the need for a spiritual assessment? A) "It's important that we plan to make sure that we don't offend you." B) "Spirituality actually has a significant effect on your overall health." C) "We need to make plans in case there are unexpected outcomes of your surgery." D) "Your beliefs determine whether we will focus more on your body or on your spirit."
B) "Spirituality actually has a significant effect on your overall health."
A nurse is completing a comprehensive assessment of a client who has been referred to the clinic. Which of the following would be most appropriate for the nurse to ask when beginning to assess the client's spirituality? A) "What religion are you?" B) "What gives you hope or peace?" C) "Do you believe in God?" D) "Would you like to speak to a chaplain?"
B) "What gives you hope or peace?
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following should the nurse do? A) Use a Snellen chart to test visual acuity. B) Ask a client to identify scents. C) Test extraocular eye movements. D) Perform the Weber test.
B) Ask a client to identify scents.
When testing muscle strength, a client has difficulty moving her right arm against resistance. Which of the following should the nurse do next? A) Move the part passively through its range of motion. B) Ask the client to move the part against gravity. C) Inspect by touch for a palpable contraction of the muscle. D) Percuss the client's shoulder joint
B) Ask the client to move the part against gravity.
During the nursing history of a newly admitted client, the nurse is reviewing a client's current medication regimen. What medication category creates a risk for decreased bone density? A) Beta-adrenergic blockers B) Corticosteroids C) Nonsteroidal anti-inflammatories (NSAIDs) D) Calcium channel blockers
B) Corticosteroids
The nurse is conducting a focused musculoskeletal assessment of an older adult client. When analyzing assessment data, the nurse should be aware of what age-related physiological changes? Select all that apply A) Absence of knee flexion B) Decreased bone density C) Decreased joint flexibility D) Joint capsule calcification E) Reduced muscle strength
B) Decreased bone density C) Decreased joint flexibility D) Joint capsule calcification E) Reduced muscle strength
When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first? A) Check for evidence of fever and chills. B) Ensure there is no injury to the cervical spine. C) Position the client prone. D) Check for a Babinski reflex.
B) Ensure there is no injury to the cervical spine.
A client has presented with signs and symptoms that are suggestive of Bell's palsy. What assessment finding is most consistent with this diagnosis? A) Inability to detect sharp and dull stimuli B) Inability to wrinkle the forehead C) Closure of the affected eye from swelling D) Muscle spasm of the lower face on the affected side
B) Inability to wrinkle the forehead
A nurse is planning care that is grounded in the fact that clients are holistic beings. Which of the following lists of components constitute the view of clients as holistic beings? A) Physical identity, psychosocial identity, religious identity B) Mind, body, spirit C) Id, ego, superego D) Spiritual identity, egocentric nature, naïve identity
B) Mind, body, spirit
A nurse has collected extensive data relating to a client's spirituality. Which type of data would the nurse need to validate the information obtained during this assessment? A) Subjective data B) Objective data C) Informal data D) Formal data
B) Objective data
Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait? A) Scissors gait B) Parkinsonian gait C) Spastic hemiparesis D) Footdrop
B) Parkinsonian gait
The nurse is reviewing a client's spirituality using the SPIRIT Spiritual Assessment Tool. Which of the following would the nurse assess when addressing the letter "P"? A) Powers B) Personal spirituality C) Spiritual prognosis D) Prayer
B) Personal spirituality
A nurse is completing an admission assessment of an adult client, during which the client states, "I've never been a religious man, but I'm definitely spiritual." How should the nurse best understand an aspect of the relationship between spirituality and religion? A) Spirituality is an Eastern concept, whereas religion is associated with Western cultures. B) Religion consists of the spiritually focused rituals and practices of a group. C) Spirituality is the codification of principles that are based on religion. D) Religion is the state of spiritual certainty that results from cultural influences.
B) Religion consists of the spiritually focused rituals and practices of a group.
The nurse is conducting a focused neurological assessment of an 81-year-old client. When analyzing the assessment data, the nurse should be aware of what age-related neurological change? A) Impaired judgment B) Tremors accompanying intentional movements C) Loss of remote memory D) Loss of sensation in distal extremities
B) Tremors accompanying intentional movements
A nurse is testing a client's deep tendon reflex. The nurse taps the tendon above the olecranon process. The nurse is assessing which reflex? A) Brachioradialis B) Triceps C) Biceps D) Achilles
B) Triceps
The nurse assesses brisk reflexes in a client during a neurological assessment. The nurse should document this finding as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
C) 3+
Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? A) 2/5 B) 3/5 C) 4/5 D) 5/5
C) 4/5
Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. Which of the following would the nurse use to confirm the suspicion? A) Phalen's test B) Tinel's test C) Ballottement test D) Leg raising test
C) Ballottement test
When assessing a client's spirituality, the nurse has the client complete a Brief Religious Coping Questionnaire. When reviewing the completed questionnaire, the nurse identifies which of the following as indicating positive religious coping? A) Client feels stress is something from God that is to be endured. B) Client wonders if God has abandoned him or her. C) Client looks to God for support in a crisis. D) Client decides what to do without relying on God.
C) Client looks to God for support in a crisis.
Which of the following would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident? A) Inability to hear high-pitched sounds B) Loss of tactile sensation C) Difficulty speaking D) Blurred vision
C) Difficulty speaking
After teaching a group of students about the brain and spinal cord, the instructor determines that the students demonstrate the need for additional teaching when they identify which of the following as being controlled by the brain stem? A) Respiratory function B) Heart rate C) Equilibrium D) Reflex actions
C) Equilibrium
Which of the following would the nurse expect to find when examining a client with a herniated lumbar disc? A) Rounded thoracic convexity B) Lumbar lordosis C) Flattened lumbar curve D) Lateral curvature of the spine
C) Flattened lumbar curve
When assessing a client's deep tendon reflexes, which technique would be most appropriate for the nurse to use? A) Use the blunt end of the reflex hammer to strike a smaller area. B) Strike the area slowly and methodically. C) Hold the reflex hammer between the thumb and index finger. D) Percuss the area of the tendon to be struck for the reflex.
C) Hold the reflex hammer between the thumb and index finger.
While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion? A) Christianity B) Judaism C) Islam D) Hinduism
C) Islam
A client has suffered a suspected a rotator cuff tear. Which of the following would the nurse expect to find? A) Limitation of all shoulder motion B) Chronic pain C) Limited abduction D) Sharp catches of pain with movement
C) Limited abduction
Which of the following would be most appropriate when the nurse notes limitation in active range of motion of a client's right shoulder? A) Test muscle strength. B) Perform passive range of motion test. C) Measure range of motion with a goniometer. D) Ask the client which is the dominant side.
C) Measure range of motion with a goniometer.
Which of the following tests would be most appropriate for the nurse to use when assessing motor function of a client's trigeminal nerve? A) Ask client to differentiate sharp and dull sensations on the face. B) Have the client smile, frown, and wrinkle the forehead. C) Palpate temporal and masseter muscles while client clenches the teeth. D) Assess dilatation of the client's pupils with direct light.
C) Palpate temporal and masseter muscles while client clenches the teeth.
A client complains of headaches each morning that resolve after getting out of bed. Which of the following would be most appropriate for the nurse to do? A) Assess the client's level of consciousness. B) Assess the client's deep tendon reflexes. C) Refer the client for immediate medical follow-up. D) Refer the client for physical therapy and occupational therapy.
C) Refer the client for immediate medical follow-up.
A nurse's colleague states, "I think Mrs. Nguyen in room 412 is a Buddhist, so she'll definitely be a vegetarian." The nurse should understand what principle of religion and spirituality when planning clients' care? A) Decisions around a religious client's care should be deferred to the clergy of that religion. B) Clients who claim to be spiritual generally oppose meat consumption. C) The beliefs of members of a particular religion are not necessarily homogeneous. D) Nurses should avoid planning care on the basis of religion.
C) The beliefs of members of a particular religion are not necessarily homogeneous.
The nurse is assessing a client's spiritual history using the SPIRIT acronym. The nurse should begin the assessment by identifying what aspect of spirituality? A) The client's religious affiliation B) The client's state of health C) The client's sources of hope D) The client's spiritual belief system
C) The client's sources of hope
A nurse recognizes the need to perform a spiritual assessment of a newly admitted hospital client, but the circumstances surrounding the client's diagnosis and family dynamics make this challenging. What variable is likely to have the greatest impact on enhancing the quality of data from the nurse's spiritual assessment? A) The nature of the nurse's spiritual beliefs B) The nurse's knowledge of major religions C) The quality of rapport between the nurse and the client D) The setting in which the assessment is performed
C) The quality of rapport between the nurse and the client
The nurse is assessing a 39-year-old woman who has a 20 pack-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the woman's risk of stroke? A) Acetaminophen B) A beta-adrenergic blocker C) ASA D) An oral contraceptive
D) An oral contraceptive
The nurse is assessing the eyes of a client who has a lesion of the sympathetic nervous system. What assessment finding should the nurse anticipate? A) Bilateral dilated pupils B) Nystagmus (involuntary eye movement) C) Argyll-Robertson pupils The nurse is assessing the eyes of a client who has a lesion of the sympathetic nervous system. What assessment finding should the nurse anticipate? A) Bilateral dilated pupils B) Nystagmus (involuntary eye movement) C) Argyll-Robertson pupils D) Constricted pupils, unresponsive to light
D) Constricted pupils, unresponsive to light
The nurse is assessing an adolescent client and notes 45-degree flexion of the cervical spine. What is the nurse's most appropriate action? A) Facilitate a referral for medical follow up. B) Palpate the spinous processes. C) Perform the LasËgue test. D) Continue the exam because this curve is normal.
D) Continue the exam because this curve is normal.
A client complains of temporomandibular joint (TMJ) pain. Which of the following would the nurse most likely assess? A) Joint dislocation B) History of fracture C) History of dental abscess D) Difficulty chewing
D) Difficulty chewing
A nurse asks a client to bring his hands together behind his head with his elbows flexed. The nurse is testing which of the following? A) Abduction B) Adduction C) Internal rotation D) External rotation
D) External rotation
A client tells the nurse that the intravenous line must be placed in his right hand. Based on the nurse's understanding of the major religions, the nurse identifies this request as reflecting which of the following? A) Judaism B) Christianity C) Islam D) Hinduism
D) Hinduism
After teaching a group of students about spirituality and religion, the instructor determines that the students need additional teaching when a student states which of the following? A) Spirituality and religion are important factors that can affect health decisions and outcomes. B) Religion and spirituality are separate and distinct, but interrelated concepts. C) There has been a tremendous growth in the understanding of spirituality in the past 20 years. D) Nursing has only recently begun to incorporate spirituality into client care.
D) Nursing has only recently begun to incorporate spirituality into client care.
A client describes herself as "dumbfounded" that she has been diagnosed with cancer, stating, "I had such a clear vision from God that I was negative for cancer. Now I have no idea what I can trust." This client's statement is suggestive of what nursing diagnosis? A) Ineffective role performance B) Complicated grieving C) Social isolation D) Spiritual distress
D) Spiritual distress
The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment? A) The client takes medications to treat hypertension. B) The client suffered a fractured humerus 1 year earlier. C) The client has a diagnosis of type 1 diabetes. D) The client had a total hip replacement 2 years ago.
D) The client had a total hip replacement 2 years ago.
The nurse is performing an assessment of a client's musculoskeletal system. The nurse should begin the assessment by examining which of the following? A) The client's leg length B) The client's lateral bending ability C) The client's cervical ROM D) The client's gait
D) The client's gait