assessment exam 2 practice questions

The nurse is preparing to assess the cardiovascular system of an adult client with emphysema. It may be difficult to hear the client's a. apical pulse b. breath sounds c. jugular veins d. carotid arteries

a. apical pulse

The nurse is planning to auscultate a female adult client's carotid arteries. The nurse should plan to a. ask the client to hold her breath b. palpate the arteries before auscultation c. place the diaphragm of the stethoscope over the artery d. ask the client to breathe normally

a. ask the client to hold her breath

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates a. diabetic ketoacidosis b. central nervous system injury c. drug overdosed. d. CHF

a. diabetic ketoacidosis

The lymph nodes that are responsible for drainage from the arms are the a. lateral lymph nodes b. central lymph nodes c. anterior lymph nodes d. posterior lymph nodes

a. lateral lymph nodes

The nurse detects paradoxical pulses in an adult client during an examination. The nurse should explain to the client that parodical pulses are usually indicative of... a. obstructive lung disease b. left sided heart failure c. premature ventricular contractions d. aortic stenosis

a. obstructive lung disease

While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible a. pneumonia b. pleuritis c. brochitis d. asthma

a. pneumonia

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to a. repeat the phrase "ninety-nine" b. repeat the letter "E" c. whisper the phrase "one-two-three" d. repeat the letter "A"

a. repeat the phrase "ninety-nine"

area of auscultation located at second ICS and right sternal border

aortic

assessment technique most often associated with evaluation of the cardiovascular system

auscultation

An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her right arm. The nurse should refer the client to a physician for possible a. congestive heart failure b. angina c. palpations d. acute anxiety reaction

b. angina

The P-wave phase of an ECG represents a. conduction of the impulse throughout the ventricles b. conduction of the impulse throughout the atria c. ventricular repolarization d. ventricular polarization

b. conduction of the impulse throughout the atria

the transmission of sound waves through the external ear and the middle ear is known as a. perceptive hearing b. conductive hearing c. external hearing d. connective hearing

b. conductive hearing

The nurse is assessing an adult male client when the nurse observes gynecomastia in the client. The nurse should ask the client if he is taking any medications for liver disorder a. inflammation b. liver disorder c. infection d. ulcers

b. liver disorder

The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the... a. second intercostal space at the right sternal border b. third to fifth intercostal space at the left sternal border c. apex of the heart near the midclavicular line d. fourth or fifth intercostal space at the left lower sternal border

b. third to fifth intercostal space at the left sternal border

the spinous process termed the vertebra prominens is in which cervical vertebra a. 5th b. 6th c. 7th d. 8th

c. 7th

During breast assessment, the nurse should consider the client's culture because a. breast cancer has a low mortality rate in canada b. canadian women have higher risk factors for breast cancer than other cultures c. African American women may not engage in breast cancer screenings d. african american women should begin screening at an earlier age

c. African American women may not engage in breast cancer screenings

a female client tells the nurse that her breasts become lumpy and sore before menstruation but get better at the end of the menstruation cycle. The nurse should explain to the client that these symptoms are often associated with a. malignant tumors b. fibroadenoma c. fibrocystic breasts d. increased estrogen production

c. fibrocystic breasts

after assessing the breasts of a female client, the nurse should explain to the client that most breast tumor occur in the ____. a. upper inner quadrant b. lower inner quadrant c. upper outer quadrant d. lower outer quadrant

c. upper outer quadrant

ear wax

cerumen

While assessing an adult client, the nurse observes decreased chest expansion at the bases of the client's lungs. The nurse should refer the client to a physician for possible a. atelectasis b. pneumonia c. chest trauma d. COPD

d. COPD

elevated sebaceous glands, known as montgomery glands, are located in the breasts a. areolas b. hair follicles c. lactiferous ducts d. areolas

d. areolas

The nurse is planning to percuss the chest of an adult male client for diaphramagtic excursion. The nurse should begin the assessment by a. asking the client to take a deep breath and hold it b. percussing upward from the base of the lungs c. percussing downward until the tone changes to resonance d. asking the client to exhale forcefully and hold his breath

d. asking the client to exhale forcefully and hold his breath

The nurse is working with a community group to set up teaching programs to increase awareness among African American women about preventive screening techniques for breast cancer. in the teaching program, the nurse should plan to include a. local female physicians who work with cancer patients b. hospital clinic workers from various racial backgrounds c. nurses who work in outpatient centers d. breast cancer patients of the same race

d. breast cancer patients of the same race

The nurse is planning a presentation about coronary heart disease for a group of middle-aged adults. What should be in the teaching plan? a. hispanic clients have a higher incidence of CHD than block or white americans b. the incidence of hypertension in the white population of the United States is greater than in the black population c. women are more likely to have serious stenosis after a heart attack d. lowering elevated cholesterol and BP decreases the risk of heart attack

d. lowering elevated cholesterol and BP decreases the risk of heart attack

The sinoatrial node of the heart is located on the a. anterior wall of the left atrium b. anterior wall of the right atrium c. upper intraventricular system d. posterior wall of the right atrium

d. posterior wall of the right atrium

The anterior chest area that overlies the heart and great vessels is called the a. endocardium b. epicardium c. myocardium d. precordium

d. precordium

The nurse has assessed the heart sounds of an adolescent client and detects the presence of an S3 heart sound as the beginning of the diastolic pressure. The nurse should... a. be referred to a cardiologist for further evaluation b. be examined again in 6 months c. restrict exercise and strenuous activities d. recognize that this finding is normal in adolescents

d. recognize that this finding is normal in adolescents

While auscultating an adult client's heart rate and rhythm, the nurse detects an irregular pattern. The nurse should.. a. assess the client for signs and symptoms of pulmonary disease b. document this as a normal finding c. schedule the client for an ECG d. refer the client to a physician

d. refer the client to a physician

The nurse plans to instruct an adult female client with regular menstrual cycles, who is not taking oral contraceptives, about breast self-examination. The nurse should plan to instruct the client to perform breast self-examination a. during menstruation b. on the same day every month c. midway between the cycles d. right after menstruation

d. right after menstruation

the roof of the oral cavity of the mouth is formed by the anterior hard palate and the a. teeth b. gums c. muscles d. soft palate

d. soft palate

erythematous scaling lesion of the breast, involving the nipple and areola unilaterally, and associated with an underlying malignancy

paget disease

common site of nasal bleeding

Kiesselbach area

lymphatic obstruction, causing edema, which thickens the skin, exaggerates the hair follicles, and gives the breast an orange peel or pigskin look

Peau d'orange

high-pitched musical sounds

Wheezes (sibilant)

the middle layer of the eye is known as the a. choroid layer b. scleral layer c. retinal layer d. optic layer

a. choroid layer

while assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. the nurse should document the clients a. estropia b. strabismus c. phoria d. exotropia

a. estropia

in the hearing pathway, hair cells of the spiral organ of cortisones are stimulated by movement of a. fluid b. sound c. air d. bone

a. fluid

an adult client tells her nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. the nurse should refer the client for evaluation of possible a. glaucoma b. increased inter cranial pressure c. bacterial infection d. migraine headaches

a. glaucoma

An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. One risk factor of coronary heart is a. high serum level of low-density lipoproteins b. low carbohydrate diets c. high serum level of high density lipoproteins d. diets that are high in antioxidant vitamins

a. high serum level of low-density lipoproteins

The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to a. position the handle of the otoscope to one side b. tip the client's head as far back as possible c. direct the otoscope tip quickly back and down the nostril d. position the handle of the otoscope straight and up

a. position the handle of the otoscope to one side

At puberty, the female breasts enlarge in response to estrogen and _________. a. progesterone b. aldosterone c. lactogen d. prolactin

a. progesterone

a nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. the nurse should a. refer the client for further evaluation b. document the presence of herpes simplex c. ask the client if his gums bleed d. document the presence of a canker sore

a. refer the client for further evaluation

Promotes the strongest stimulus to breathe

an increase in carbon dioxide in the blood

Darkly pigmented area surrounding the nipple of the mammary gland

areola

groups of lymph nodes located under the arm (the axilla)

axillary lymph nodes

the tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the a. mandible b. frenulum c. gums d. soft palate

b. frenulum

The functional part of the breast that allows for milk production consists of tissue termed a. fibrous b. glandular c. adipose d. lactiferous

b. glandular

The nurse observes dimpling in an adult female client's breasts. The nurse should explain to the client that dimpling of the breast may indicate a a. fibroadenoma b. tumor c. genetic deviation d. fibrocystic breast

b. tumor

The nurse is preparing to examine the breasts of a female client who had a left radical mastectomy 3 years ago. When examining the client, the nurse observes redness at the scar area. The nurse should explain to the client that this may be indicative of a. additional tumors b. poor lymphatic drainage c. an infectious process d. metastasis to the right breast

c. an infectious process

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should a. place the bell of the scope firmly on the posterior chest wall b. auscultate from the base of the lungs to the apices c. ask the client to breathe deeply from her mouth d. ask the client to breathe normally through her nose

c. ask the client to breathe deeply from her mouth

While assessing an older adult client, the nurse detects a bruit over the carotid artery. A bruit is... a. a normal sound heard in adult clients b. a wheezing sound c. associated with occlusive arterial disease d. heard when the after is almost totally occluded

c. associated with occlusive arterial disease

The semilunar valves are located a. between the left atrium and the left ventricle b. between the right atrium and the right ventricle c. at the exit of each ventricle at the beginning of the great vessels d. posterior wall of the right atrium

c. at the exit of each ventricle at the beginning of the great vessels

the submandibular glands open under the tongue through openings called a. parasinal ducts b. stenson ducts c. wharton ducts d. lacrimonasal ducts

c. wharton ducts

cracking at the corner of the lips seen in riboflavin deficiency

cheilosis

transmission of sound waves through the external and middle ear

conductive hearing

fibrous glands extending vertically from the breast surface to attach on the chest wall muscle

cooper ligaments

low-pitched, bubbling, moist sounds

crackles (coarse)

high-pitched, short, popping sounds

crackles (fine)

a crackling sensation

crepitus

The nurse assesses an adult client breath sounds and hears sonorous wheezes, primarily during the client's expiration. The nurse should refer the client to a physician for a possible a. asthma b. chronic emphysema c. pleuritis d. bronchitis

d. bronchitis

The S4 heart sound can be heard a. can be heard during systole b. is often termed ventricular gallop c. is usually due to a heart murmur d. can be heard during diastole

d. can be heard during diastole

the chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and a. transmit light rays b. maintain the retinal vessels c. change refractory of the lens d. cleanse the cornea and the lens

d. cleanse the cornea and the lens

the nurse is caring for an adult female client when the client tells the nurse that she has had a clear discharge from her nipples for the past month. The nurse should ask the client if she has been taking a. antidepressants b. antibiotics c. insulin d. contraceptives

d. contraceptives

fibrous tissue that provides support for the glandular tissue of the breast is termed a. lateral ligaments b. wharton ligaments c. pectoral ligaments d. cooper ligaments

d. cooper ligaments

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should a. refer the client for further evaluation b. examine the client for other signs of glaucoma c. ask the client if there is a genetic history of blindness d. document the findings in the clients records

d. document the findings in the clients records

an adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. the nurse should explain to the client that sudden changes in vision are often associated with a. diabetes b. the aging process c. hypertension d. head trauma

d. head trauma

the strongest stimulus to breathe, under normal circumstances a. hypoxemia b. hypocapnia c. pH changes d. hypercapnia

d. hypercapnia

a client tells the nurse that she has difficulty seeing while driving at night. the nurse should explain to the client that nightblindness is often associated with a. retinal deterioration b. head trauma c. migraine headaches d. vitamin a deficiency

d. vitamin a deficiency

The rich blood supply of the nose serves to a. help propel moist air to the body b. propel debris to the throat c. filter large particles from the air d. warm the inspired air

d. warm the inspired air

enlargement of one or both male breasts, seen more frequently in adolescent boys and elderly men

gynecomastia

method for assessing the internal nose

inspection using otoscope with short wide tip attachment

Ducts conveying the milk secreted by the lobes of the breast to and through the nipples

lactiferous ducts

reservoirs for storing milk, located behind the nipple

lactiferous sinus

responsible for drainage from arms

lateral lymph nodes

normal variation that occurs in the crease between the upper and lower lip

lip pits

Specialized gland of the skin of females, which secrets milk for nourishment of the young

mammary gland

roentgenography of the breast to detect any underlying mass

mammography

surgical removal of breast tissue

mastectomy

inflammation of the breast

mastitis

pigmented projection at the tip of each breast, which allows passage of milk from the breast

nipple

the optic nerves from each eyeball cross at the a. optic chiasm b. virtuous humor c. optic disc d. visual cortex

optic chiasm

difficulty breathing when lying supine

orthopnea

earache

otalgia

drainage from the ear

otorrhea

forward protrusion of the sternum

pectus carinatum

markedly sunken sternum and adjacent cartilages

pectus excavatum

transmission of sound waves in the inner ear

perceptive or sensorineural hearing

Low-pitched, dry, grating sounds

pleural friction rub

gradual hearing loss

presbycusis

method used to palpate frontal sinuses

press up on brow on each side of nose

method used to palpate maxillary sinuses

press up with thumbs on sinuses

area of auscultation located at second ICS and left sternal border

pulmonic

most common site of tongue cancer

side of tongue

significance of a red glow with transillumination

sinus filled with air

absence of a red glow with transillumination

sinus filled with fluid or pus

audible variation between closure of two valves

splitting

openings found on buccal mucosa across from second upper molars

stenson ducts

infection of the ear canal

swimmers ear

event of the heart when contraction of the ventricles forces blood into major vessels

systole

cone-shaped breast tissue that projects up into the axillae

tail of spence

palpable murmur described as feeling like the throat of a purring cat

thrill

grade 3 tonsils

touch the uvula

method used to test for fluid in the sinuses

transillumination

base of malleus but also serves as a center point landmark

umbo

true spinning motion

vertigo

openings found on either side of the frenulum of the floor of the mouth

wharton ducts

low-pitched snoring or moaning sounds

wheezes (sonorous)

Straight movements of the eye are controlled by the A. lacrimal muscles. B. oblique muscles. C. corneal muscles. D. rectus muscles.

D. rectus muscles.

while assessing the ears of an adult client, the nurse observes that the tympanic membrane is completely immobile. the nurse should further assess the client for signs and symptoms of a. infection b. skull injury c. vestibular disorders d. healed perforations

a. infection

the functional reflex that allows the eyes to focus on near objects is termed a. pupillary reflex b. accommodation c. refraction d. indirect reflex

b. accommodation

photoreceptors of the eye are located in the eyes a. ciliary body b. lens c. retina d. pupil

c. retina

while assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the clients a. eyelid reflexes b. refractory mechanism c. lacrimal reflexes d. corneal reflexes

d. corneal reflexes

transmission of sound waves in the inner ear is known as a. conductive hearing b. tympanic hearing c. neuromotor hearing d. perceptive hearing

d. perceptive hearing

ringing in the ears

tinnitus

The nurse is assessing a client who has been taking antibiotics for an infection for 10 days. The nurse observes whitish curd-like patches in the client's mouth. The nurse should explain to the client that these spots are most likely a. Candida albicans infection b. Koplik spots c. leukoplakia d. Fordyce spots

a. Candida albicans infection

the tarsal plates of the upper eyelid contain a. meibomian glands b. sebaceous glands c. tear ducts d. ocular muscles

a. meibomian glands

an adult client tells the nurse that his father had cataracts. he asks the nurse about risk factors for cataracts. the nurse should instruct the client that a potential risk factor is a. lack of vitamin c b. uv exposure c. obesity d. use of antibiotics

b. uv exposure

a variation that looks split or partially severed and may be associated with a sub mucous cleft palate

bifid uvula

The cone of light is located in the... a) inner ear b) middle ear c) external ear d) semicircular ear

c) external ear

the nurse is preparing to examine the sinuses of an adult client. after examining the frontal sinuses, the nurse should proceed to examine the a. ethmoidal sinus b. laryngeal sinuses c. maxillary sinuses d. sphenoidal sinuses

c. maxillary sinuses

Bony protuberance in the midline of the hard palate

torus palatinus

after examining the clients tympanic membranes, the nurse documents "right tympanic membrane, red and bulging with no light reflex" the nurse recognizes that these are signs of a. acute otitis media b. serous otitis media c. skull trauma d. trauma from infection

a. acute otitis media

a bony ridge located at the point where the manubrium articulates with the body of the sternum is termed the sternal a. angle b. notch c.space d. prominens

a. angle

The nurse is assessing the mouth of an older adult and observes that the client appears to have poorly fitting dentures. The nurse should instruct the client that she may be a greater risk for a. aspiration b. malocclusion c. gingivitis d. throat soreness

a. aspiration

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's a. base of the heart b. pulmonic valve area c. apex of the heart d. second left interspace

a. base of the heart

The bicuspid, or mitral, valve is located a. between the left atrium and the left ventricle b. between the right atrium and the right ventricle c. at the beginning of the ascending aorta d. at the exit of each ventricle near the great vessels

a. between the left atrium and the left ventricle

The nurse is planning to inspect an adult client's mouth, using a tongue depressor. The nurse should plan to a. depress the tongue blade slightly off center b. depress the tongue blade as close to the center as possible c. ask the client to keep the mouth partially open d. insert the tongue blade at the back of th eclient's tongue

a. depress the tongue blade slightly off center

The nurse is planning a presentation to a group of high shcool students about the risk factors for oral cancer. Which of the following should be included in the nurse's plan? a. diets low in fruits and vegetables are a possiable risk factor for oral cancer b. about 40% of all cancers occur in the lips, mouth, and tongue. c. the incidence of oral cancers is higher in women than in men d. most oral cancers are detected in people in the 70s

a. diets low in fruits and vegetables are a possiable risk factor for oral cancer

the thin-double layered serous membrane that lines the chest cavity is termed a. parietal pleura b. pulmonary pleura c. visceral pleura d. thoracic pleura

a. parietal pleura

the nurse is preparing to examine an adult clients eyes, using a snellen chart. the nurse should a. position the client 20 ft away from the chart b. ask the client to remove his glasses c. ask the client to read each line with both eyes open d. instruct the client to begin reading from the bottom of the chart

a. position the client 20 ft away from the chart

a 45-year old client tells the nurse that he occasionally sees spots in front of his eyes. the nurse should a. tell the client that these often occur with aging b. refer the client to an opthalmologist c. re-examine the client in 2 weeks d. assess the client for signs of diabetes

a. tell the client that these often occur with aging

An extension of the soft palate of the mouth, which hangs in the posterior midline of the oropharynx, is the a. uvula b. frenulum c. taste buds d. sublingual fold

a. uvula

sensory receptors in the ear that help to maintain both static and dynamic equilibrium are located in the semicircular canals and the a. vestibule b. tympanic membrane c. cone of light d. eustachian tube

a. vestibule

the nurse is caring for a healthy adult client with no history of vision problems. the nurse should tell the client that a thorough eye exam is recommended every a. year b. 2 years c. 3 years d. 4 years

b. 2 years

the apex of each lung is located at a. level of the diaphragm b. area slightly above the clavicle c. level of the sixth rib d. left oblique fissure

b. area slightly above the clavicle

The nurse is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the a. area on top of the tongue b. area underneath the tongue c. inside of the cheeks d. area near the salivary glands

b. area underneath the tongue

an adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. the nurse refers the client to a physician for evaluation of possible a. glaucoma b. increased intracranial pressure c. hypertension d. ophthalmic headache

b. increased intracranial pressure

the nurse assess an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's a. pectus thorax b. pectus excavatum c. pectus carinatum d. pectus diaphram

b. pectus excavatum

a client visits the local clinic after experiencing head trauma. the client tells the nurse that he has a consistent blind spot in his right eye. the nurse should a. examine the area of head trauma b. refer the client to an ophthalmologist c. assess the client for double vision d. ask the client if he sees halos

b. refer the client to an ophthalmologist

an adult client tells the nurse that his 80-year old father is almost completely deaf. after an explanation to the client about risk factors for hearing loss, the nurse determines that the client needs further instruction when the client says a. "there is a genetic predisposition to hearing loss" b. "certain cultural groups have a higher rate of hearing loss" c. "it is difficult to prevent hearing loss of worsening of hearing" d. "chronic otitis media has been associated with hearing loss"

c. "it is difficult to prevent hearing loss of worsening of hearing"

an adult client tells the nurse that he has been experiencing gradual vision loss, the nurse should a. ask about the clients diet b. determine whether there is a history of glaucoma c. check the clients blood pressure d. ask the client if he has any known allergies

c. check the clients blood pressure

the nurse has performed the rinne test on an older adult client. after the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. the nurse determines that the client is most likely experiencing a. normal hearing b. sensorineural hearing loss c. conductive hearing loss d. central hearing loss

c. conductive hearing loss

While assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. The nurse should refer the client to a physician because this is usually indicative of... a. pulmonary hypertension b. aortic stenosis c. mitral valve stenosis d. pulmonary hypotension

c. mitral valve stenosis

the bony orbit and fat cushion of the eye serves as a a. caruncle b. channel c. protector d. filter

c. protector

The nurse is assessing a 50-year-old client's breasts and observes a spontaneous discharge of fluid from the left nipple. The nurse should a. document this as a normal finding b. ask the client if she has had retracted nipples c. refer the client for a cytology exam d. determine whether the client wears a supportive bra

c. refer the client for a cytology exam

the nurse is examining an adult clients eyes. the nurse has explained the positions test to the client. the nurse determines that the client needs further instructions when the client says that the positions test a. assesses the muscle strength of the eye b. assesses the functioning of the cranial nerves innervating the eye muscles c. requires the covering of each eye separately d. requires the client to focus on an object

c. requires the covering of each eye separately

an adult client visits the clinic and complains of tinnitus. the nurse should ask the client if she has been a. dizzy b. hypotensive c. taking antibiotics d. experiencing ear drainage

c. taking antibiotics

An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are a. touching the uvula b.visible upon inspection c. touching each other d. midway between the tonsillar pillars and uvula

c. touching each other

The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to a) constant misalignment of the eyes. b) muscle weakness. c) congenital cataracts. d) decreased accommodation.

d) decreased accommodation.

an adult client tells the nurse that she frequently experiences burning and itching of both eyes. the nurse should assess the client for a. foreign body b. recent trauma c. blind spots d. allergies

d. allergies

The nurse has assessed the nose of an adult client and has explained to the client about her thick yellowish nasal discharge. The nurse determines that the client understands the instructions when the client says that the yellowish discharge is most likely due to a. too much smoking b. chronic allergies c. trauma to the nasal passages d. an upper respiratory infection

d. an upper respiratory infection

an adult client visits the clinic complaining of recurrent ulcers in the mouth. the nurse assesses the client's mouth and observes a painful ulcer. the nurse should document the presence of a. cancerous lesion b. candida albicans infection c. oral ulceration d. aphthous stomatitis

d. aphthous stomatitis

the lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria is a. bocnioles b. alveolar sacs c. alveolar ducts d. cilia

d. cilia

an adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. the nurse should instruct the client that prolonged wearing of contact lenses can lead to a. retinal damage b. cataracts c. myopia d. corneal damage

d. corneal damage

A client has had a recent mastectomy and visits the clinic for postoperative evaluation. The client tells the nurse that she has been depressed and feels as if she is less of a woman. The most appropriate nursing diagnosis for this client is a. ineffective individual coping related to mastectomy b. fear of additional breast cancer related to the presence of risk factors c. PC: hematoma after mastectomy d. disturbed body image related to mastectomy

d. disturbed body image related to mastectomy

Before examining the mouth of an adult client, the nurse should first a. ask the client to leave dentures in place b. don sterile gloves for the procedure c. offer the client mouthwash d. don clean gloves for the procedure

d. don clean gloves for the procedure

The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2, what priority assessment would the nurse include? a.assess signs of nonproductive cough b. review blood work including RBC and WBC c. Assess the characteristics of sputum d. evaluate changes in respiratory pattern and rate

d. evaluate changes in respiratory pattern and rate

The size and shape o the breasts in females are related to the amount of _________. a. glandular tissue b. fibrous tissue c. lactiferous ducts d. fatty tissue

d. fatty tissue

the nurse is preparing to examine the ears of an adult client with an otoscope. the nurse should plan to a. ask the client to tilt the head slightly forward b. release the auricle during examination c. use a speculum that measures 10 mm in diameter d. firmly pull the auricle out, up, and back

d. firmly pull the auricle out, up, and back

an adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. the nurse should assess the client for a. recent exposure to irritants b. increased intracranial pressure c. excessive tearing d. foreign body

d. foreign body

The nurse is caring for a female client who has received a diagnosis of fibrocystic breast disease. The nurse has instructed the client about the disease. The nurse determines that the client needs further instructions when the client says she should avoid drinking a. regular coffee b. regular tea c. diet colas d. grapefruit juice

d. grapefruit juice

Client's jugular veins are fully extended. These signs are indicative of a. pulmonary emphysema b. diastolic murmur c. patent ductus arteriosus d. increased central venous pressure

d. increased central venous pressure

While assessing an adult client, the client tells the nurse that she "has had difficulty catching her breath since yesterday." The nurse should assess the client further for signs and symptoms of a. emphysema b. cardiac disease c. trauma to the chest d. infection

d. infection

an adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. the nurse should assess the clients eye for a. viral infection b. double vision c. allergic reaction d. lacrimal obstruction

d. lacrimal obstruction

the clavicles extend from the acromion of the scapula to the part of the the sternum is termed a. body b.xiphoid process c. angle d. mnaubrium

d. mnaubrium

the nurse is planning to perform an ear examination on an adult client. after explaining the procedures to the client, the nurse should a. ask the client to remain standing b. show the client the otoscope c. ask the client to remove his contact lenses d. observe the clients response to the explanations

d. observe the clients response to the explanations

an adult client visits the clinic and tells the nurse that she has been experiencing frequent nosebleeds for the past month. the nurse should a. ask the client if she has had recent oral surgery b. assess the client's nasal passages for blockage c. ask the client if she is a smoker d. refer the client for further evaluation

d. refer the client for further evaluation

while assessing the ears of an adult client, the nurse observes bloody drainage in the clients ear. the nurse should a. document the findings in the clients chart b. determine whether a foreign body is present in the ear c. assess the client for further signs of otitis media d. refer the client to a physician

d. refer the client to a physician

a client has tested 20/40 on the distant visual acuity test using a snellen chart. the nurse should a. document the results in the client's record b. ask the client to read a handheld vision chart c. ask the client to return in 2 weeks for another examination d. refer the client to an optometrist

d. refer the client to an optometrist

A client visits the clinic and tells the nurse that she has painful cracking in the corners of her lips. The nurse should assess the client's diet for a deficiency of a. vitamin C b. flouride c. vitamin A d. riboflavin

d. riboflavin

the ossicles contained in the middle ear include the malleus, the incus, and the a. pars tensa b. pars flaccida c. umbo d. stapes

d. stapes

An adolescent client tells the nurse that her mother says she grinds her teeth when she sleeps. The nurse should explainto the client that grinding the teeth may be a sign of a. precancerous lesions b. poor oral hygiene c. malabsorption d. stress and anxiety

d. stress and anxiety

the nurse is planning to conduct the weber test on an adult male client. to perform this test, the nurse should plan to a. strike a tuning fork and place it at the base of the clients mastoid process b. whisper a word with two distinct syllables to the client c. ask the client to close his eyes while standing with feet together d. strike a tuning fork and place it on the center of the clients head or forehead

d. strike a tuning fork and place it on the center of the clients head or forehead

The nurse is planning a presentation to a group of high school students on the topic of lung cancer. Which of the following should the nurse plan to include in the presentation? a. compared with whites in the US, African Americans have a lower incidence of lung cancer b. lung cancer is the 3rd leading cause of death in the US c. There is a higher incidence of lung cancer in women than men in the US d. studies have indicated that there is a genetic component in the development of lung cancer

d. studies have indicated that there is a genetic component in the development of lung cancer

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible a. pulmonary edema b. brochitis c. asthma d. tuberculosis

d. tuberculosis

aphthous stomatitis

inflammation of the mouth with small, painful ulcers

methods used to test for sinus tenderness

palpation and percussion

the meibomian glands secrete a. an oily substance to lubricate the eyes b. sweat c. hormones d. clear liquid tears

a. an oily substance to lubricate the eyes

The nurse observes an orange peel appearance, or peau d' orange, of the areolae of a client's breasts. The nurse should explain to the client that this is most likely due to a. blocked lymphatic drainage b. fibrocystic breast disease c. fibroadenomas d. radiation therapy

a. blocked lymphatic drainage

While palpating the apex, left sternal border, and base in an adult client, the nurse detects a thrill. The nurse should further assess the client for... a. cardiac murmur b. left sided heart failure c. constrictive pericarditis d. congestive heart failure

a. cardiac murmur

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible a. chronic bronchitis b. atelectasis c. renal failure d. congestive heart failure

a. chronic bronchitis

The nurse has discussed the risks for breast cancer with a group of high school seniors. The nurse determines that one of the students needs a further instructions when the student says that one risk factor is a. having a baby before the age of 20 years b. a family history of breast cancer c. consumption of a high-fat diet d. late menopause

a. having a baby before the age of 20 years

the conjunctiva of the eye is divided into the palpebral portion and the a. canthus portion b. intraocular portion c. nasolacrimal portion d. bulbar portion

d. bulbar portion