CoursePoint Final Exam Practice Test

During which part of the comprehensive assessment would the nurse auscultate after inspecting but before percussing? A. Abdomen B. Heart C. Neck D. Anterior chest

A. Abdomen Rationale: The nurse inspects, and then auscultates, the abdomen. This is followed by percussion and then palpation.

A client complains of a burning sensation in the esophagus after eating. Which associated condition should the nurse most suspect? A. Acid reflux B. Pancreatic cancer C. Acute pancreatitis D. Gastric ulcer

A. Acid reflux Rationale: The onset of pain is a diagnostic clue to its origin. For example, acute pancreatitis produces sudden onset of pain, whereas the pain of pancreatic cancer may be gradual or recurrent. A client may have excessive gas after ingesting certain foods. A burning sensation in the esophagus may occur with gastric acid reflux after eating. Pain related to gastric ulcers may occur when the stomach is empty.

Assessment of a client's bowel sounds is best obtained by performing which assessment technique? A. Auscultation B. Inspection C. Percussion D. Palpation

A. Auscultation Rationale: Auscultation is the act of listening with a stethoscope to sounds produced within the body and will provide the nurse with assessment data related to bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner using visual, auditory, and olfactory senses in the process. Palpation is an assessment technique that uses the sense of touch. Percussion is the act of striking one object against another to produce a sound.

The nurse is admitting a client to the hospital following a motor vehicle collision in which alcohol may have been a contributing factor. What tool might the nurse use to assess whether alcohol is a problem in this client's life? A. CAGE B. ABCT C. MMPI D. HOPE

A. CAGE Rationale: If alcohol use might be a problem, the CAGE is a quick first-step questionnaire to use as an assessment tool. The MMPI is the Minnesota Multiphasic Personality Inventory used to aide in diagnosing psychological problems. The ABCT is used for assessment of mental status. It includes Appearance (posture, movement, hygiene, and dress), Behavior (level of consciousness, eye contact, facial expressions, speech), Cognitive function (orientation, attention span, memory, judgment), and Thought processes and is not a tool. The HOPE tool is used for assessing spirituality.

A client states, "I'm worthless and I don't deserve to live." This theme in the client's expressed thought may signal unhealthy responses to which disorder? A. Depression B. Mania C. Delirium tremens D. ADHD

A. Depression Rationale: This theme in the client's expressed thoughts may signal unhealthy responses to depression. The other options are not indicative of a depressed state.

The nurse is assessing a 51-year-old morbidly obese client who is seeking care for the recent loss of sensation in his feet and toes. The client also complains of intermittent burning and tingling in his feet that radiate up his legs. For which of the following health problems should the nurse first assess? A. Diabetic peripheral neuropathy B. Alcohol abuse C. Lead poisoning D. Multiple sclerosis

A. Diabetic peripheral neuropathy Rationale: Diabetic peripheral neuropathy is associated with loss of sensation, burning, and tingling in the feet that often radiate up the legs in a stocking-like fashion. Obesity is also a risk factor for diabetes. Lead poisoning, MS, and alcohol abuse are not commonly associated with the client's symptoms.

The nurse is preparing to conduct an examination of a client's breasts and axilla. Which of the following equipment will the nurse need for this examination? A. Drape B. Stethoscope C. Penlight D. 2 X 2 gauze

A. Drape Rationale: The nurse will need a drape to ensure for the client's privacy during the examination of the breasts and axilla. A stethoscope would be required for auscultation which is not required during a breast and axilla examination. A penlight is generally used to assess eyes and mouth and would not be needed during a breast and axilla examination. A breast and axilla examination is non-invasive, therefore, 2 X 2 gauze will not be needed.

Which movement should the nurse instruct the client to perform to assess range of motion for the knee? A. Flexion B. Abduction C. Circumduction D. Rotation

A. Flexion Rationale: The nurse should instruct the client to perform flexion to assess the range of motion for the client's knee. Circumduction, rotation, and abduction movements are not possible in the knees. Circumduction is the circular motion of the joint. Rotation involves turning the head to the right shoulder then back to midline and then turning the head to the left shoulder then back to midline. Abduction refers to moving away from the midline of the body. The knees are capable of performing only flexion and extension.

The nurse understands that when the sympathetic nervous system is stimulated what occurs? (Select all that apply.) A. Increased cardiac output B. Decreased cardiac output C. Increased blood pressure D. Decreased blood pressure E. Increased heart rate

A. Increased cardiac output C. Increased blood pressure E. Increased heart rate Rationale: When the sympathetic nervous system is stimulated, epinephrine and norepinephrine are released which causes an increased heart rate and cardiac output and increase in the blood pressure.

A nursing student has been assigned to care for a client whose history suggests the need for a mental status assessment. This client most likely has a history of health problems affecting what body system? A. Neurologic B. Renal C. Respiratory D. Cardiovascular

A. Neurologic Rationale: The structure and function of the neurologic system can affect one's mental status. Cerebral abnormalities disturb the client's intellectual ability, communication ability, or emotional behaviors. Although problems involving the respiratory, cardiovascular, and renal systems may affect mental status, the neurologic system is the major system affecting a client's mental status.

A female older adult client is being assessed by a male nurse on a medical unit in the hospital. During the physical examination, the client states, "It is against my religious customs to have physical contact with a male who is not my husband. May I carry on with a female nurse please?" What is the nurse's best response? A. Offer to exchange client assignments with a female nurse. B. Tell the client that these are not North American customs. C. Inform the client about privacy and confidentiality. D. Explain nurse-client boundaries to the client.

A. Offer to exchange client assignments with a female nurse. Rationale: In accordance with the ETHNIC model for ethnographic geriatric education, collaboration plays a part in the assessment of the older adult with a cultural identity different from the health care provider. In an effort to be collaborative, culturally competent, and maintain the nurse-client relationship, the nurse should exchange client assignments with a female nurse. Although it is important to discuss privacy and confidentiality with the client, this is not the concern she wants to have addressed by making a request for a female nurse. The nurse-client boundary is a critical element of the therapeutic relationship. This can be explained to the client; however, it does not address the cultural factors impacting the assessment of this individual client. To tell the client that these are not North American customs communicates an ethnocentric view of health and does not promote culturally competent care.

When the mental health nurse ask the client "Do you recall what month and year this is?" The nurse is assessing which part of the mental status examination? A. Orientation B. Insight C. Judgment D. Abstract reasoning

A. Orientation Rationale: One of the most basic assessments of cognitive function is the client's orientation to person, place, and time. Judgment may be viewed as the action-oriented counterpart to insight. To assess abstract reasoning the nurse may ask the client to describe the meaning of well-known proverbs. Insight is the cognitive process of understanding.

A nurse has been ordered to include an ear assessment as part of a head-to-toe examination of a client. Which of the following pieces of equipment will the nurse need for this assessment? A. Otoscope B. Stethoscope C. Snellen chart D. Ophthalmoscope

A. Otoscope Rationale: An otoscope would be needed to assess the ears. An ophthalmoscope and a Snellen chart are used to assess the eyes. A stethoscope is needed for various assessments requiring auscultation but would not be needed to assess the ears.

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment? A. Palpation B. Percussion C. Inspection D. Auscultation

A. Palpation Rationale: The thyroid gland is assessed by palpation, although it is not palpable in some clients.

While performing an assessment the nurse presses the client's arm with the tip of her thumb, holds for a few seconds and releases. The nurse observes an indent in the client's skin. What is the nurse assessing? A. Pitting edema B. Peripheral pulses C. Skin temperature D. Capillary refill

A. Pitting edema Rationale: Pitting edema is associated with systemic problems, such as congestive heart failure or hepatic cirrhosis, and local causes such as venous stasis due to insufficiency or obstruction or prolonged standing or sitting (orthostatic edema).

When implementing nursing interventions for a client who has attempted suicide, which of the following is most important? A. Providing a safe environment by removing items that could cause harm B. Setting clear boundaries and making sure the client abides by them C. Not allowing the client to interact with other clients D. Checking on the client every 4 hours

A. Providing a safe environment by removing items that could cause harm Rationale: The highest priority in this case is to maintain safety of the client and prevent risk of harm to self or others. Lesser concerns would involve setting clear boundaries and checking on the client regularly. The client would be encouraged to interact with other clients as long as there is no risk for harm to them.

Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? (Select all that apply.) A. Quitting smoking B. Following a sedentary lifestyle C. Maintaining a healthy weight D. Regularly exercising E. Eating a high-sodium diet

A. Quitting smoking C. Maintaining a healthy weight D. Regularly exercising Rationale: Clients with obesity, in particular abdominal obesity, are at increased risk for ischemic stroke. Nurses should teach clients to reduce calorie intake and to gradually increase activity. Smokers are also at increased risk for stroke. Nurses should counsel clients at every visit about willingness to quit smoking.

A nursing instructor is observing a nursing student assess a client's capillary refill. Which action by the student indicates the proper technique? A. Student compresses the client's nail bed until it blanches. B. Student gently compresses the wrist area on the side of the thumb. C. Student asks client to turn hands slowly over and back. D. Student applies firm pressure to the hand, noting any indentation.

A. Student compresses the client's nail bed until it blanches. Rationale: Capillary refill is assessed by compressing the nail bed until it blanches and then releasing the pressure, noting the time it takes for the color to return. Gentle compression of the wrist area on the thumb side is appropriate when taking a radial pulse. Applying firm pressure to note indentation tests for pitting edema. Having the client turn his or her hands over and back allows for inspection of hand color.

When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts? A. Symmetry (comparison of bilateral body parts). B. Indications of general health status. C. Vital signs of all extremities (arms and legs). D. Actual measurements in centimeters.

A. Symmetry (comparison of bilateral body parts). Rationale: When conducting a physical assessment, the nurse assesses and compares all bilateral body parts. The symmetry of parts of the body (such as the skull) and the extremities (arms and legs) is an important assessment to assess and document.

Which of the following can a nurse assess by palpation? A. Temperature, turgor, moisture B. Vision, hearing, cranial nerves C. Tissue density, gait, reflexes D. Heart sounds, lung sounds, blood pressure

A. Temperature, turgor, moisture Rationale: Palpation is an assessment technique that uses the sense of touch. The hands and fingers can assess temperature, turgor, texture, moisture, vibrations, and shape.

The client presents to the nurse stating that his jaws feel "stuck". What joint should the nurse assess? A. Temporomandibular B. Subtalar C. Sternoclavicular D. Radioulnar

A. Temporomandibular Rationale: The temporomandibular is where the mandible and temporal joint articulate. The sternoclavicular is at the junction of the manubrium and clavicle. The radioulnar is at the radius and ulna. The joint in the foot is the subtalar.

When conducting a focused health assessment, the nurse asks questions specifically targeting what? A. The client's specific issues and symptoms B. The client's sexual orientation C. The client's gender D. The client's culture

A. The client's specific issues and symptoms Rationale: The nurse focuses questions on issues and symptoms specific to the client. In this way, the client is viewed as a person who has multiple things that are affected by the health status. These questions are related to the primary problems and concerns for the client. A focused assessment does not ask questions specifically about culture, gender, or sexual orientation.

Which of the following brief screening measures is useful in assessing memory? A. Three-item recall B. Copying intersecting pentagrams C. Spelling "world" backwards D. Serial 7s

A. Three-item recall Rationale: If the client cannot remember three items after 1 minute has passed, then this is a positive result and indicates a need for further testing. This is part of the "10-Minute Geriatric Screener."

A nurse has explained the purpose and procedure for a comprehensive assessment and has directed the client to an appropriate position on the bed. The nurse has also provided a drape with which to cover the client. What is the primary purpose of providing a drape during the assessment process? A. To provide the client with modesty during the assessment. B. To keep the client warm while body parts are exposed. C. To keep the client's skin dry during the assessment. D. To provide a barrier during palpation and percussion to ensure objective interpretation of findings.

A. To provide the client with modesty during the assessment.

Moving a part of the body away from the midline is called? A. Adduction B. Abduction C. Extension D. Rotation

B. Abduction Rationale: Movement of a part away from the center of the body is called abduction. Adduction is movement of a part of the body toward the midline. Rotation can be either internal or external, referring to rotation of a joint toward or away from the body. Extension is a straightening movement that increases the angle between body parts.

During an admission assessment, the nurse asks a client the meaning of the proverb, "people in glass houses should not throw stones." The nurse is assessing the client's what? A. Orientation B. Abstract reasoning C. Memory D. Concentration

B. Abstract reasoning Rationale: To assess for this disruption, nurses may ask clients to describe the meaning of well-known proverbs, such as "People who live in glass houses should not throw stones."

The nurse is conducting a functional assessment of an older adult client. The nurse should focus questions on which area? A. Quality of life B. Activities of daily living C. Recent personal losses D. Feelings about aging

B. Activities of daily living Rationale: A functional assessment is an evaluation of a person's ability to carry out the basic self-care activities of daily living, such as bathing, eating, grooming, and toileting. Issues such as the client's feelings related to aging, quality of life, and recent personal losses may influence functional ability, but these are not the essence of functional assessment.

When a client is obese or has a thick chest wall, what is difficult to palpate? A. Grade 4 murmur B. Apical impulse C. JVP D. Sternal angle

B. Apical impulse

A client with peripheral vascular disease is discharged from the health care facility. Which risk-reduction teaching tip should the nurse discuss during discharge teaching? A. Eat a low-protein diet. B. Avoid smoking. C. Decrease dietary fiber intake. D. Limit physical activity.

B. Avoid smoking. Rationale: The nurse should encourage the client to stop smoking, because it causes vasoconstriction (also contributes to further plaque formation), which increases the complications brought about by peripheral vascular disease. The nurse should ask the client to increase, not decrease, dietary fiber intake, and to eat a low-fat diet, not a low-protein diet. The nurse should ask the client to get regular exercise and maintain a moderate level of physical activity rather than avoid physical activity. Regular exercise improves peripheral vascular circulation and decreases stress, pulse rate, and blood pressure, thereby decreasing the risk for developing peripheral vascular disease.

A client is admitted to the health care facility for the onset of a stroke. To test the function of cranial nerve I, the nurse should ask the client to do which of the following? A. Press the tongue against the tongue blade B. Close eyes and assess for smell C. Identify taste with the eyes closed D. Say "aah" to assess the uvula

B. Close eyes and assess for smell Rationale: To assess the function of cranial nerve I (olfactory), the nurse should ask the client to close the eyes and assess for smell. The nurse asks the client to say "aah" and observes the rise of the uvula as part of the assessment of the mouth and throat. Cranial nerve VII and IX are assessed by asking the client to identify taste with the eyes closed. When testing for cranial nerves IX and X, the nurse asks the client to press the tongue against the tongue blade to assess tongue strength.

Assessment of a client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following? A. Obtunded B. Coma C. Stupor D. Lethargy

B. Coma Rationale: Coma reflects a client who is unresponsive to all stimuli with the eyes remaining closed. Obtunded indicates that the client opens eyes to loud voice, responds slowly with confusion, and seems unaware of the environment. With stupor, the client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep. With lethargy, the client opens eyes, answers questions, and falls back to sleep.

During an admission assessment, the nurse notes that the client has diabetes with peripheral neuropathy. What finding would the nurse expect to find? A. Severe pain in legs B. Decreased sensation in the feet C. Open sores on legs D. Bluish discoloration

B. Decreased sensation in the feet Rationale: A client with peripheral neuropathy would have decreased sensation in extremities. Pain, discoloration, and open sores would not be expected.

The nurse is using a goniometer while conducting the physical examination of a client's musculoskeletal status. What will the nurse use this device to measure? A. Ease of ambulation B. Degree of joint motion C. Amount of subcutaneous tissue D. Length of extremities

B. Degree of joint motion Rationale: The goniometer is used to measure the degrees of joint motion. A tape measure is used to measure extremity length. No device is used to measure the ease of ambulation. Skinfold caliper is used to measure the amount of subcutaneous tissue.

Which of the following arteries can be palpated below the inguinal ligament between the anterior superior iliac spine and the symphysis pubis? A. Dorsalis pedis artery B. Femoral artery C. Ulnar artery D. Popliteal artery

B. Femoral artery

A client has rheumatoid arthritis most prominent in the hands, where the client has decreased range of motion (ROM), pain, and tenderness. What is an appropriate nursing diagnosis for this client? A. Risk for infection related to pain and inflammation B. Impaired physical mobility related to reduced strength and ROM C. Risk for falls related to degenerative joint disease D. Risk for depression related to immobility

B. Impaired physical mobility related to reduced strength and ROM Rationale: Decreased ROM, pain, and tenderness are most likely to impair the client's physical mobility. The client is not totally immobile, and nothing in the scenario indicates that the client is depressed. The client is not at risk for falls from the problems in the hands and is not showing signs of infection.

After teaching a group of students about the important organs to be assessed during an abdominal assessment, the instructor determines that the teaching was successful when the students identify which organ as the largest solid organ in the body? A. Pancreas B. Liver C. Kidney D. Spleen

B. Liver

A nursing student is reviewing the electrical conduction of the heart. The student is correct in identifying the sinoatrial node of the heart as which of the following? A. Bundle of His B. Pacemaker C. Conduction system D. Purkinje fibers

B. Pacemaker

A nurse asks a supine client to raise his knee partially. The nurse then places the thumbs on the knee while positioning the fingers deep in the bend of the knee. The nurse is palpating the pulse of which artery? A. Dorsalis pedis B. Popliteal C. Posterior tibial D. Femoral

B. Popliteal

An elderly client is very immobile, sitting in a chair most of the day or spending time in bed. Immobility greatly increases the client's risk for which of the following skin conditions? A. Fungal infection B. Pressure ulcers C. Bruising D. Stasis dermatitis

B. Pressure ulcers Rationale: The client as described is most at risk for pressure ulcer development. Pressure ulcers in any of the following areas should be staged and interventions begun immediately: sacral and ischial areas, greater trochanteric area, and heels. The other options are distracters to the question.

The family members of an elderly client tell the nurse, "He has lost his appetite. He eats very small amounts, and only twice a day." Which suggestion would be most appropriate? A. Counsel them to weigh him daily. B. Recommend nutrient-dense foods. C. Advise them to restrict fluid intake. D. Inform them that he will eat when he is hungry.

B. Recommend nutrient-dense foods. Rationale: Older adults need nutrient-dense foods to ingest enough essential nutrients. Telling them that he will eat when he is hungry is inappropriate. Loss of appetite is a nearly universal cofactor of both physical and mental disease in the elderly. Weighing the client periodically, rather than daily, would be more appropriate. Restricting fluid intake may predispose the client to possible dehydration.

The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should... A. place the client in a side-lying position. B. ask the client to empty his bladder. C. ask the client to hold his breath for a few seconds. D. tell the client to raise his arms above his head.

B. ask the client to empty his bladder. Rationale: Ask the client to empty the bladder before beginning the examination to eliminate bladder distention and interference with an accurate examination.

The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first... A. palpate the incision site. B. inspect the abdominal area. C. auscultate for bowel sounds. D. percuss for tympany.

B. inspect the abdominal area. Rationale: The sequence for assessment of the abdomen differs from the typical order of assessment. Auscultate after you inspect so as not to alter the client's pattern of bowel sounds. Percussion then palpation follows auscultation.

In order to let an older adult client establish his or her cultural identity, which statement would be most appropriate for the nurse to make first? A. "I have read books about your culture to help me understand your illness." B. "I will contact your spiritual adviser to help me understand your illness." C. "Tell me your beliefs about the illness you are experiencing." D. "I will make sure you are the only person I speak to about your illness."

C. "Tell me your beliefs about the illness you are experiencing." Rationale: Experts recommend letting the older adult client establish his or her own cultural identity by exploring cultural explanations of the illness. Inviting the older adult client to share personal beliefs about the illness aligns with the recommended assessment of four key areas of cultural identity. Once the older adult client has established personal cultural beliefs about the illness, the nurse can make the other statements if appropriate.

The nurse is performing an abbreviated head-to-toe assessment of a client. When the nurse asks the client about his pain, the client states, "My stomach's really killing me right now." How should the nurse first respond to this client's statement? A. Tell the client pain will be addressed after the assessment. B. Assess the client's level of consciousness. C. Ask the client to rate his pain on a 0-to-10 scale. D. Offer the client an oral analgesic medication.

C. Ask the client to rate his pain on a 0-to-10 scale. Rationale: The nurse should follow up a complaint of pain by asking the client to rate it. This assessment must precede interventions such as administering analgesia. It would most often be inappropriate to delay addressing the client's pain in order to complete the full assessment. A complaint of pain does not necessarily indicate a need to assess LOC.

The nurse is conducting an abdominal assessment with a client. What should the nurse do prior to documenting that a client's bowel sounds are absent? A. Measure oxygen saturation B. Auscultate for heart and lung sounds C. Auscultate the abdomen for 5 minutes D. Complete the entire assessment

C. Auscultate the abdomen for 5 minutes Rationale: One must listen for 5 minutes before determining that a client's bowel sounds are absent. There is no need to measure oxygen saturation, complete the entire assessment, or auscultate heart and lung sounds before determining that a client's bowel sounds are absent.

A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address? A. Remote memory B. Mental status exam C. Balance D. Sensation

C. Balance Rationale: Balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor and cerebellar systems. Remote memory and mental status exam provide information about the client's cognitive ability. Testing for sensation would address issues with specific cranial nerves or problems involving the parietal lobe.

Which statement about assessment findings obtained from a comprehensive assessment would be identified as part of the general survey? A. Sclera white; conjunctiva slightly reddened without lesions B. Hair neat clean with white and gray streaks; no scalp lesions noted C. Client alert and cooperative; sitting comfortably on chair with hands in lap D. Head symmetrically round; neck nontender with full range of motion

C. Client alert and cooperative; sitting comfortably on chair with hands in lap Rationale: The statement about the client alert and cooperative and sitting comfortably reflects information typically gathered during the general survey. The statement about the hair reflects examination of the skin and hair. The statement about the sclera and conjunctiva reflect data related to the eyes. The statement about the head and neck reflect data related to those areas.

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. Coordination D. Cardiac function

C. Coordination Rationale: The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. Therefore, a priority assessment area would be coordination. Vital signs, respiratory status, and cardiac function are not controlled by the cerebellum.

Which of the following represents an age-related change in the lungs? A. Increased speed of expiration B. Increased elastic recoil of lung tissue C. Decreased chest wall compliance D. Increased respiratory muscle strength

C. Decreased chest wall compliance Rationale: The lungs age along with the rest of the body. These changes include decreased lung and chest wall compliance, increased expiratory time, decreased muscle strength and cough, and decreased elastic recoil.

When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate? A. Normal reaction time B. Increased reaction time C. Decreased reaction time D. Absent

C. Decreased reaction time Rationale: Older clients usually have deep tendon reflexes intact, although a decrease in reaction time may slow the response.

The nurse performing an admission assessment on an older adult. What would be an expected finding? A. Numbness and tingling B. Delirium C. Decreased vision D. Dizziness

C. Decreased vision Rationale: Decreased vision is part of the aging process and may be a safety concern. Dizziness, delirium, numbness and tingling would not be an expected finding.

A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what? A. Malnutrition B. Dementia C. Depression D. Decreased mobility

C. Depression Rationale: Depression may occur in older adults for various reasons. It is more common in people with multiple chronic health problems and in those who have recently suffered the loss of a spouse, friend, family member, or pet. Decisions about moving out of a family home because of increasing care needs may also lead to depressive symptoms.

The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action? A. Assess blood pressure. B. Check for pupil reaction. C. Ensure a patent airway. D. Count respirations.

C. Ensure a patent airway. Rationale: If skin color is cyanotic or pale, breathing is difficult, posture is strained, facial expression is anxious, and overall appearance indicates distress, focus on the immediate problem. Airway, breathing, circulation should be assessed first for a client in distress.

Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls? A. Social B. Physiological C. Environmental D. Cognitive

C. Environmental Rationale: While adapting individuals' social, cognitive, and physiological circumstances can present challenges, modifications to address environmental threats to safety can often be made more easily.

A nurse is conducting the general survey at the beginning of the head-to-toe assessment. Which of the following does the nurse need to address as part of the general survey? A. Palpate the skin for moisture B. Auscultate the lungs C. Evaluate personal hygiene D. Check for peripheral pulses

C. Evaluate personal hygiene Rationale: The nurse would actually palpate the skin for moisture once he or she was at the portion of the assessment focusing specifically on the skin. The nurse would auscultate the lungs and check for peripheral pulses at the portion of the assessment focusing specifically on the respiratory and cardiac systems. Inspecting skin color, appearance, and hygiene is done as part of the general survey.

The nurse is assessing the neurological status of an unconscious client. The nurse should use which assessment scale? A. Braden B. Norton C. Glasgow D. Morse

C. Glasgow Rationale: An appropriate scale to assess the neurological status of an unconscious client is the Glasgow Coma Scale (GCS). The Norton and Braden scales are used to assess skin. The Morse Fall scale is used to assess the risk for falls.

Assessment of the musculoskeletal system usually proceeds from general to specific and from? A. Right to left B. Bottom to top C. Head to toe D. Anterior to posterior

C. Head to toe Rationale: As with other systems, assessment of the musculoskeletal system usually proceeds from general to specific and from head to toe. Focused assessments may be more appropriate when the client reports an injury to a specific area or joint.

Which of the following would the nurse suspect when a client with a cardiac condition complains of not sleeping well and having to get up frequently at night to urinate? A. This indicates the heart is working efficiently. B. The client most likely sleeps without a pillow at night. C. Increased urination at rest may indicate heart failure. D. The client has decreased performance levels of activities of daily living.

C. Increased urination at rest may indicate heart failure. Rationale: With heart failure, increased renal perfusion during periods of rest or recumbency may cause nocturia. Nocturia does not indicate that the heart is working efficiently. Depending on the client's fatigue level from not sleeping well, as well as other complaints, the client's ability to perform activities of daily living may be affected. If the client is experiencing dyspnea at night, he or she will likely be sleeping on more than one pillow at night.

The nurse applies a pulse oximeter to the patient's fingertip. What measurement is appropriate for this device? A. White blood cell count 7800/mm3 B. Capillary glucose level 112 mg/dL C. Oxygen saturation 97% on room air D. Hemoglobin level 13.9 mg/dL

C. Oxygen saturation 97% on room air Rationale: Pulse oximetry measures the arterial oxygenation saturation, or SpO2. A probe is placed on the client's finger or earlobe. The toe is used for infants and young children. This device does not measure hemoglobin level, white blood cell count, or blood glucose level.

The nurse is preparing to conduct an admission assessment on an older adult client. What would be important to do before interviewing this client? A. Make sure the door is not blocked B. Speak in a louder than normal voice C. Reduce or eliminate background noise D. Turn up the client's hearing aid

C. Reduce or eliminate background noise Rationale: It is essential to reduce or eliminate background noise as much as possible when carrying on conversations. This includes turning off the television or radio in the client's room and closing the door to reduce sounds of telephones, beepers, alarms, or pagers. Before beginning the interview, it would not be necessary to make sure the door is not blocked or to speak in a louder than normal voice. The scenario does not say that the client is using a hearing aid.

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? A. Right lower quadrant B. Left upper quadrant C. Right upper quadrant D. Left lower quadrant

C. Right upper quadrant Rationale: The liver is the largest solid organ in the body. It is located below the diaphragm in the right upper quadrant of the abdomen.

A nurse assesses a female adult client who states that she has a urinary tract infection. The nurse notes that the client is unkempt, wearing stained clothing, and has a strong body odor. The client mentions that she was evicted from her apartment two weeks ago. Which nursing diagnosis would the nurse identify for this client? A. Impaired skin integrity related to neurologic deficits B. Deficient fluid volume related to possible urinary tract infection C. Self-care deficit related to possible homelessness D. Caregiver role strain related to fatigue

C. Self-care deficit related to possible homelessness Rationale: The client's appearance and body odor suggest a problem with self-care issues. This is further supported by the client's loss of housing. No data support that the client is a caregiver or that she has impaired skin integrity. Further information would need to be collected to substantiate a nursing diagnosis of deficient fluid volume.

The nurse is assessing a client's gait. Which finding would alert the nurse to the need for a referral for further evaluation? A. Stands on heels and toes B. Arms swinging in opposition C. Shuffling of feet D. Weight evenly distributed

C. Shuffling of feet Rationale: Shuffling of the feet suggest a problem that would most likely require a referral for further evaluation. Evenly distributed weight, ability to stand on heels and toes, and arms swinging in opposition are considered normal findings.

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. Annual MRI screening B. Nutritional supplementation C. Smoking cessation D. Improved coping skills

C. Smoking cessation Rationale: Smoking is a major risk factor for stroke, and clients should be encouraged to quit. Screening with diagnostic imaging is not currently recommended. Impaired coping is not a significant risk factor. A healthy diet reduces the risks of stroke, but supplements may or may not be required.

The nurse is admitting an older male client diagnosed with congestive heart failure. Several risk factors for falls have been identified on the admission database. What is the nurse's best action to prevent falls? A. Scan the client's armband before medication administration. B. Use two client identifiers, such as name and date of birth. C. Utilize safety alarms that are available on the unit. D. Use SBAR and medical terminology for verbal communication.

C. Utilize safety alarms that are available on the unit. Rationale: Using safety alarms, such as bed alarms, can help prevent falls. Using SBAR and medical terminology improve staff communication. Scanning the client's armband and using two client identifiers ensure the nurse identifies the client correctly but do not prevent falls.

Examination of the skin should be... A. performed at the very end of the physical assessment. B. integrated and completed only with the musculoskeletal examination. C. integrated throughout the head-to-toe examination. D. completed at the beginning of the physical assessment before proceeding to other parts of the exam.

C. integrated throughout the head-to-toe examination. Rationale: As you perform each part of the head-to-toe assessment, assess skin for color variations, texture, temperature, turgor, edema, and lesions.

A client says that an object placed in the hand is a pair of scissors when the object is a paper clip. Which aspect of the client's neurologic system should the nurse identify as being compromised? A. responsiveness B. motor C. sensory D. position sense

C. sensory Rationale: The nurse performed stereognosis which is a technique used to assess the sensory status. Assessment of the motor status includes gait, muscle strength, and muscle tone. Position sense determines if the client has intact proprioception. Responsiveness refers to level of consciousness.

The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease? A. "If you can eliminate red meat from your diet, your risk of heart disease will drop significantly." B. "Anything that you can do to reduce stress in your life will benefit your heart health." C. "Try to ensure that you're screened for heart disease at least once every six months." D. "Your risk for heart disease will drop greatly if you're able to stop smoking."

D. "Your risk for heart disease will drop greatly if you're able to stop smoking." Rationale: Smoking is among the most significant risk factors for heart disease. Screening does not need to be performed on a twice yearly basis. Stress reduction is beneficial, but smoking is a greater risk factor than stress. Dietary fat is a risk factor, but for most clients there is not a need to wholly eliminate red meat from the diet.

When receiving the shift report, the nurse should identify which client as being at highest risk for falls? A. 47-year-old client receiving gastrostomy tube feedings B. 34-year-old postoperative client on bedrest C. 58-year-old diagnosed with terminal cancer D. 73-year-old with confusion and incontinence

D. 73-year-old with confusion and incontinence Rationale: Confusion and incontinence place this client at highest risk for falls due to the need to frequently go to the bathroom and possibly not calling for help if confused. The client on bedrest should have 2 siderails up and not be at high risk for falls. Gastrostomy tube feedings imply that this client is at higher risk for pressure ulcers and poor wound healing than risk for falls. Cancer itself is not a risk factor for falls.

Claire's daughter brings her in today after she fell at her home. Which assessments are indicated at this time? A. Orthostatic vital signs B. Review of her medications C. Assessment of gait and balance D. All of the above

D. All of the above Rationale: Falls are common in the elderly, and can often result in serious injuries. When assessing the cause of falls, gait and balance should be checked first. Medications, particularly use of more than three, are associated with falls. Vision problems, lower limb joint problems, and cardiovascular problems, such as arrhythmias, may be reasonable to search for. Orthostatic vital sign changes should be sought.

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following would the nurse do? A. Perform the Weber test. B. Test extraocular eye movements. C. Use a Snellen chart to test visual acuity. D. Ask a client to identify scents.

D. Ask a client to identify scents. Rationale: Cranial nerve I is the olfactory nerve, which would be tested by having the client occlude one nostril and identify a scent. Using the Snellen chart tests CN II, the optic nerve. Testing extraocular eye movements evaluates tests CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). The Weber test evaluates CN VIII (acoustic/vestibulocochlear).

The nurse notes that a client suffers from chronic obstructive pulmonary disease (COPD). Which assessment finding is the nurse most likely to observe in this client? A. Thyroid enlargement B. Positive Babinski sign C. Skeletal scoliosis D. Barrel chest

D. Barrel chest Rationale: In barrel chest, which may accompany chronic obstructive pulmonary disease (COPD), the AP-to-transverse ratio approximates 1:1, giving the chest a round appearance. Thyroid enlargement or masses can be seen more easily when the client swallows and while illuminating client's neck with a tangential light. If reflexes are 3-4, they are brisker than normal. If they are 0-1, they are diminished or absent. A positive Babinski sign indicates a poor neurological outcome. Skeletal scoliosis and kyphosis can limit respiratory excursion. Asymmetry and paradoxical respirations occur in flail chest.

A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse? A. Decreased B. Normal C. Tachycardia D. Bradycardia

D. Bradycardia Rationale: The proper documentation of this rate is bradycardia, a rate less than 60 beats per minute. The normal adult heart rate is 60 to 100 beats per minute. Tachycardia is a heart rate above 100 beats per minute. This heart rate is decreased, but this is not a proper documentation term.

A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what? A. Grating noise B. Popping and cracking noises C. Tactile emphysema D. Crepitus

D. Crepitus Rationale: Crepitus may be heard as a popping sound and may be felt as grating in the joint as it moves. The other options are incorrect since they are not considered medical terms that describe the assessment findings.

During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what? A. Impaired mobility B. Pressure ulcers C. Stroke D. Falls

D. Falls Rationale: The client is at risk for falls due to impaired mobility and decreased movement of his lower extremities. There is no evidence to support the client is at risk for a stroke or pressure ulcers.

When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize? A. Social patterns; past medical history B. Dietary habits; social patterns C. Surgical history; family history D. Family history; dietary habits

D. Family history; dietary habits Rationale: Poor diet and a family history are both identified as risk factors for colorectal cancer. These aspects of the history would supersede the client's surgical history and social patterns.

The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location? A. Third intercostal space, left axillary line B. Second intercostal space, left sternal border C. Fourth intercostal space, left sternal border D. Fifth intercostal space, left midclavicular line

D. Fifth intercostal space, left midclavicular line

The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states, "It shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker." The nurse should recognize the need to teach the client about what topic? A. Strategies for making her husband quit smoking B. Genetic causes of lung cancer C. Age-related changes to respiratory function D. Health risks of secondhand smoke

D. Health risks of secondhand smoke Rationale: Second-hand smoke puts clients at risk for COPD (including emphysema and chronic bronchitis) or lung cancer later in life. The relationship between genetics and lung disease is not a high priority, and the husband himself must be motivated for smoking cessation. Age-related respiratory changes are not likely to be a priority in this woman's respiratory health.

When preparing an education session for a group of women who have been identified as postmenopausal, the nurse should include which teaching point? A. Minimize weight lifting exercises. B. Stop taking proton pump inhibitor medications. C. Drink two to three glasses of red wine per day. D. Increase intake of vitamin D and calcium.

D. Increase intake of vitamin D and calcium. Rationale: Dietary intake of vitamin D and calcium promotes bone strength by increasing bone mineralization and density. Muscle strengthening exercise is encouraged as it appears to maintain and possibly increase bone mass. Although moderate alcohol consumption can be beneficial in the postmenopausal years, taking more than one to two alcoholic drinks per day can promote bone loss. If a client is required to take a proton pump inhibitor, the client should not be told not to take it for bone health. Instead, the client should be advised to take a calcium citrate supplement to support normal acid production leading to decreased bone loss in association with this medication.

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence? A. Motor/cerebellar, sensory, reflexes, cranial nerves, mental status B. Cranial nerves, motor/cerebellar, sensory, reflexes, mental status C. Reflexes, sensory, motor/cerebellar, cranial nerves, mental status D. Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

D. Mental status, cranial nerves, motor/cerebellar, sensory, reflexes Rationale: The nurse should perform the assessment of the nervous system from a level of higher cerebral integration to a level of lower reflexes.

Loss of bone density that occurs with greatest frequency in postmenopausal women is called? A. Kyphosis B. Lordosis C. Scoliosis D. Osteoporosis

D. Osteoporosis Rationale: Loss of bone density is termed osteoporosis. Some osteoporosis occurs in all people, but it is most evident in women with small bone frames. Women experience rapid loss of bone density for the first 5 to 7 years after menopause. Lordosis, kyphosis, and scoliosis are conditions that affect the spinal alignment.

The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse's assessment technique? A. Palpation of the point of maximum impulse on the chest. B. Auscultating all heart sounds with the bell and diaphragm. C. Inspecting bilateral jugular veins. D. Palpating carotid pulses simultaneously.

D. Palpating carotid pulses simultaneously. Rationale: Carotid pulse palpation should be conducted by feeling one side at a time; otherwise the client my become dizzy or lightheaded. All other assessment techniques are correct.

A nurse is preparing a health education class for a group of older adult clients at a local senior center. The nurse is focusing on health promotion and disease prevention. Which condition would the nurse cite as a common cause of infection-related deaths in the elderly? A. Pyelonephritis B. Cellulitis C. Meningitis D. Pneumonia

D. Pneumonia Rationale: Pneumonia is the most common cause of infection-related deaths in the elderly. Pyelonephritis, meningitis, and cellulitis are less common causes.

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole? A. S4 B. S2 C. S3 D. S1

D. S1 Rationale: The S1 heart sound is associated with systole, while the S2, S3, and S4 heart sounds are associated with diastole.

A student in the vascular surgery clinic is asked to perform a physical examination on a client with known peripheral vascular disease in the legs. Which of the following aspects are most important to note? A. Muscle bulk and tone B. Nodules in joints C. Lower extremity strength D. Size, symmetry, and skin color

D. Size, symmetry, and skin color Rationale: Size, symmetry, and skin color are important aspects to note in physical examination. Swelling in the legs, cyanosis, and lack of appropriate hair growth are all signs of peripheral vascular disease.

The nurse is planning a presentation to a group of adults on the topic of strokes. Which of the following should the nurse plan to include in the teaching plan? A. Postmenopausal women taking estrogen are at greater risk for STROKE. B. Clients who smoke while taking oral contraceptives are not at higher risk. C. Strokes are the number one cause of death in the United States. D. Smoking and high cholesterol levels are risk factors for STROKE.

D. Smoking and high cholesterol levels are risk factors for STROKE. Rationale: Risk factors for heart disease and stroke that are modifiable include high cholesterol and cigarette smoking.

A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which principles would guide the nurse's assessment of the client's mental status? A. The nurse should first explain to the couple that senility is expected among adults over age 80. B. The nurse must modify the cognitive assessment to exclude assessments requiring reading or writing. C. The nurse must explain that the results of the assessment will be used to determine if admission to long-term care is necessary. D. The nurse must differentiate between age-related changes and the signs and symptoms of dementia.

D. The nurse must differentiate between age-related changes and the signs and symptoms of dementia. Rationale: Aging has common forms of decline that are often mistaken for dementia or that resemble dementia. These include slower thinking, problem solving, learning, and recall; decreased attention and concentration; more distractedness; and need for hints to jog memory. It is important to differentiate dementia from common cognitive changes that occur with age. It is a fallacy, however, to expect older adults to naturally become "senile." There is no obvious need to exclude reading and writing from assessment. Suggestions regarding long-term care would be premature and anxiety-provoking.

The nurse is admitting a new client to the floor and asks if the client has any dizziness. Why does the nurse do this? A. To check for an absorption problem B. To assess for pancreatic problems C. To assess for liver problems D. To check for possible dehydration

D. To check for possible dehydration Rationale: Dizziness may result from possible dehydration linked to inadequate fluid or caloric intake. Pancreatic problems and liver problems do not cause dizziness. An absorption problem would not cause dizziness in and of itself.

The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to... A. squat down as far as he is able to do so. B. touch the tip of his nose with his finger. C. keep his eyes open while he bends at the knees. D. stand erect with arms at the sides and feet together.

D. stand erect with arms at the sides and feet together. Rationale: Perform the Romberg test. Ask the client to stand erect with arms at side and feet together. Note any unsteadiness or swaying. Then with the client in the same body position, ask the client to close the eyes for 20 seconds. Again note any imbalance or swaying.

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible... A. pancreatitis. B. intra-abdominal bleeding. C. ascites. D. umbilical hernia.

D. umbilical hernia. Rationale: An enlarged, everted umbilicus suggests umbilical hernia.

When applying the principle of ABC (airway, breathing, circulation) prioritization, which complication is priority for the nurse to address? A. Wound infection B. Bacteremia C. Aspiration pneumonia D. Urinary tract infection

C. Aspiration pneumonia Rationale: Aspiration pneumonia compromises the client's airway and is the priority concern to address. Wound infection, Urinary tract infection, and bacteremia do not directly compromise the airway.

During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following? A. Diabetes mellitus in his extended family B. Heart attacks in his father and siblings C. Weight patterns within his family D. Hypertension in his grandparents

B. Heart attacks in his father and siblings Rationale: Risk of developing heart disease is increased if one or more immediate family members (parents or siblings) have had an MI, hypertension, or high cholesterol.

The nurse is preparing to perform a musculoskeletal examination on an adult client. The nurse has explained the examination procedure to the client. The nurse determines that the client needs further instructions when the client says... A. "You will be asking me to change positions often." B. "You'll continue with range of motion even if I have discomfort." C. "You'll be assessing the size and strength of my joints." D. "You'll be comparing bilateral joints."

B. "You'll continue with range of motion even if I have discomfort." Rationale: Do not force the part beyond its normal range. Stop passive motion if the client expresses discomfort or pain. Be especially cautious with the older client when testing ROM. When comparing bilateral strength, keep in mind that the client's dominant side will tend to be the stronger side.

Which aspects of the mental status exam refer to data about how thoughts connect to one another? A. Orientation B. Mood C. Behavior D. Thought process

D. Thought process Rationale: Thought process refers to data about how thought connect to one another. One of the most basic assessments of cognitive function is the client's orientation to person, place, and time.

A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says... A. "I should cut down on the number of iron tablets I am taking each day." B. "I should discontinue the iron tablets and eat foods that are high in iron." C. "Constipation should decrease if I take the iron tablets with milk." D. "I can decrease the constipation if I eat foods high in fiber and drink water."

D. "I can decrease the constipation if I eat foods high in fiber and drink water."

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate? A. "Some of the examination may be painful, but I will be gentle." B. "I have to do this, so just relax and it won't last long." C. "This is nothing to worry about. I won't hurt you." D. "Let me tell you what I will be doing. It should not be painful."

D. "Let me tell you what I will be doing. It should not be painful." Rationale: The client may be anxious for many reasons. Tell the client that the assessments should not be painful. Explaining the assessment in general terms can help decrease the client's embarrassment, fear of possible abnormal physical findings, or fear of "failing" a test.

Which question is appropriate for a nurse to ask a client to assess the client's recent memory? A. "When is your birthday?" B. "Why are you at the health care clinic today?" C. "How are an orange and an apple different?" D. "What did you eat for breakfast today?"

D. "What did you eat for breakfast today?" Rationale: When assessing a client's recent, or short-term, memory ask the client about things and events that are happening currently. Asking the client what he or she ate for breakfast is testing recent memory. Asking the client their birth date tests remote memory. Asking how an orange and an apple are different tests a client's ability for abstract reasoning. Asking the client the reason for today's health clinic visit is used to identify the client's chief complaint.

A nurse is performing an abdominal assessment. The correct order of assessment techniques would be... A. inspect, auscultate, deeply palpate, lightly palpate B. inspect, deeply palpate, lightly palpate, auscultate C. inspect, lightly palpate, auscultate, deeply palpate D. inspect, auscultate, lightly palpate, deeply palpate

D. inspect, auscultate, lightly palpate, deeply palpate

After inspecting the skin of the legs, feet, and toes, what should the nurse do? A. percuss muscle tone B. measure thigh circumference C. auscultate for femoral bruit D. palpate pulses

D. palpate pulses Rationale: After inspecting the skin the nurse should palpate the client's pulses. Percussion is not used to assess muscle tone. The femoral artery is not auscultated for bruits. Thigh circumference would be measured if there was a noticeable difference in size.

True/False: The nurse auscultates the apical pulse and then palpates the PMI (point of maximal impulse). To best palpate the PMI, the nurse places two fingers at the left border of the heart in the 5th intercostal space.

True