Health Assessment Midterm
An nursing instructor is discussing the functions of the breasts. A student asks about the function of Montgomery glands. What would be the instructor's best answer?
" "During lactation, they secrete a protective lubricant."
The client tells the nurse that she has benign breast disease and so she is not worried about any lumps or nodules in her breasts. How would the nurse best respond?
" "It is important to perform self breast examinations as there could be changes or additional lumps in your breasts that would need further examination."
A client has been found to have a breast lump and an ultrasound has been ordered. The client voices concerns to the nurse she is afraid of the painful testing she is going to endure. How should the nurse best respond?
" "This noninvasive test uses high frequency waves to determine if the mass is solid or cystic."
A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?
" Airway patent, breathing quiet, denies dyspnea
A client denies performing breast self-examination however practices breast awareness. What is this client focusing on when following this practice?
" Appearance, feel, and shape of the breasts and nipples
What can the nurse recommend to a young female client who is seeking to reduce her risk for breast cancer? Select all that apply.
" Engage in regular, strenuous physical activity, " Have children before 30 years of age, " Breast-feed if possible
How should a nurse instruct a client to perform a breast self-examination to most effectively cover the entire breast?
" Up-and-down pattern starting at the underarm and moving across the breast
48.-A nurse is auscultating the voice sounds of a client with consolidation in his left lower lobe of his lung due to tumor. Which of the following findings should the nurse expect on performing pectoriloquy?
"1-2-3" is heard clearly.
37. Which statement by the nurse demonstrates a cultural bias?
"American healthcare is really so much better than that provided by any other country."
56.Which statement by the nurse demonstrates a cultural bias?
"American healthcare is really so much better than that provided by any other country."
Which general survey question focuses on the common "fifth vital sign"?
"Are you experiencing any pain right now?"
52.-A nurse inspects the gums and teeth of a middle-aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?
"Are you experiencing any tooth pain?"
58.-A nurse inspects the gums and teeth of a middle-aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?
"Are you experiencing any tooth pain?"
42.-A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client?
"Are you experiencing sinus pressure and congestion?'
The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions?
"Are you having pain from your surgery?"
43. Which question should the nurse ask when assessing a client for a possible detached retina?
"Are you seeing flashing lights?" (p. 326)
11.-A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath change in activity level or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
"Are you taking any medications on a regular basis?"
64. A nursing instructor is teaching about cultural awareness and sensitivity in client care. The student demonstrates understanding of the above when making which of the following statements?
"Cultural awareness happens first when the nurse obtains culturally specific information from the client's health history."
80. A nursing instructor is teaching about cultural awareness and sensitivity in client care. The student demonstrates understanding of the above when making which of the following statements?
"Cultural awareness happens first when the nurse obtains culturally specific information from the client's health history."
4.-A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?
"Do you experience any ringing, roaring, or crackling in your ears?"
While the nurse is obtaining a client's health history regarding the head and neck, the client tells the nurse about having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next?
"Do you have difficulty swallowing?
A nurse measures a client's blood pressure and obtains a reading of 150/85 mm Hg. Which question should the nurse ask the client in regards to this reading?
"Do you need to empty your bladder?"
A female client describes headache symptoms that seem to indicate a migraine. Which of the following questions during the client interview would, if answered in the positive, tend to confirm the nurse's suspicion?
"Does the headache occur regularly with your menstrual cycle?"
31.Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
48.Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
66.Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding?
"Have you been sitting for a long time?"
19.-A client presents with otalgia and yellow-green discharge from the external ear canal. Which question should the nurse ask to determine the cause of this problem?
"Have you had any recent trauma to the inside of your ear?"
56.-A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition?
"Have you taken any antibiotics in the past few weeks?"
60.The nurse prepares to document information collected during an assessment. Which statement correctly documents subjective data?
"I have pain across my entire forehead."
The nurse prepares to document information collected during an assessment. Which statement correctly documents subjective data?
"I have pain across my entire forehead."
18. Which statement by the nurse demonstrates an understanding of the importance that a client's culture plays in the client's health and wellness?
"I need to understand the client's cultural background to best interpret the client's needs."
36. Which statement by the nurse demonstrates an understanding of the importance that a client's culture plays in the client's health and wellness?
"I need to understand the client's cultural background to best interpret the client's needs."
54. Which statement by the nurse demonstrates an understanding of the importance that a client's culture plays in the client's health and wellness?
"I need to understand the client's cultural background to best interpret the client's needs."
31.-The client asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse?
"It identifies a problem with the normal pathways for sound to travel to your inner ear."
A nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "Validate my data? What does that mean?" How should the nurse respond to this client?
"It means I need to make sure that all the information I gathered today is reliable and accurate."
28.Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
45.Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
64.Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
83.Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
6.A nursing student has learned the importance of documenting only appropriate and accurate information. Which of the following is an appropriate notation in a client's record?
"Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10."
110.The nurse is admitting a client to a medical unit. The client is concerned that all of his private health information is on the computer and an error may occur. What is the most appropriate response of the nurse?
"The electronic medical record is one of the tools we use to keep you safe."
28. A 6 year old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye?
"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." (p. 321)
Which general survey questions will provide the nurse information regarding the client's personal makeup? Select all that apply.
"What ethnic culture do you identify with?"
A nurse is conducting a health history interview for an older adult. Which of the following questions or statements would be important for nutritional assessment?
"What prescribed and over-the-counter medicines do you take?"
The nurse is conducting a nutrition history with a young adult with signs and symptoms of an eating disorder. Which question exemplifies the most effective way for the nurse to ask about body image?
"What would you change about your body, if you could?"
83. The nurse is conducting a cultural assessment with a client who recently immigrated to the United States. Which interview question is of most importance when addressing family history as it impacts the client's care?
"Who is primarily responsible for making family decisions since arriving in the United States?"
6.-The results of a client's Rinne test are as follows: bone conduction > air conduction. How should the nurse explain these findings to the client?
"You have a conductive hearing loss."
37.The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
57.The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
76.The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
91.The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
33-Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?,
,Red, bulging, with an absent light reflex
A nurse working at a health clinic performs nutritional assessments on a variety of clients in one day. Which of the following clients would be at increased risk for malnutrition? Select all that apply.
- A single mother of three who makes $20,000 per year - A 33-year-old smoker who says that food has lost its taste - An elderly woman with Alzheimer's disease - A 12-year-old girl with Crohn's disease
A nurse is preparing to evaluate an elderly client's risk for developing pressure sores after a 2 week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose?
- Braden scale
A home health care nurse is instructing an elderly client on nutrition and health. Which of the following measures should the nurse mention as methods of ensuring food safety? Select all that apply.
- Cleaning lettuce before chopping it up for a salad - Separating raw from cooked ground beef to prevent cross-contamination - Using a meat thermometer to ensure that a turkey is fully cooked
A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply.
- Diabetes - Hypertension -Sleep apnea
A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in?
- Lithotomy
A nursing instructor is discussing nutrition screening and assessment with a clinical group. What would this instructor identify for the students as parts of a complete nutrition screening assessment? Select all that apply.
- Physical examination - Focused history of common symptoms - Serial laboratory values
A client has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply.
- activity level - blood pressure - cholesterol
A client has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply.
- blood pressure - cholesterol - activity level
Which factors should the nurse consider when counseling a client who is having difficulty gaining weight? Select all that apply.
- location of grocery stores in the client's area - access to financial resources - presence of food allergies - mood dysregulation
One disadvantage of the open ended assessment form is that it
- requires a lot of time to complete.
4.During the chest auscultation portion of a general survey, a 31year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
-"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
What assessment parameters are included when assessing a client's nutritional status? (Mark all that apply.)
-Body mass index - Clinical examination findings -Dietary Data
8.A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using welldefined standards of practice. Which of the following best defines this type of charting?
-Charting by exception
A nurse is maintaining a problem oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
-Progress notes
Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.)
-Shape of the lips -Shape of the nose -Shape of the eyes
A family member of a client recovering from a traumatic brain injury asks the nurse what safeguards can be put in place at home to prevent future head injuries. What should the nurse instruct this family member? (Select all that apply.)
-Use rails on stairs -Remove extension cords from high traffic areas -Avoid the use of throw rugs.
A nurse visits an older adult client at home in order to conduct a risk assessment for falls. Which factors would most likely increase the risk for falls for this client? Select all that apply.
-a throw rug in the dining room -bathtubs in all bathrooms -a television cord runs across the floor
The nurse assesses a client with noisy breathing including a gasping sound with respiration. The nurse notes tracheal deviation from the usual midline position. Which conditions should the nurse assess for further? Select all that apply.
-mediastinal mass -atelectasis -pneumothorax-goiter
51.-A nurse examines a client with complaints of a sore throat and finds that the tonsils are just visible. Using a grading scale of 1+ to 4+ how should the nurse appropriately document the tonsils?
1+
The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record?
1+
To calculate the ideal body weight for a woman, the nurse allows
100 pounds for 5 feet of height.
To calculate the ideal body weight for a woman, the nurse allows?
100 pounds for 5 feet of height.
A nurse is calculating the ideal body weight for a female client who 5 feet 5 inches and has a medium body frame. Which of the following is this client's ideal body weight?
125
14.-When assessing the posterior chest what is a starting point for counting ribs and interspaces?
12th rib
A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?
145 lb
A nurse is assessing the respiratory rate of an elderly client. Which of the following findings in breaths per minute would indicate a normal respiratory rate in this client?
18
A nurse assesses a 114-pound adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client?
19 BMI
During a comprehensive assessment of an adult client, the nurse can best hear high pitched sounds by using a stethoscope with a
1½-inch diaphragm.
41.-Upon assessment of the tonsils the nurse finds them to be obstructing 30% of midline. This nurse would document this as what?
2+
3.-An increased risk of falls is dangerous for any client. What client would be at an increased risk of falls?
A client with vertigo.
12. A nurse has a regular client who is an immigrant from China and who follows the traditional medical system of that culture. To improve the ability to understand and work with this client, the nurse researches this client's cultural view of health. Which of the following would the nurse most likely discover?
A focus on maintaining balance between yin and yang
46.-A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client?
A grey-white line
21.-A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?
A large amount of exudate in the sinuses
14. You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what?
A left temporal hemianopsia (p. 330).
10.-Which description of exterior landmarks indicates normal positioning of the lungs?
Anteriorly the lower border of the lung crosses the 6th rib at the midclavicular line.
24.-While inspecting the thorax the nurse views it from posterior and lateral positions to assess which of the following?
Anteroposterior to lateral diameter
7. The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes the condition, common in older adults, as which of the following?
Arcus senilis (p. 323)
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
Are you taking any medications on a regular basis
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
Are you taking any medications on a regular basis?"
During the physical examination of a client, a nurse notes that the client has tenderness of the breasts. Which question should the nurse ask the client with regard to this finding?
Are you taking oral contraceptive pills
A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?
Arthritic changes of the cervical spine
An 81 year old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client?
Arthritis
When can the general inspection be started?
As soon as the examiner first sees the client
23. A woman newly immigrated to the United States is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client?
Assessing if the client speaks and understands English
3. A woman newly immigrated to the United States is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client?
Assessing if the client speaks and understands English
45. A woman newly immigrated to the United States is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client?
Assessing if the client speaks and understands English
80.The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?
Assessment data in the medical record
99.The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?
Assessment data in the medical record
The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?
Assessment data in the medical record
18. A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?
At 20 feet from the chart, the client sees what a person with good vision can see at 50 ft (p. 317)
43.-As a part of the ear examination for hearing loss a nurse conducts a Weber test on a client. To accurately perform this test the nurse should place the base of the tuning fork in which of the following locations?
At the center of the client's forehead
52.-As a part of the ear examination for hearing loss a nurse conducts a Weber test on a client. To accurately perform this test the nurse should place the base of the tuning fork in which of the following locations?
At the center of the client's forehead
23-When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.),
At train stations, Using lawnmowers, At concerts
During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?
Atelectasis
A nursing student is caring for a male client who has been admitted in a severely malnourished state. For what signs of malnutrition would the student observe?
Bleeding of the gums
The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except:
Blood pressure
A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading?
Blood pressure cuff is tightly fitted.
The nurse is reviewing the client's medical record. Which of the following does the nurse recognize as accurate documentation? (Select all that apply.)
Bowel sounds are hyperactive in all 4 quadrants, Coarse rhonchi noted throughout lung fields, Left dorsalis pedis pulse weaker than right.
A nurse obtains a pulse rate on an adult client of 56 beats per minute. What is the correct term that the nurse should use to document this finding?
Bradycardia
34. A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client?
Brain tumor (p. 308).
54. The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and
Cleanse the cornea and the lens (p. 306)
54.A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
73.A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
2.The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?
Client safety increases
The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?
Client safety increases
Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure?
Client sitting with arm slightly flexed and even with the heart
26.Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?
Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10
Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?
Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10
A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?
Clustered
40.-During the lung assessment for a client with pneumonia the nurse auscultates low-pitched bubbling moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?
Coarse crackles
A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?
Coin or key
What is the primary purpose of the client record?
Communication
105.A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that the client has gained 6 pounds over a week. How should the nurse validate this data?
Compare objective findings with subjective findings.
1. The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?
Conjunctiva (p. 304)
45. A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following?
Conjunctiva (p. 322).
26. The nurse is caring for a client who is from another country, and states to the charge nurse, "I just don't know if the client really understands what I am saying, and I am not understanding the client either, even though he speaks English." What stage of cultural awareness is the nurse experiencing?
Conscious incompetence
48. The nurse is caring for a client who is from another country, and states to the charge nurse, "I just don't know if the client really understands what I am saying, and I am not understanding the client either, even though he speaks English." What stage of cultural awareness is the nurse experiencing?
Conscious incompetence
33. The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding?
Consensual light response present in left eye (p.324)
22.-A nurse is inspecting the ears of an Asian client and observes that her earlobes appear solderedor tightly attached to adjacent skin with no apparent lobe. Which of the following should the nurse do next?,
Continue with the examination
44.-A nurse is inspecting the ears of an Asian client and observes that her earlobes appear soldered or tightly attached to adjacent skin with no apparent lobe. Which of the following should the nurse do next?
Continue with the examination
11. Which features would most likely be noted on funduscopic examination of someone with glaucoma?
Increased cup-to-disc ratio (p. 334)
The nurse is reviewing the chart of a newly admitted client and identifies the client has Marfan syndrome. What assessment finding would the nurse expect to find?
Elongated fingers
A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?
Isolated systolic hypertension
115.A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?
It allows several health team members to view the client record simultaneously.
78.A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?
It allows several health team members to view the client record simultaneously.
94.A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?
It allows several health team members to view the client record simultaneously.
A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?
It allows several health team members to view the client record simultaneously.
A nurse receives a report from the shift nurse that a client has new onset of peripheral cyanosis. The nurse recognizes that which of the following is the most likely underlying cause?
Local Vasoconstriction
After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)
Location Distribution pattern Elevation Color
During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?
Look for a source such as infection in the area that it drains
23. Which action by the nurse indicates the appropriate use of an ophthalmoscope?
Employ the right eye to examine the client's right eye (P. 317)
The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?
Encourage the use of safety equipment
In which disease process should a nurse expect to see a client with the presence of pitting edema?
End stage renal disease
A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure?
Ensuring that contact with the skin is maintained
While examining a client's breasts, a nurse notices milky discharge from the nipple. The client explains that she recently had a baby and is currently breastfeeding. The nurse understands that which type of tissue in the breast is responsible for allowing milk production?
Glandular
19.-In order to effectively assess the oral mucosa the nurse should have which assessment tools available?
Gloves. Penlight. tongue depressor
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?
Graves' disease
What is the most common type of hyperthyroidism?
Graves' disease
15.-A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear?
Gray
A nurse is working with a client who has just been given a prescription for warfarin (Coumadin). Which foods should the nurse warn this client to avoid due to its interference with the effectiveness of warfarin?
Green, leafy vegetables
What are the primary frameworks used in conducting a health assessment? Select all that apply
Head to toe, Functional systems, Body systems
96.What are the primary frameworks used in conducting a health assessment? Select all that apply
Head to toe- Functional systems-Body systems
A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement?
Headache Impact Test
76. During a client interview, the nurse is focusing on cultural influences particularly when assessing: (Select all that apply.)
Health care beliefs and practices High-risk behaviors Nutrition
60. During a client interview, the nurse is focusing on cultural influences particularly when assessing: (Select all that apply.)
Health care beliefs and practices Nutrition High-risk behaviors
11.-The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?
Hearing intact bilaterally on whisper test
27.-The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?
Hearing intact bilaterally on whisper test
55.-The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?
Hearing intact bilaterally on whisper test
A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sound?
Heart murmur
30.-The thoracic cavity contains which of the following organs? Select all that apply.
Heart. Lungs. Most of the esophagus
A nurse is busy caring for several clients but understands the importance of taking the time to chart properly. Charting serves many purposes, which include: (Check all that apply.)
Helps facilities to receive accreditation, Allows for communication with other heath team members, Provides proof for reimbursement, Serves as legal evidence
A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention?
Helps make vitamin D in the body, protects against damage to the body from sunlight, aids in maintaining body temperature, largest organ of the body
47.-The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube?
Helps to regulate pressure in the middle ear
An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the client's vital signs to be what?
Higher than normal
A nurse inspects a client's nails and notes that the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?
History of cigarette smoking
You are the clinic nurse assessing a new client that has come in to see a physician. The assessment data that you collect reveals that the client is a 23 year-old female weighing 175 lb with a height of 5 ft 3 in. Her body mass index is 31. What would she be considered?
Obese
23.-A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?
Observe for the use of accessory muscles
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?
Observe for the use of accessory muscles
For which assessment would the nurse plan to use light palpation?
Papular rash
47.-On assessing a client's mouth the nurse finds that the uvula is deviated and the palate fails to rise. Which of the following conditions should the nurse most suspect in this client?
Paralysis of cranial nerve X (vagus)
50. Equipment used for objective data collection involving the eyes includes which of the following? Select all that apply.
Penlight.Ophthalmoscope.Snellen chart.Occlusive covers (p. 315)
60.-A client has been diagnosed with conductive hearing loss. The nurse understands that which of the following could be the cause of this type of hearing loss?
Perforated eardrum
A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?
Perform a focused assessment
13. On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?
Perform both the distant and near visual acuity tests (p. 318)
Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?
Psoriasis
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?
Psoriasis, fungal infections, trauma
49.-The client tells the nurse that he has been coughing up pink frothy sputum. The nurse notifies the health care provider because the client may have what condition?
Pulmonary edema
36.The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?
Reassess blood pressure
The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?
Reassess blood pressure
A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?
Macule
65.The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
86.The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
13.-Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
Narrowing or partial obstruction of an airway passage
Auscultation of a 23 year old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
Narrowing or partial obstruction of an airway passage
84.A client with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the client's chart. The nurse knows to look at what part of the client's medical record to check the current medical diagnosis?
Progress notes
85.The nurse is reviewing the client's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the client's status?
Progress notes
9.A nurse is maintaining a problemoriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?-
Progress notes
A client with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the client's chart. The nurse knows to look at what part of the client's medical record to check the current medical diagnosis?
Progress notes
The nurse is reviewing the client's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the client's status?
Progress notes
A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope
61.The medical record serves many purposes. What are they? (Select all that apply.)
Research-Framework for medical information-Care planning-Means for financial reimbursement
4.-When percussing the anterior chest for tone a nurse should anticipate what tone over the majority of the lung fields?
Resonance
A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?
Resonance
A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low pitched, hollow sound, indicating normal lungs. Which of the following describes this finding? -
Resonance
What would be the expected tone elicited by percussion of a normal lung?
Resonance
25.-When percussing the posterior lung fields which of the following findings is expected?
Resonance over all lung fields
When percussing the posterior lung fields, which of the following findings is expected?
Resonance over all lung fields
A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?
Sibilant wheezes heard primarily during expiration but may also be heard on inspiration
8. A nursing student realizes that which of the following is an important variation of communication?
Silence
13.A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?
Specialty area assessment form
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?
Sternocleidomastoid
What is used to gauge central and peripheral nervous system disorders?
Strength of a reflex
1.-A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?
Stridor
A high pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?
Stridor
25.To make a legal entry into the medical record, the nurse must document what?
Time of the assessment
3.To make a legal entry into the medical record, the nurse must document what?
Time of the assessment
To make a legal entry into the medical record, the nurse must document what?
Time of the assessment
A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?
Tinea Corposis
21.-During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates loop diuretics, quinidine, quinine, or aminoglycosides?,
Tinnitus and sensorineural hearing loss
33.After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?
To communicate effectively with other health care team members
After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?
To communicate effectively with other health care team members
A nurse is interviewing a client regarding his personal health history to obtain subjective information to assist in her assessment of his skin. She asks him, "Have you has any recent hospitalizations or surgeries?" Which of the following is the best rationale for asking this question?
To determine the client's risk for acquiring a methicillin-resistant Staphyloccoccus aureus (MRSA) infection
A nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, "Do you send long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question?
To determine the clients risk for pressure ulcers
While performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?
To determine whether a structure is filled with air or fluid or is a solid structure
What is the importance of assessing vital signs? (Select all that apply.)
To establish a baseline To monitor risks for alterations in health To evaluate the client's responses to treatment
101.A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?
To have up-to-date information on which to base clinical decisions
41.A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?
To have up-to-date information on which to base clinical decisions
62.A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?
To have up-to-date information on which to base clinical decisions
81.A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?
To have up-to-date information on which to base clinical decisions
A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?
To have up-to-date information on which to base clinical decisions
1.A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events
100.A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events
22.A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events
A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events
When would a nurse obtain a mid-arm circumference measurement?
To provide percentage of body fat and muscle tissue.
Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is the best rationale for this action?
To see the client before the client assumes a social face or behavior
48.-When assessing a client the nurse notes that the tonsils are touching the uvula. How would the nurse document the tonsils?
Tonsils are T3
A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)?
Systolic pressure
Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?
Systolic pressure 180 mm Hg.
29.A nursing instructor is teaching how to document vital signs on the chart. The student demonstrates understanding of accurate documentation when she makes the following recording
T 37C, P 80, R 12 breaths/min, BP 118/62 mm Hg.
When inspecting structures such as the jugular venous pulse, what would be the best lighting to use?
Tangential lighting
9.-The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?
Teaching strategies to reduce complications of existing diagnoses
The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?
Teaching strategies to reduce complications of existing diagnoses
A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them?
Temperature, pulse, respirations, and blood pressure
5. As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?
The client and the examiner see the examiner's finger at the same time. (p. 318).
A client has an oral temperature of 37.2 °C (99 °F). The nurse interviews the client. Which of the following pieces of interview data could be an influence on this high body temperature?
The client has just run 4.82 km (3 miles) outside before coming to the interview.
38.-A nurse is admitting a client to the hospital. When reviewing the client's medical record the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means?
The client has unilateral hearing loss
29. The nurse is educating a client from another country about the medications they will be taking. The client continually interrupts the nurse during the conversation. When the nurse considers the many ways cultural differences can affect communication, how should the nurse interpret the client's interruptions?
The client is deeply engaged in the conversation.
49. The nurse is educating a client from another country about the medications they will be taking. The client continually interrupts the nurse during the conversation. When the nurse considers the many ways cultural differences can affect communication, how should the nurse interpret the client's interruptions?
The client is deeply engaged in the conversation.
During a general survey, the nurse asks if the client is feeling cold. What did the nurse most likely observe in the client?
The client is wearing clothing that is inconsistent with warm weather.
A nurse assesses a female client's core body temperature and finds that she has a slightly elevated temperature. Which of the following factors could explain this finding? Select all that apply.
The client just finished exercising. The client is ovulating. The client is stressed.
Which of the following should be included in the documentation of subjective data in the nurse's findings from the physical examination of the head and neck in the client with acute neck pain?
The client reports worsening pain in the neck when she looks down.
12.A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.
The client's weight-lifting routineThe client's occupationThe client's family history of cancer
91. An elderly client is touring the United States and has a heart attack. When admitting this client to the coronary care unit, what would be important to note in the family history?
The decision makers for the family
69. Suzie is a 16-year-old daughter in the Hanes family. She is the youngest of five children. She has had a series of illnesses and does not seem to be regaining her strength. She likes school but is falling behind a bit. Her mother is very attentive to her needs but does not seem overly concerned with the continuing pattern of illness. Which of the following is most likely a Hanes family belief?
The family values taking sick roles and caregiver roles.
The nurse is assessing a new client's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the client's systolic blood pressure?
The first appearance of faint but distinctive tapping sounds
41. A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?
The larger the bottom number, the worse the visual acuity.(p. 316)
When assessing the breath sounds of a newly admitted client, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse?
The lung has become airless
Which of the following statements most accurately provides the underlying rationale for the use of auscultation and percussion as assessment techniques?
The nature and elasticity of tissue and body structures influence sound.
25. The nurse is caring for a first-time mother and newborn in the postpartum unit. The nurse overhears the new mother ask family members to prepare the nursery and purchase clothing for the baby. What would the culturally sensitive nurse suspect?
The new mother may believe buying infant clothing before the delivery is bad luck.
47. The nurse is caring for a first-time mother and newborn in the postpartum unit. The nurse overhears the new mother ask family members to prepare the nursery and purchase clothing for the baby. What would the culturally sensitive nurse suspect?
The new mother may believe buying infant clothing before the delivery is bad luck.
5. The nurse is caring for a first-time mother and newborn in the postpartum unit. The nurse overhears the new mother ask family members to prepare the nursery and purchase clothing for the baby. What would the culturally sensitive nurse suspect?
The new mother may believe buying infant clothing before the delivery is bad luck.
20.-Which action by the nurse is consistent with Weber's test?
The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.
Which illustrates the nurse using the technique of inspection?
The nurse detects a fruity odor of the client's breath.
13. What must occur before a client will be willing to teach the nurse about her culture?
The nurse needs to establish rapport and trust
Which describes the nurse using the technique of palpation?
The nurse notes increased warmth surrounding an abdominal incision.
Which describes the nurse using the technique of percussion?
The nurse notes resonance over the individual's thorax.
13.-Which action by the nurse is consistent with the Rinne test?
The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction.
A client comes to the cardiovascular intensive care unit (CVICU) directly after a three-vessel coronary artery bypass graft (CABG). The client's orders state "maintain systolic blood pressure greater than 90 but less than 120." How does this order affect the monitoring of the client's blood pressure?
The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits
29.-A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?
The short process of the malleus
48.-A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?
The short process of the malleus
14.-The nursing instructor is discussing the difference between sensorineural and conductive hearing loss with his class. The discussion turns to evaluation for determining what kind of hearing loss a client has. What Weber test results would indicate the presence of a sensorineural loss?
The sound is better in the ear in which he has better hearing.
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?
The underlying bones
A client asks why the nurse touches the area near the arm pit when conducting a breast examination. What should the nurse respond to this client?
The upper outer quadrant of the breast extends into the axillae
45.-A 52-year-old client fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?
The vestibular portion of the inner ear
A nurse is assessing the blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
There is an auscultatory gap
Palpation of a 15 year old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?
There is an infection in the area that these nodes drain.
40. A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?
There is no reaction in the opposite pupil to light (p. 324)
70. Which of the following statements is true of sickle cell disease and other hemoglobinopathies?
They are associated with high-malaria environments.
46. What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client?
Thick, purulent drainage is noted at inner corner of both eyes.
The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2cm lump that is fixed and hard. Why does this finding require emergency investigation?
This could be a sign of cancer
The nurse notes that a client has the thoracic structure shown. How should the nurse document this finding?
Thoracic kyphoscoliosis
When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?
Thready pulse
51.A nurse is documenting a skin condition that she has observed while examining a client. Which of the following descriptions would be most appropriate to include in the client's chart?
Three lesions, 5 mm in diameter, producing purulent yellow drainage on the client's right anterior forearm
29.-A 58-year-old man who is HIV-positive has presented with thick white plaques on his oral mucosa. What diagnosis would the nurse first suspect?
Thrush
37.-When assessing the client's risk for hearing loss it is important to ask about the history of exposure to noise. What related client teaching would be important? (Select all that apply.)
Types of protective equipment usedInstructions for the use of protective ear equipmentEffectiveness of protective equipment
60.-Which food is most appropriate for the nurse to recommend for a client who suffers frequent nosebleeds due to hereditary hemorrhagic telangiectasia?
Vegetable omelet
An inexperienced nurse has just performed percussion on a client's chest and detected hyper resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Verify the data by having another nurse come in to perform the percussion.
12.-When planning care for a client with an inner ear infection the nurse will need to include interventions for which of the following potential problems?,
Vertigo
Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding?
Vesicle
13.-When visualizing the structures of the nose the nurse recalls that air travels from the anterior nares to the trachea through the
Vestibule, nasal passages, and nasopharynx
43.-The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is composed of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
Warm and humidify inspired air
49.-You are teaching a physiology class for pre-nursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer?
Warm the inspired air
Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply
Wash hands, Identify ways to ensure client privacy, Obtain and check needed equipment.
The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?
Watch chest movement before removing the stethoscope after counting the apical beat
39.-A nurse performs an initial examination of a client brought to the emergency department after sustaining a head injury in an automobile accident. Which characteristic of discharge from the ears should alert the nurse that the client has a cerebrospinal fluid leak?
Watery or bloody
A nurse is preparing a client for a physical examination of his skin, hair and nails. Which of the following interventions should the nurse implement?
Wear gloves when palpating lesions, having the client remove his toupee, use sunlight if possible to inspect the skin, keep the room door closed.
40.-The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?
Weber's test
62.-The submandibular glands open under the tongue through openings called
Wharton ducts.
A nurse is examining a client suspected of having a fungal infection of the skin. Which piece of equipment should the nurse use to confirm the presence of fungus?
Wood's
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Wood's light
36.-During an assessment the nurse observes the client's throat as shown. Which cranial nerve should the nurse suspect is damaged in this client?
X
38. A client comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse?
You will need to see the doctor to have your eyes checked
It would be a priority for the nurse to provide counseling about nutrition and exercise for weight loss for which client?
a client with body mass index of 27 and blood pressure of 145/80 mm Hg
A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is
a foreign body obstruction
The nurse is assessing a dark skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of
a great degree of cyanosis
The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of
a metastasis
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had
a recent illness
While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for
acromegaly.
19. What aspects of culture are relevant when conducting a health assessment on a foreign-born client admitted for surgery? Select all that apply.
alternative medicine practices nutritional or dietary considerations whether there are any existing language barriers
57. What aspects of culture are relevant when conducting a health assessment on a foreign-born client admitted for surgery? Select all that apply.
alternative medicine practices nutritional or dietary considerations whether there are any existing language barriers
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
an infectious process
While conducting a physical examination, the nurse notices the client's mucous membranes are pale in color. Which nutritional deficiency is most likely for this client?
anemia
15.-A bony ridge located at the point where the manubrium articulates with the body of the sternum is termed the sternal
angle.
A client denies performing breast self-examination however practices breast awareness. What is this client focusing on when following this practice?
appearance, feel, and shape
The apex of each lung is located at the
area slightly above the clavicle
16.-The apex of each lung is located at the
area slightly above the clavicle.
36.-The apex of each lung is located at the
area slightly above the clavicle.
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
areola of the breast
Elevated sebaceous glands, known as Montgomery glands, are located in the breast's
areolas
To assess for anemia in a dark skinned client, the nurse should observe the client's skin for a color that appears
ashen
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
ask client to breathe deeply through mouth
The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first
ask the client if touching the head is permissible.
44.-The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
ask the client to breathe deeply through her mouth.
20. A client from a non-English speaking culture is experiencing a health problem. What should the nurse do to ensure that communication with this client is culturally appropriate?
be respectful of the client's culture
39. A client from a non-English speaking culture is experiencing a health problem. What should the nurse do to ensure that communication with this client is culturally appropriate?
be respectful of the client's culture
The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
bilateral lung sounds clear."
During an assessment the nurse suspects that a client has a vitamin C deficiency. What information did the nurse use to make this clinical determination?
bleeding gums
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
blocked lymphatic drainage
While assessing an adult client's feet for fungal disease using a wood light, the nurse documents the presence of a fungus when the florescence is
blue
When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using
blunt percussion.
While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client?
bone.
A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?
bradypnea
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
chronic bronchitis
The nurse is assessing an African American clients skin. After the assessment, the nurse should instruct the client that African American persons are more susceptible to
chronic discoid lupus erythematosus
28.-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
chronic obstructive pulmonary disease.
18.-During the physical examination of the mouth the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem?
herpes simplex
9. Care that considers the client's body, mind, and spirit is which type of nursing care?
holistic care
Which type of discharge should a nurse consider normal with palpation of the nipples during a breast examination of a nonlactating female client?
clear
When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding?
coarse crackles
A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply)
complete, accurate, timely, organized, concise
53.-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
conductive hearing loss.
26.-The transmission of sound waves through the external ear and the middle ear is known as?
conductive hearing.
The nurse is examining the breast of a clinic client and palpates a lump. What would the nurse be sure to document about this lump? Select all that apply.
consistency, distinctness, mobility
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
contraceptives
30. A male nurse is caring for an elderly woman who has become withdrawn and somewhat confused since the nurse has come on duty. When the nurse goes into the room to bathe the client, she refuses to allow it. The best explanation for her actions would be which of the following?
cultural differences
32.-What characteristic nail color should the nurse recognize as an indication of hypoxia?
cyanotic
An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of
decreased body metabolism.
During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing
deep palpation.
During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing?
deep palpation.
25.-The nurse is planning to inspect an adult client's mouth using a tongue depressor. The nurse should plan to
depress the tongue blade slightly off center.
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
depression
Hair follicles, sebaceous glands, and sweat glands originate from the
dermis
24.A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
details are often missing
A teenaged client is seen by the nurse for report of excessive thirst and weight loss despite high food intake. Which health condition is most likely responsible for these symptoms?
diabetes mellitus
43.-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
diabetic ketoacidosis.
The nurse is concerned that a client has undiagnosed cancer of the breast. What assessment finding is most likely related to this clinical determination?
dimpling
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
disturbed body image related to mastectomy
The client reports to the nurse that she is concerned she has cancer as she has been experiencing clear discharge from her breasts. What is the best response of the nurse?
do you take meds
8.- Before examining the mouth of an adult client the nurse should first
don clean gloves for the procedure.
17.If the nurse makes an error while documenting findings on a client's record, the nurse should
draw a line through the error, writing "error" and initialing.
If the nurse makes an error while documenting findings on a client's record, the nurse should
draw a line through the error, writing "error" and initialing.
The nurse percusses the lungs of a client with pneumonia. What percussion note would the nurse expect to document?
dullness
One disadvantage of the open
ended assessment form is that it - requires a lot of time to complete.
39.One disadvantage of the open
ended assessment form is that it-requires a lot of time to complete.
58.One disadvantage of the open
ended assessment form is that it-requires a lot of time to complete.
The nurse is assessing a 15 year old male and finds soft, fatty enlargement of breast tissue. The nurse would document this as what?
gynecomastia
88. The nurse knows that nonverbal communication can be difficult to interpret among of people of different cultures because of the many variations. These variations include which of the following? (Select all that apply.)
hand gestures patterns of space touch eye contact
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 further instructions when the student says that one risk factor is
having a baby before 20 years old
Under normal circumstances, the strongest stimulus to breathe is
hypercapnia
50.-After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination?
hyperresonance
A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?
hyperresonance
The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?
hyperthyroidism
A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of
hypothyroidism
While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of
hypoxia
A client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?
impaired gas exchange
A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?
ineffective airway clearance
Light palpation is most appropriate to assess the
inflamed areas of skin
The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?
inflammation of the parietal pleura
The only layer of the skin that undergoes cell division is the
innermost layer of the epidermis
Which characteristics are present in a cancerous breast lesion? Select all that apply.
irregular shape, nontender, retraction of nipple
An adult white client visits the clinic for the first time. During the assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's
oral mucosa
Which of the following is an average normal temperature in centigrade for a healthy adult?
oral: 37.0°C
A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):
organized, timely, Complete, Accurate, concise
43.A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):
organized-accurate-concise-timely-Complete
49.A nurse is maintaining a problem
oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?-Progress notes
67.A nurse is maintaining a problem
oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?-Progress notes
The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?
otoscope
squamous cell carcinoma is associated with
overall amount of sun exposure
A 44-year-old woman comes to the clinic complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a self-breast examination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Her past medical history is significant for hypothyroidism. She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. Examination shows a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczema-like crust around her nipple. Underneath a nontender 2-cm mass is palpable. The axilla contains only soft moveable nodes. The left breast examination and axilla are unremarkable. What visible skin change of the breast does she have?
paget's disease
112.While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the
pain relief measures.
38.While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the
pain relief measures.
A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?
palpation
While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an
parotid gland enlargement.
42.-The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's
pectus excavatum.
The nurse is having difficulty visualizing the apical impulse during a physical examination of the cardiovascular system. Which assessment tool is required for a more accurate assessment?
penlight
While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using
percussion.
113.The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection.
59.The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection.
77.The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection.
92.The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection.
The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection.
The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should
record the vital signs.
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
refer for cytology exam
A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information?
relieving factors
The nurse notes that client's breathing pattern is regular but has periods of deep, rapid breathing followed by periods of apnea. What should the nurse consider as causing this client's breathing patterns? Select all that apply.
renal failure, Drug OD, > intracranial pressure, severe congestive heart failure
17.-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
repeat the phrase "ninety-nine."
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
repeat the phrase 99
One disadvantage of the open ended assessment form is that it -
requires a lot of time to complete.
108.An inexperienced nurse has just performed percussion on a client's chest and detected hyper
resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?-Verify the data by having another nurse come in to perform the percussion.
71.An inexperienced nurse has just performed percussion on a client's chest and detected hyper
resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?-Verify the data by having another nurse come in to perform the percussion.
When inspecting the nipples, which of the following findings is unexpected?
retraction of nipple
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
right after menstruation
A nurse teaches a group of young women about how to properly perform a self breast examination. How should the nurse explain the best time to perform the exam?
right after the menstrual flow stops
A client who is an active outdoor swimmer recently received a diagnosis of discoid system lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is
risk for ineffective health maintenance related to deficient knowledge of effect of sunlight on skin lesions.
A nurse examines a client diagnosed with fibroadenoma. Which characteristic of the lump should the nurse expect to find in the client?
round, firm, well-defined
A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's
sclera
The spinous process termed the vertebra prominens is in which cervical vertebra?
seventh
A client arrives in the emergency department after a severe motor vehicle accident. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. What pathophysiological process is likely the cause of this breathing pattern?
severe brain damage
A nurse should ask a client to assume which position to begin the examination of the breasts?
sitting
The apex of each lung is located at the
slightly above clavicle
An African American female client visits the clinic. She tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear lobe. The nurse should document a
keloid
The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. The nurse anticipates that the client may be
lacking adequate finances.
The lymph nodes that are responsible for drainage from the arms are the
lateral lymph nodes
When examining the breasts of a client, the nurse finds a collection of fatty tissue that appears as a lump. The nurse knows that this is which of the following conditions?
lipoma
As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra clavicular region. This finding is consistent with which condition?
malignancy
During the physical examination of a female client, the nurse notes that the client's axillary lymph nodes are enlarged, hard, and fixed. The nurse recognizes that these findings are consistent with what disease process?
malignancy
A client visits the clinic for a routine physical examination. The nurse prepares to asses the client's skin. The nurse asks the nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a generic component with skin cancer, especially
malignant melanoma
The clavicles extend from the acromion of the scapula to the part of the sternum termed the
manubrium
35.-The clavicles extend from the acromion of the scapula to the part of the sternum termed the
manubrium.
24.-The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses the nurse should proceed to examine the
maxillary sinuses.
7.-The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses the nurse should proceed to examine the
maxillary sinuses.
Which of the following assessment findings is most likely benign on breast examination?
one larger than the other
53. The most effective way for a nurse to learn about an ethnic group within the community in which he/she practices is
spend time with a variety of individuals of that ethnic group.
81. The most effective way for a nurse to learn about an ethnic group within the community in which he/she practices is
spend time with a variety of individuals of that ethnic group.
What clinical manifestation of the nail should the nurse anticipate assessing in a client with iron deficiency anemia?
spoon nails
The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that
squamous cell carcinomas are most common on body sites with heavy sun exposure
75. A new nurse asks her preceptor if the new baby she is caring for is breast- or bottle-feeding. The preceptor tells the new nurse that the mother is Hispanic and to give the baby a bottle because Hispanics do both until the mother's milk comes in. This is an example of:
stereotyping.
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?
stridor
25.-The nurse is planning to conduct the Weber test on an adult male client. To perform this test the nurse should plan to?,
strike a tuning fork and place it on the center of the client's head or forehead.
8.-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
tuberculosis.
An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a
tumor related headache.
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?
unequal expansion of chest
Which terms are used to identify the lobes of the right lung? Select all that apply
upper lobe, middle lobe, lower lobe
19.-Which terms are used to identify the lobes of the right lung? Select all that apply.
upper lobe.middle lobe .lower lobe
A nurse is examining the breasts of a client. In which quadrant should the nurse most expect to find a tumor?
upper outer quadrant
The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?
use as a drape
To assess an adult client's skin tugor, the nurse should
use two fingers to pinch the skin under the clavicle
18.The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
validate all data before documentation of the data.
40.The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
validate all data before documentation of the data.
The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
validate all data before documentation of the data.
Short, pale, and fine hair that is present over much of the body is termed
vellus
What pattern of palpation is currently the best validated technique for detecting breast masses?
vertical strip pattern
The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's
vesicles
The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's
vital signs.
A client's skin color depends on melanin and carotene contained in the skin, and the
volume of blood circulating in the dermis
49.-A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear
whispered sounds
To alleviate a client's anxiety during a comprehensive assessment, the nurse should
xplain each procedure being performed and the reason for the procedure.
44.During the chest auscultation portion of a general survey, a 31
year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?-"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
The thoracic cavity contains which of the following organs? Select all that apply.
·Heart · Most of the esophagus · Lungs
At what percent of weight over ideal weight is a person considered obese?
20%
10. Which Vision acuity reading indicates blindness?
20/200 (p. 307)
48. A client in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?
20/200 or less (p. 317)
A nurse is working with a client whose ideal body weight is 172 lb. At what weight would this client first be considered obese?
206.4lb
Which of the following is the BMI that indicates the lowest risk of developing health problems?
23
A nurse assesses a 175-pound adult client who is 5 feet 11 inches tall. What is the estimated body mass index (BMI) for this client?
24.4
A nurse is measuring an adult male client's mid-arm circumference (MAC) as part of the overall assessment of the client's nutritional status. Which of the following is the standard reference for the MAC for an adult male?
29.3 cm
37.-The nurse examines the pharynx of a client and records that the tonsils are touching the uvula. The nurse would grade the tonsils as
3+
57.-A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching the uvula. Using a grading scale of 1+ to 4+ how should the nurse appropriately document the tonsils?
3+
An individual is considered obese when his or her BMI is:
30-39
3.-A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+ how should the nurse appropriately document the tonsils?
4+
The nurse encourages a client to perform a monthly self-breast examination between what days of the menstrual cycle?
4-7
A waist circumference of greater that which of the following is indicative of excess abdominal fat in men?
40
A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?
45 to 60
A nurse assesses a 350-pound adult client who is 6 feet 1 inch tall. What is the estimated body mass index (BMI) for this client?
46
When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet?
5
When should a woman conduct self breast examination with respect to her menses?
5 - 7 days following menses
61. If a client seems reluctant to make eye contact, a health care provider should consider the possibility that this is which of the following?
An indication of discomfort or intimidation
A nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mm Hg. What is this client's pulse pressure?
50 mm Hg
A nurse recognizes that which client is at greatest risk for the development of skin cancer?
55-year-old male who lived in California for 20 years
A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?
< 90 deg
90.A nurse is explaining to a new client that the office uses electronic health records (EHRs) for all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR?
A record supplied by a physician in which diagnoses and prescribed treatments are recorded
A nurse is explaining to a new client that the office uses electronic health records (EHRs) for all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR?
A record supplied by a physician in which diagnoses and prescribed treatments are recorded
54.-A client has Darwin tubercle. What is this?
A small painless nodule on the helix
A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?
A stage III ulcer
11.A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?
A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight
A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?
A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight
Which of the following clients is most likely to be diagnosed with migraine headaches?
A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room
Where is the temporal artery palpated?
Above the cheek bone near the scalp line
A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status?
Accessibility
35. The functional reflex that allows the eyes to focus on near objects is termed
Accommodation (p. 307)
31.-A client presents to the health care clinic with reports of a 3-day history of fever sore throat and trouble swallowing. The nurse notes that the client is febrile with a temperature of 101.5°F tonsils are 2+ and red and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?
Acute Pain
Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?
Acute infection
A client with scabies visits the health care facility for a follow up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?
Adequate lighting
The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what?
Alcohol-based rub
A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones? Select all that apply
Angle the binaurals towards the nose, Readjust the ear pieces to ensure a snug fit, Eliminate distracting noises from the environment
53.-When collecting a client's medical history the nurse should ask if the client is taking which medications that most likely contribute to complaints of recurrent epistaxis? (Select all that apply.)
Anticoagulants . Herbal supplements. Antihistamines
A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?
Anxiety
Before assessing vital signs, the nurse knows that it is important to assess what?
Any medications the client is currently taking
95.The nurse manager reviews documentation completed by a graduate nurse. Which entry should the manager question? Select all that apply
Appetite good-Right foot swollen-Vital signs normal
After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?
Application of an alcohol-based hand rub
Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?
Ashen gray
The nurse is assessing a client's readiness to quit smoking. Place in order the steps in which the nurse will conduct this assessment.
Ask about tobacco use, Advise to quit, Assess willingness to quit, Assist to quit, Arrange follow-up
A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background?
Ask permission before palpating the head and neck
The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action?
Ask permission to talk to the client in front of visitors.
44. A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?
Ask the client about previous trauma to the eyes (p. 323)
44.-Which action by the nurse is appropriate to provide a clear view of the uvula for observation?
Ask the client to say "aaah"
The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first?
Ask the client to sip and swallow water.
A client has arrived to the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do?
Ask the client to sit quietly in a chair for 5 minutes.
A nurse is inspecting a client's breasts. The nurse notices that one breast is larger than the other. Which action should the nurse take next
Ask the client whether the larger breast has increased in size recently
7.-A mother of a small child calls the clinic and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action?
Ask the mother how long the tubes have been in place.
14.A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?
Ask the other nurse to read back what first nurse reported
59.-Upon inspection of an elderly client's ears using an otoscope the nurse observes a cloudy appearance to the tympanic membranes with prominent landmarks. What action should the nurse perform first?
Ask whether the client is experiencing ear pain or pressure
42.-High doses of this medication can produce bilateral tinnitus?
Aspirin
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?
Assess the client regarding characteristics of the pain
A 57 year old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?
Assess the client's blood pressure.
An 86-year-old male client with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. As well, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with assessment?
Assess the client's temperature by axilla
A 66 year old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?
Assess the woman for hypothyroidism.
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles
Attempting to roll the structure up and down and side to side
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?
Auscultate with the bell over the lateral lobes
The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?
Begin above the right clavicle and percuss each section comparing the right chest with the left chest.
10. A nurse assesses a 4-year-old boy who experiences gas, a stomachache, and diarrhea after consuming lactose products. The nurse recognizes the data as what type of biological variation?
Biochemical
15.-A nurse is assessing the mouth of a client and finds that she has a smooth red shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?
B12
4.-A nurse is assessing the mouth of a client and finds that she has a smooth red shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?
B12
55.-A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding the nurse should suspect which of the following causes?
Bacterial infection
The healthcare provider states that the client's blood count with differential demonstrates a shift to the left. The nurse expects to see which lab result when reviewing the differential?
Bands greater than 10%
31. The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should
position the client 609.6 cm (20 ft) away from the chart. (p. 316)
While performing an examination of the head and neck, a nurse notices left sided facial drooping. The nurse recognizes this as what condition?
Bell's palsy
24. Employ the right eye to examine the client's right eye
Blunt force trauma often results in fracture of the orbit (P. 304)
25. Blunt force trauma often results in fracture of the orbit
Blunt force trauma often results in fracture of the orbit (p. 317)
31. In preparing to assess a client from a different culture, a nurse is aware that one needs to assess both factors that affect the client's approach to providers and factors that affect the client's disease, illness, and health state. Which of the following is a factor the nurse should consider that primarily affects the client's approach to providers?
Body language
52.In preparing to assess a client from a different culture, a nurse is aware that one needs to assess both factors that affect the client's approach to providers and factors that affect the client's disease, illness, and health state. Which of the following is a factor the nurse should consider that primarily affects the client's approach to providers?
Body language
67. In preparing to assess a client from a different culture, a nurse is aware that one needs to assess both factors that affect the client's approach to providers and factors that affect the client's disease, illness, and health state. Which of the following is a factor the nurse should consider that primarily affects the client's approach to providers?
Body language
Waist circumference guidelines may not be accurate for adult clients who are shorter than 152.4 cm (5 ft) in height. This restriction is also a concern for which other anthropometric measurement?
Body mass index (BMI).
15. Which of the following statements is true about biologic variation?
Both genetics and environment produce biologic variation.
34. Which of the following statements is true about biologic variation?
Both genetics and environment produce biologic variation.
A nurse cares for a client with a stage 2 pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?
Broken, with the presence of a blister
Which of the following statements relating to assessment of the lungs and thorax is most accurate?
Bronchitis is characterized by excess mucus production and chronic cough
The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?
Bruit
42. The conjunctiva of the eye is divided into the palpebral portion and the
Bulbar portion (p. 304)
82.One of the goals of nursing is to provide care that is safe to clients. What is the best way for nurses to realize this goal?
By continual communication with all members of the health care team
9.-The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to
position the handle of the otoscope to one side.
40.-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
Candida albicans infection.
The nursing assistant obtains vital signs and reports a blood pressure of 180/95 to the nurse. What is the nurse's best action?
Instruct the nursing assistant to obtain a manual blood pressure.
A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?
Marfan syndrome
The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?
C7
Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?
COPD
A nurse is working with a client with a chronic disease that has contributed to the client developing cachexia, a type of malnutrition. As a result, the client demonstrates abnormal metabolic rate, anorexia, muscle wasting, severe weight loss, and general decline in condition. Which chronic disease, strongly associated with cachexia, does the client most likely have?
Cancer
54.-An older client who wears dentures complains of having sore gums. What can the nurse instruct the client to help with this problem?
Massage the gums every day.
A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease?
Change in size, bleeding of a mole, asymmetrical, itching
59.-A nurse is working with a client from Asia who has just been diagnosed with oropharyngeal cancer. Which culture-related risk factor should the nurse most suspect in this client?
Chewing betel nuts
22.-What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?
Cheyne-Stokes
107.A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
A nurse is providing nutritional instruction to a client with cardiovascular disease. The nurse mentions a nutrient that is a necessary component of bile salts (which aid in digestion), serves as an essential element in all cell membranes, is found in brain and nerve tissue, and is essential for the production of several hormones such as estrogen, testosterone, and cortisone. The nurse warns the client, however, that this nutrient when consumed in excess can lead to heart attacks and strokes. To which of the following nutrients is the nurse referring?
Cholesterol
53. The middle layer of the eye is known as the
Choroid layer (p. 305)
29.-A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?
Chronic obstructive lung disease
During the physical assessment of a client, a nurse observes that the client tends to lean forward, using the arms to support the upper body. The nurse recognizes this as a sign of what disease process?
Chronic obstructive pulmonary disease
16.Which assessment is most likely performed when a client is admitted to the hospital?
Comprehensive
Which assessment is most likely performed when a client is admitted to the hospital?
Comprehensive
2. A client comes to the ED with lower abdominal pain. She is extremely emotional and moving wildly on the gurney. A nurse says to another nurse that the client is "way overdoing it." What action should the nurse take to best provide care for this client?
Conduct a cultural assessment to better understand the client's perception of pain and illness.
42. A client comes to the ED with lower abdominal pain. She is extremely emotional and moving wildly on the gurney. A nurse says to another nurse that the client is "way overdoing it." What action should the nurse take to best provide care for this client?
Conduct a cultural assessment to better understand the client's perception of pain and illness.
30. 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
Corneal damage (p. 309)
A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?
Meningitis
Since the nurse is unable to obtain an oversized cuff to assess an adult client with a large arm, the nurse uses an average-sized cuff. What blood pressure reading will the nurse most likely obtain for this client?
Reading will be high
70.A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
89.A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
28. A new graduate nurse from a small community college is going to work in an urban setting. She embraces the thought of working in a more diverse setting and wants to learn about different cultures. What behavior is this nurse exhibiting?
Cultural desire
6. A new graduate nurse from a small community college is going to work in an urban setting. She embraces the thought of working in a more diverse setting and wants to learn about different cultures. What behavior is this nurse exhibiting?
Cultural desire
77. A new graduate nurse from a small community college is going to work in an urban setting. She embraces the thought of working in a more diverse setting and wants to learn about different cultures. What behavior is this nurse exhibiting?
Cultural desire
27. The nurse knows that she will be caring for a client from Southern Korea who has been visiting with a family member. The nurse obtains some information about the Korean culture so that she will be able to meet the clients needs. What is the nurse demonstrating?
Cultural knowledge
A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?
Cushing's disease
On which health problem should the nurse focus when assessing this client?
Cushing's syndrome
A nurse is collecting a through and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response?
Nail problems can be caused by an underlying systemic illness
29. A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?
Corrective lenses (p. 309)
104.A nurse charting the medical record for a client knows that which of the following forms of charting involves writing information about the client and client care in chronological order?
Narrative charting
The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?
Cranial nerve VII
22.-A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?
Cranial nerve XII (hypoglossal)
A nurse is assessing the general status and vital signs of a client. Which of the following are subjective findings, which the nurse obtained from the client? Select all that apply
Date and location of the clients last blood pressure check Onset and character of the clients chest pain A list of all of the client's current medications
14.-A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client?
Cyanotic
The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client?
Cyanotic left lower extremity
A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?
Document this as an expected assessment finding
19.Why is accurate and effective documentation most important?
Documentation constitutes a legal record.
Why is accurate and effective documentation most important?
Documentation constitutes a legal record.
A nurse cared for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?
Documents the findings in the client's record as normal
An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "result of an accident." The nurse suspects that the client may be experiencing
Domestic abuse
The nurse would use what part of the hand when assessing temperature during palpation?
Dorsal surface
The nurse is conducting a physical examination of a client who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?
Dorsiflexion of the foot
53.A nurse makes an incorrect entry onto a client's paper record during documentation of the assessment data. What is the correct way for the nurse to fix this error?
Draw a line through the error, write "error," and initial the entry.
34.-What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?
Dullness
57.-What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?
Dullness
46.-A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?
Hyperresonance
Which clinical manifestation should the nurse expect to find in a client with edema?
Decreased skin mobility
The nurse should know that some disease processes affect facial expression. What are they? (Mark all that apply.)
Depression Parkinsonism Hyperthyroidism
A nurse is working with a 13-year -old boy who complains that he has begun to sweat a lot more than he used to. He asks the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of the skin?
Dermis
72. The nurse spends a day off in a part of a non-English speaking community in order to learn more about the culture to improve interactions when providing client care. What cultural activity is this nurse demonstrating?
Desire
42.A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
Details are often missing
63.A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
Details are often missing
A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
Details are often missing
59. What should a nurse do to ensure an effective face-to-face interaction with clients from different cultural backgrounds?
Develop a cultural habit and build effective relationships
74. What should a nurse do to ensure an effective face-to-face interaction with clients from different cultural backgrounds?
Develop a cultural habit and build effective relationships
87. What should a nurse do to ensure an effective face-to-face interaction with clients from different cultural backgrounds?
Develop a cultural habit and build effective relationships
43. A new graduate nurse, attending a hospital orientation, is asked to explain what the goals of a cultural assessment include. What would be the graduate nurse's best answer?
Developing and implementing a culturally congruent plan of care
73. A new graduate nurse, attending a hospital orientation, is asked to explain what the goals of a cultural assessment include. What would be the graduate nurse's best answer?
Developing and implementing a culturally congruent plan of care
85. A new graduate nurse, attending a hospital orientation, is asked to explain what the goals of a cultural assessment include. What would be the graduate nurse's best answer?
Developing and implementing a culturally congruent plan of care
11. A nurse is assessing a client from India who complains of panic, sexual dysfunction, fatigue, weakness, and loss of appetite. Which culture-bound syndrome should the nurse suspect in this client?
Dhat
51. A nurse examines a client's retina during the ophthalmic examination and notices light colored spots on the retinal background. The nurse should ask the client about a history of what disease process?
Diabetes (p. 326)
A client presents to the health care clinic and reports the appearance of a rough texture and darkening color to the skin around the neck. The nurse knows this client should be assessed for which disease process?
Diabetes mellitus
19. The nurse is teaching about the importance of regular eye examination and should include information about which conditions that place clients at highest risk for blindness?
Diabetes.Hypertension (p. 326)
12.-Which of the following muscles is primarily responsible for thoracic cavity enlargement?
Diaphragm
Which of the following muscles is primarily responsible for thoracic cavity enlargement?
Diaphragm
Body temperature is not impacted by which of the following factors?
Diet
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?
Disinfect the stethoscope before touching the client
2.-Which question asked by the nurse is assessing problems with tinnitus?
Do you experience buzzing in your ears?"
15. 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?
Document the findings in the client's records. (p. 330)
During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse?
Document this as a normal finding
34.-A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?
Dysphagia
2.-A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?
Dyspnea
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding
Dyspnea
The student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs?
Hyperresonant
39.-During assessment of the oral cavity the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?
Either side of the frenulum on the floor of the mouth
The paramedics are called to a gym to see an individual who has been exercising and developed pain in the upper right quadrant of the abdomen. The initial vital sign reading indicates a pulse of 175 beats per minute. This pulse would be considered what? (Mark all that apply.)
Elevated due to pain Elevated due to anxiety Elevated due to activity
26. Blunt force trauma often results in fracture of the orbit
Exopthalmos (p. 321)
8. What is a characteristic symptom of Graves hyperthyroidism
Exopthalmos (p. 321)
17. When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding?
Exotropia (p. 319)
50. A nurse recognizes that the belief that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others is called what?
Ethnocentrism
65. A client requests to be cared for by a nurse who is a member of his own culture. The nurse recognizes that which barrier exists in regards to this client's nursing care?
Ethnocentrism
7.-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?
Evaluate changes in respiratory pattern and rate.
30.The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
46.The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
7.The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
Which of the following is a general procedural rule when performing a complete physical examination?
Examine the right then the left side of the body.
Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for?
Examining the tongue
A nurse is preparing to examine a 45 year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?
Explain the importance of the examination and the risks of breast cancer
58.-An avid swimmer presents with ear pain. Her history includes pain and drainage from the left ear. On examination she has pain when the ear including the tragus is manipulated. The canal is narrowed and erythematous with some white debris in the canal. The rest of the examination is normal. What diagnosis would be most appropriate for this client?
External otitis
114.During an accrediting agency visit, it is found that some client care standards are not being met. Where should problem solving occur in this instance?
Facility level
93.During an accrediting agency visit, it is found that some client care standards are not being met. Where should problem solving occur in this instance?
Facility level
A nurse is teaching a class on hypertension in a community setting. What risk factor would the nurse be sure to address to the class?
Family history
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?
Fixed to underlying tissue
45.-A client comes to the clinic and states "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?
Fluid in the alveoli
35.A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?
Focused
55.A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?
Focused
A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?
Focused
39. A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?
Focused on the bridge of the nose (p. 319)
7. The student nurse is aware that culturally competent care is described as which of the following?
Following five constructs of cultural awareness, knowledge, skill, encounters, and desire
51.-A nurse asks a client to say "ninety-nine" while palpating the posterior thorax. The nurse is demonstrating effective technique in assessing for what respiratory characteristic?
Fremitus
21.-What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?
Friction rub
79.What are the primary frameworks used in conducting a health assessment? Select all that apply
Functional systems-Head to toe-Body systems
33.-The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?
Funnel chest
32. A nurse is assessing a Navajo client, who has presented to the health clinic with complaints of feeling endangered, confusion, bad dreams, and hallucinations. Which culture-bound syndrome should the nurse suspect in this client?
Ghost sickness
63.-During an assessment the nurse observes the condition shown in the client's mouth. What should the nurse suspect is occurring with this client?
Gingival hyperplasia
When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head?
Hair color
The nurse is preparing for a physical examination of a client. What should the nurse do first?
Hand hygiene
9. What information, acquired during an eye assessment and history, would the nurse document as lifestyle habits?
Has smoked for last 12 years.Uses sunglasses when outdoors.Uses protective eyewear when appropriate
The nurse is preparing to perform a physical examination of a client who is an orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client based on his religious beliefs?
Have a nurse who is the same sex as the client examine him
2. A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?
Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time (p. 318)
22. The nurse is planning to assess a client's near vision. Which technique should be used?
Have the client read newspaper print held 14 inches from the eyes (p. 316)
56.-A client is concerned about developing lung cancer as he smoked for years. He tells the nurse that he quit smoking last year but wonders if there is anything else he can do to reduce his risk for developing this disease. Which of the following should the nurse recommend?
Having his home checked for radon
86. When caring for a client from a culturally different background, what is the goal for incorporating the client's health beliefs and practices into the nursing plan of care?
Improvement of the client's health outcomes
2.-You are caring for a client in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The client a 25-year history of smoking. You perform an assessment and ask the client about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?
Hoarseness
28.-A nurse practitioner is assessing a client in the ED following a motor vehicle accident. The client complains of ear pain. The nurse practitioner is performing an otoscopic examination. What would demonstrate the correct technique for using the otoscope?
Holding the otoscope so that the thumb is by the window, Holding the client's ear at the helix, Rotating the otoscope slightly
17.-A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose mouth throat and sinuses. What would the educator include in the presentation?
How to reduce periodontal disease
What structure is found midline in the tracheal area just beneath the mandible?
Hyoid bone
When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid
The nurse is reviewing the client's medical record. Which does the nurse recognize as accurate documentation?
Hyperactive bowel sounds are heard in all four quadrants.
47. A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition?
Hyphema
A client presents at the clinic for a routine checkup. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect?
Hypothyroidism
A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?
Hypothyroidism
The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?
In the midline, a few centimeters behind the tip of the mandible
A nurse collects nutritional information on a client. Which statement by the client needs to be validated by careful objective data?
I drink two large bottles of caffeinated beverages every day.
A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of postoperative care teaching?
I must take thyroid hormone replacement medication for the rest of my life.
23.When charting by exception is used in a health care agency, the most important aspect of this method is what?
Identifying the standards and norms for the institution
When charting by exception is used in a health care agency, the most important aspect of this method is what?
Identifying the standards and norms for the institution
54.-A client presents to the health care facility with a 2-week history of persistent dry hacky cough chest tightness and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?
Impaired Gas Exchange
An older adult client is admitted to the hospital after a fall during which the client's head was injured. While performing the admission assessment, the nurse finds a large ecchymosis over the C7 T1 area. The client reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this client?
Impaired comfort related to possible neck injury
While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?
Impending stroke
A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?
Impetigo
44. When caring for a client from a culturally different background, what is the goal for incorporating the client's health beliefs and practices into the nursing plan of care?
Improvement of the client's health outcomes
58. When caring for a client from a culturally different background, what is the goal for incorporating the client's health beliefs and practices into the nursing plan of care?
Improvement of the client's health outcomes
The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply.
Increased heart rate Increased blood pressure Increased cardiac output
Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?
Increased pulse rate
53.-A client presents to the health care facility with sudden onset of shortness of breath inability to lie flat and a deep wet cough. A nurse observes a respiratory rate of 18 breaths per minute use of accessory muscles to breathe and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?
Ineffective Airway Clearance
A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states, " I am so ugly with this rash!" Which diagnoses can the nurse confirm with this data?
Ineffective individual coping, anxiety, disturbed body image
4. A middle aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?
Instruct the client to hold the chart 14 inches from the eyes
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication? What assessment technique is performed for every body part and body system?
Inspection
Which of the following techniques are used in a physical assessment? Select all that apply
Inspection, Palpation, Auscultation
26.-A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?
Instruct the client to cough forcefully
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?
Instruct the client to cough forcefully
98.How does the client's medical record affect financial reimbursement? (select all that apply.)
Insurance companies audit client records to ensure that billing is accurate
During the examination of the breasts, a young adult client's nipples becomes erect and the areolas pucker. The nurse explains to the client that these findings indicate:
Intact tactile stimulation of the area
During general inspection, the examiner:
Integrates visual, auditory, and olfactory data
47.The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
102.How does computerized documentation enhance communication? (Select all that apply.)
It is legible and time dated-It permits multiple simultaneous users- It increases compliance
Which of the following statements is true of the role of inspection in the physical examination?
It is often the source of the most physical signs.
20.-The nurse auscultates the base of the lungs to assess for what reason?
It is where fluid occurs with pulmonary edema.
10.Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings.
32.Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings.
50.Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings.
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings.
27.Examples of objective data include all the following except:
Itchy skin
Examples of objective data include all the following except
Itchy skin
During a neck assessment, where would the nurse focus palpation of the thyroid isthmus?
Just below the cricoid cartilage
the nails, located on the distal phalanges of the fingers and toes, are composed of
Keratinized epidermal cells
11.-An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis?
Kiesselbach plexus
A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?
Knee-chest
In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism?
Laboratory tests
21. A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?
Lacrimal apparatus (p. 308)
32. A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?
Lacrimal apparatus (p. 308)
36. 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 client's eye for
Lacrimal obstruction (p. 308)
A nurse is examining a client's goiter and explaining the characteristics and functions of the thyroid gland. Which of the following should the nurse mention? Select all that apply.
Largest endocrine gland in the body-Produces hormones that increase the metabolic rate of most body cells-Consists of two lateral lobes-Covered mostly by the sternomastoid muscles
50.-A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?
Laryngeal cancer
55.-A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?
Laryngeal cancer
109.The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action?
Leave the room to obtain another armband for the client.
A nurse obtains a client's blood pressure (BP) on admission in both arms: right arm BP is 130/75 mm Hg and left arm BP is 140/80 mm Hg. Which arm should the nurse use for subsequent blood pressure reading?
Left arm
74.A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply.
Legal document of care-Promoting effective communication between caregivers-A method to gather research data-Determining eligibility for reimbursement
Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?
Level of consciousness
A nurse needs to position a client in the supine position for the physical examination. The nurse should ask the client to do which of the following?
Lie on the back with legs together on the examination table.
The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?
Light
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?
Light palpation
What physical assessment technique should a nurse use to obtain a pulse on a client?
Light palpation
Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?
Limit position changes as much as possible
You should use the bell of the stethoscope when auscultating what type of sounds?
Low-frequency sounds
During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?
Lungs
The nurse feels a small mass in the neck of a client. It is mobile in both the up and down and side to side directions. Which of the following is the nurse most likely feeling?
Lymph node
68.Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?
Meaningful use of electronic health records
87.Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?
Meaningful use of electronic health records
The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?
Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing.
A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?
Measure the client's vital signs, height, and weight.
The nurse observes unlicensed assistive personnel (UAP) at a client's bedside. Which action is UAP performing as depicted in this picture?
Measuring radial pulse
The nurse is caring for a client recovering from surgery with an open wound. The nurse should encourage this client to increase the intake of which foods?
Meat and dairy products.
17.Sickle cell disease and other hemoglobinopathies such as thalassemia are often found in persons originating from which geographical regions?
Mediterranean and Africa.
52. What are the glands that are located on the tarsal plates and open on the lid margins?
Meibomian glands (p. 304)
A 5-year-old African American boy asks the nurse what makes his skin so dark. Which of the following substances is the major determinant of skin color?
Melanin
A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal inflammation
A 38 year old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over the counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?
Migraine
A client reports right sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?
Migraine headache
A nurse is assessing the nutritional status of an elderly client. Which of the following tools would be best for the nurse to use for this client?
Mini nutritional assessment (MNA-SF)
68. The nurse is assessing a client and notices that when being asked questions, the client does not make eye contact. The nurse should include what in the plan of care?
Minimal eye contact due to culture
What included in personal protective equipment? Select all that apply
Mouth, nose, eye protection Gloves Gown
Which statement by the client about the skin needs validation by the collection of objective data by the nurse?
My feet hurt and are always cold to the touch
A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?
Neuropathic
5.-When teaching a class of school-age children about hygienehe nurse should include which information about the ears?,
Never put anything smaller than your elbow in your ears.
82. Which of the following statements is true of cultural groups and magico-religious beliefs in their health belief systems?
No culture is without an element of magico-religious beliefs.
Which assessment form provides a nurse with the ability to compare nursing data across clinical populations, settings, geographical areas, & time?
Nursing minimum data set
The nurse aide reports to the nurse that an older adult client has abnormal vital signs. What is important to remember in this type of situation?
Normal readings vary according to age
89. A nurse is aware that pregnancy and childbirth hold different taboos among various cultures. Some of these taboos include which of the following? (Select all that apply.)
Not permitting the father to see mother or baby until the baby is cleaned Having the mother avoid reaching over her head to prevent the umbilical cord from going around the baby's neck Not buying baby clothes before birth
The parents of a newborn express concern upon seeing the pediatrician palpate and gently express a small amount of whitish, milk-like liquid from the baby's nipples. They anxiously ask, "What can be done to fix this problem?" What is the nurse's best response?
Nothing is wrong with your baby. This liquid will clear up spontaneously
The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse?
Notify the health care provider
34.-The nurse palpates a client's auricles and notes an enlarged lymph node on one ear. No redness is observed and the client denies pain or tenderness. What is the nurse's best action?,
Notify the healthcare provider about the finding.
A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?
Notify the healthcare provider immediately.
The nurse is admitting an elderly client with a diagnosis of congestive heart failure. Admission vital signs are respirations 38; pulse 172; blood pressure 86/72. How should the nurse best respond?
Notify the rapid response team
52.A nurse is currently in the assessment phase of the nursing process with a client. Which pieces of information should the nurse document during this phase? Select all that apply.
Nursing history-Information provided by the client-Physical assessment data
6.-When auscultating the lungs the nurse listens over symmetrical lung fields for which of the following?
One deep inspiration and expiration through the open mouth
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?
Open the mouth
A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?
Ophthalmoscope
A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?
Opiates, which may cause hypoventilation
A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?
Palmar surface
A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition?
Orthostatic hypotension
A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when client falls occur?
Orthostatic hypotension
Assessment of the pulse amplitude is accomplished by which of the following?
Palpating the flow of blood through an artery
10-A client calls the clinic and tells the nurse that the doctor told her that she has "otalgia." The client cannot remember what the doctor explained this to be. How would the nurse most appropriately respond?
Otalgia is pain in the ear."
18.-A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?
Otitis externa
51.-Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?
Otosclerosis
What can cause edema in a client with a weak heart?
Overhydration
In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following?
Palpitation
84. The nurse is caring for an adult client who is refusing pain medication after an open kidney surgery. What would the nurse include in the client's cultural assessment to understand this client's actions?
Pain assessment
32.-You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa?
Pain on manipulation of the auricle
50.-You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa?
Pain on manipulation of the auricle
56.-A client has been brought to the emergency unit of a health care facility following an automobile accident. Which finding about the lips supports the diagnosis of anemia and shock?
Pallor
52.-The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?
Palmar base
A 73 year old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?
Parkinson's disease
A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease?
Parkinson's disease
Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition?
Parotid enlargement
18.-A triage nurse is working in the emergency department of a busy hospital. Four clients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which client would be the nurse's highest priority?
Patient C
A client rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment?
Patient rated pain level as being a 5 using the rating scale.
14. As a novice nurse caring for a client from a different culture, what may the nurse find confusing or upsetting?
Patient's nonverbal communication
33. As a novice nurse caring for a client from a different culture, what may the nurse find confusing or upsetting?
Patient's nonverbal communication
A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis?
Perioral
A nurse is discussing breast self-examination (BSE) with a 60-year-old woman. Which of the following should the nurse recommend?
Picking a set day of the month that the client will remember on which to perform BSE
Which technique should the nurse use to properly assess a client's skin tugor?
Pinch the skin over the clavicle and observe its return to the original shape.
1.-Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test?
Place arms around the client without touching
3.-Which action by a nurse demonstrates proper technique for assessment of chest expansion?
Place both hands on the posterior chest at T9 press thumbs together and then ask client to take a deep breath
Which action by a nurse demonstrates proper technique for assessment of chest expansion?
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath
39.-The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse?
Pleural effusion
31.-A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?
Pleurisy
5.-A 47-year-old receptionist comes to the office with fever shortness of breath and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain weight loss or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco alcohol or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head eyes ears nose and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion increased fremitus during palpation and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?
Pneumonia
A nursing student will soon be graduating and beginning a new job at a local health clinic. The nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for this student to gain confidence in assessment skills?
Practice performing a physical examination on a classmate, friend, or relative.
16.-Which terms refers to the progressive hearing loss associated with aging?
Presbycusis
30.-The nurse is assessing the hearing of an older adult. Which type of hearing problem might the nurse expect to find in the older adult?
Presbycusis
6. A nurse notices a middle aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?
Presbyopia (p 318)
A nonpregnant female presents to the health care facility and reports new onset of breast discharge. The nurse assesses the discharge to be milky in appearance without breast tenderness or masses. What additional data should the nurse obtain from this client?
Prescribed medications such as antipsychotic agents
When assessing a client's respirations, what is most important to include in the documentation?
Presence of dyspnea
63. A client of a different culture than the nurse is enjoying the afternoon in the park playing with her daughter. She later arrives 30 minutes late to her doctor's appointment and does not understand the problem when the receptionist tells the client that she will have to reschedule. This client views time in which context?
Present
1.-A client is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess this client's symptom? (Select all that apply.)
Press up on the frontal sinuses from under the bony brows. Press up on the maxillary sinuses.
20.-A client is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess this client's symptom? (Select all that apply.)
Press up on the frontal sinuses from under the bony brows.Press up on the maxillary sinuses.
A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?
Previous injuries to the head and neck
16. When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze, dilation on distant gaze (p. 324).
A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?
Pustular acne
16.-Which instructions should the nurse provide to the client taking a sublingual medication?
Put the medication underneath your tongue.
62. A nurse documents on the client's assessment form, "skin color appropriate for race". Why is this not an appropriate assessment statement?
Race is not a physical characteristic.
A young adult client has just had Xrays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?
Range of motion of the neck
32.-A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?
Receding and ischemic gums
5.-A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?
Receding and ischemic gums
During the physical examination of a 65year old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client?
Recognize the weakened pulsation as an age-related change
28.-Which assessment of the tongue should a nurse recognize as abnormal?
Red with loss of papillae
17-Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?
Red, bulging, with an absent light reflex
12.-A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection?
Red, swollen, with purulent discharge
38.-Which characteristic of the gums should a nurse expect to assess in a client who has scurvy?
Red.bleeding
A client with a body mass index of 28 tells the nurse she is concerned about her risk for hypertension. What can the nurse recommend to this client?
Reducing her weight by 5% can lower her risk
The functional part of the breast that allows for milk production consists of tissue termed
glandular
34.A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope
72.A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope
The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?
Retake the blood pressure
20. Photoreceptors of the eye are located in the eye's
Retina (p. 305)
21. When performing a cultural assessment on a client from another country, what can a nurse do to ensure the client receives culturally sensitive care?
Show genuine interest in the client's culture and personal life experiences.
57.-A nurse performs a Rinne test on a client who relates a history of decreased hearing in the right ear. The test demonstrates that the client has conductive hearing loss in the right ear. What is the correct documentation of this test by the nurse?
Right: BC greater than AC; left AC greater than BC
The nurse is assessing an elderly client's blood pressure and finds it to be high. Which of the following characteristics should the nurse suspect to find in respect to this client's arteries?
Rigid
41.-Which of the following tests use a tuning fork between two positions to assess hearing?
Rinne
33.-A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client?
Rinse mouth with antifungal medication as prescribed.
6.-A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client?
Rinse mouth with antifungal medication as prescribed.
An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that it has become difficult to cut his toenails because the nails have become hard and brittle. The client also states that his feet are always cold and he must wear socks to bed. Which nursing diagnosis can be confirmed from this data?
Risk for impaired skin integrity
A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a client. The nurse should be aware of what risk when using this assessment technique
Risk for injury
66. A nurse provides care for a client who experiences anxiety, gastrointestinal complaints, and a fear of being poisoned or killed. The nurse recognizes this as which culture-bound syndrome?
Rootwork
You are educating your client on taking blood pressure at home. What would be important to include in your client education?
Routine recalibration of the device
15.The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
SBAR
41. When performing a cultural assessment on a client from another country, what can a nurse do to ensure the client receives culturally sensitive care?
Show genuine interest in the client's culture and personal life experiences.
47.-A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?
Sibilant wheezes heard primarily during expiration but may also be heard on inspiration
41.-The spinous process termed the vertebra prominens is in which cervical vertebra?
Seventh.
40. When the nurse asks a client of African origin for the reason for coming to the health clinic, the client responds by saying, "Bad blood." The nurse recognizes that the client is most likely referring to which of the following?
Sexually transmitted infection
27. Blunt force trauma often results in fracture of the orbit
She can see at 20 feet what a normal person could see at 100 feet. (p. 317)
1. When performing a cultural assessment on a client from another country, what can a nurse do to ensure the client receives culturally sensitive care?
Show genuine interest in the client's culture and personal life experiences.
When palpating the female breast for masses, the nurse distinguishes which of the following characteristics as a potentially cancerous mass?
Single, firm, fixed nodule
10.-The nurse is performing the assessment shown. What is the nurse assessing in this client?
Sinuses
30.-A nurse should assist a client to assume what position to best assess the mouth nose and sinuses?
Sitting with the head erect and at the eye level of the nurse
46.-The nurse is presenting an educational event for gardeners. When discussing the ears what would be an important topic to cover?
Skin cancer prevention
A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?
Skin warm and dry to the touch
45.-On examination of a client the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process?
Small bowel obstruction
A nurse is examining the breasts of a 75 year old woman. Which of the following are normal findings in the breasts of an older adult? Select all that apply.
Smaller, flatter nipples, Nipples that are less erectile on stimulation, Pendulous breast
37. The nurse is caring for a 63yearold client who can neither read nor speak English. What would be the appropriate chart to use to assess this client's vision?
Snellen E (p. 316)
A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?
Snellen chart
90. A nurse administrator is leading a seminar on cultural awareness in health care, beginning the seminar by defining culture. Which of the following elements should the nurse administrator include, based on the definition provided by Purnell and Paulanka (2008)? Select all that apply.
Socially transmitted Affects decision making Characteristic of a population or people Forms worldview
51. A nurse administrator is leading a seminar on cultural awareness in health care, beginning the seminar by defining culture. Which of the following elements should the nurse administrator include, based on the definition provided by Purnell and Paulanka (2008)? Select all that apply.
Socially transmitted Forms worldview Characteristic of a population or people Affects decision making
A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?
Somatic
The nurse assess an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as
Stage 2
A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement?
Stage 2 hypertension
61.-Which glands are responsible for mouth drainage? Select all that apply.
Sublingual.Submandibular.Parotid
27.-In palpating the chest of a client a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?
Suprasternal notch
As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?
The blood pressure increases.
97.When documenting assessment information in the medical record, what does the nurse know that the assessment information must accurately reflect? Select all that apply
What the nurse palpated-What the nurse observed- What the nurse heard
A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?
Symmetrical shape
A 29 year old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over the counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?
Tension
5.The nurse knows that when documenting on a client's chart, assessment information must be concise and accurate, and that all descriptions must be as precise as possible. An example of the best documentation of a wound is:
The abdominal wound measures 6 cm by 9 cm with a 1-cm depth.
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?
The ability of the arteries to stretch
55. A client is being assessed for indications of a possible obstructed nasolacrimal duct in the right eye. Under what circumstances should the nurse avoid compressing the lacrimal sac?
The area around the sac is inflamed (p. 323)
How should the nurse palpate the skin of a client to assess its texture?
Touch with the palmar surface of the three middle fingers
22. A nursing student is caring for an older adult from a culture different from her own. The nurse's preceptor asks the student what would be an important assessment to make to provide quality nursing care for this client. What would be the student's most appropriate response?
Transcultural assessment
The lateral lymph nodes are located along the upper humerus and drain most of the arm.
True
When beginning a height measurement on a 14-year-old, the nurse should instruct the client to stand on the scale with heels together.
True
A nurse implements which skin assessment to determine the presence of dehydration in a client?
Tugor
Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is the instructor describing?
Tympanic
The nurse recognizes that assessment of core body temperature is quick, noninvasive, and safe using which method?
Tympanic
A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment?
characteristic symptoms
Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?
Under the breast
3. When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in what direction
Up (p. 321-322)
The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?
Upon meeting the client and family members
12. How can a nurse accurately assess the distant visual activity of a client who is non English speaking?
Use a Snellen E chart to perform the examination (p. 316)
106.A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?
Use phrases instead of sentences to record data.
69.A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?
Use phrases instead of sentences to record data.
88.A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?
Use phrases instead of sentences to record data.
What is the most common measurement used to determine abdominal visceral fat?
Waist circumference.
When performing a nutritional assessment on a client, a nurse observes that the client has a red, beefy tongue. The nurse recognizes this finding as a deficiency of which essential nutrient?
Vitamin B
23.-During the nursing assessment the nurse identifies the client has a smooth glossy tongue. The nurse understands this is caused by what?
Vitamin B12 deficiency
The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin
Vitamin D
27.-The nurse notes that the client's tongue appears as shown. What should the nurse suspect is occurring with this client?
Vitamin deficiency
21.When documenting assessment information in the medical record, what does the nurse know that the assessment information must accurately reflect? Select all that apply
What the nurse observed -What the nurse palpated -What the nurse heard
A 35-year-old archaeologist comes to the office for a regular skin examination. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this client?
age
The nurse documents that a 45-year-old male is 177.8 cm (5 ft 10 in) tall and weighs 97.5 kg (215 lb). He tells the nurse that he "has a good appetite, but doesn't get much exercise because of his busy work schedule." An appropriate NANDA nursing diagnosis for this client is
altered nutrition, more than body requirements related to intake greater than calories expended.
The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?
assists the nurse in formulating appropriate subjective questioning
A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?
asthma
75.The nurse is preparing to document assessment findings in a client's record. The nurse should
avoid slang terms or labels unless they are direct quotes
111.The nurse is preparing to document assessment findings in a client's record. The nurse should
avoid slang terms or labels unless they are direct quotes.
56.The nurse is preparing to document assessment findings in a client's record. The nurse should
avoid slang terms or labels unless they are direct quotes.
The nurse is preparing to document assessment findings in a client's record. The nurse should
avoid slang terms or labels unless they are direct quotes.
A 72-year-old retired saleswoman comes to the office with a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The client denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetrical with no skin changes. The nurse can express bloody discharge from the client's left nipple. No discrete masses are palpable, but her left axilla has a hard 1-cm fixed node. The remainder or her heart, lung, abdominal, and pelvic examinations are unremarkable. What is the most likely cause of nipple discharge in her circumstance?
breast cancer
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
breast cancer clients of the same race
Screening measures for breast cancer include all of the following except:
breast x rays
Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.
bronchial
The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees' c. Breasts d. Chest and thorax e. Cardiovascular
c, d, e, b, a
A client's blood pressure is affected by
cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.
While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are
caused by aging of the skin in older adults
The nursing student is learning to palpate the axillary nodes during a breast examination. Which nodes is he or she most likely to palpate?
central nodes
78. The nurse knows that nonverbal communication can be difficult to interpret among of people of different cultures because of the many variations. These variations include which of the following? (Select all that apply.)
eye contact touch hand gestures patterns of space
The size and shape of the breasts in females are related to the amount of
fatty tissue
Benign conditions of the breast include
fibrocystic changes
A primary function of the hair in the nose and eyelashes is to serve as a
filter for dust
An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of
fissures
Which technique is appropriate for the nurse to use to palpate a client's breast?
flat pads of 3 fingers
The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head?
flex the neck forward
A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?
fluid in the alveoli
A female client visits the clinic and complains to the nurse that her skin feels "dry." the nurse should instruct the client that skin elasticity is required to adequate
fluid intake
24.-In the hearing pathwayhair cells of the spiral organ of Corti are stimulated by movement of ?,
fluid.
In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed
focused.
Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum?
forward protrusion
49. When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark skinned individuals?
fundus is grayish brown with a purplish cast (p. 321)
The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?
funnel chest
A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings?
funnel chest (pectus excavatum)
16. The nurse and a client are developing a transcultural nursing care plan related to hypertension. The nurse will include in the plan
nutritional information specifically for the client's culture.
35. The nurse and a client are developing a transcultural nursing care plan related to hypertension. The nurse will include in the plan
nutritional information specifically for the client's culture.
38. What aspects of culture are relevant when conducting a health assessment on a foreign-born client admitted for surgery? Select all that apply.
nutritional or dietary considerations alternative medicine practices whether there are any existing language barriers
71. What aspects of culture are relevant when conducting a health assessment on a foreign-born client admitted for surgery? Select all that apply.
nutritional or dietary considerations whether there are any existing language barriers alternative medicine practices
The nurse is preparing to assess the respirations of an alert adult client. The nurse should
observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in).
35.-The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client the nurse should
observe the client's response to the explanations.
The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of:
orthostatic hypotension.
What color of sputum would support the diagnosis of heart failure?
pink
While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 1cm. The nurse documents this as a
plaque
The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse?
pleural effusion
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
pneumonia
37.-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
pneumonia.
At puberty, the female breasts enlarge in response to estrogen and
progesterone
Montgomery glands secrete
protective lubricant
The client tells the nurse that he has been coughing up pink, frothy sputum. The nurse notifies the health care provider because the client may have what condition?
pulmonary edema
(Mark all that apply.)
rash, unusual discharge, discomfort, change in shape, edema
20.What information concerning a client's respirations should the nurse record after completing a general physical assessment?
rate, rhythm, and depth of respirations taken for a full minute
What information concerning a client's respirations should the nurse record after completing a general physical assessment?
rate, rhythm, and depth of respirations taken for a full minute
55. Which characteristic demonstrates the nurse's understanding and practice of cultural competent nursing? Select all that apply.
recognizes the need to provide all clients holistic care states, "I'm really interested in learning about the dietary practices of the Hasidic Jews."
connecting the skin to underlying structures is/are the
subcutaneous tissue
The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?
superficial
The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to
swallow a small sip of water.
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for
symptoms of stress
61.-An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been
taking antibiotics.
8.-An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been?
taking antibiotics.
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?
tension
103.The nurses who provide care in a large, long
term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?-Vulnerability to legal liability since the nurse's safe, routine care is not recorded.
24. When performing a cultural assessment, an important point to remember would be
that definitions of family differ
4. When performing a cultural assessment, an important point to remember would be
that definitions of family differ
46. When performing a cultural assessment, an important point to remember would be
that definitions of family differ
79. A nurse understands that culture heavily influences diet and nutrition. Which of the following can seriously affect a client's appetite?
time the meal is served
26.-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
touching each other.
38.-The nurse auscultates very loud high-pitched lung sounds that are equal in length over a client's anterior chest. Which area did the nurse most likely hear these sounds?
trachea
The nurse auscultates very loud, high-pitched lung sounds that are equal in length over a client's anterior chest. Which area did the nurse most likely hear these sounds?
trachea