Module 2: Health Promotion and Disease Prevention., Health Promotion and Disease Prevention (MODULE 2)

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On assessing a client's skin, the nurse notes the presence of several large red-blue and purple areas on the client's body that do not blanch when pressure is applied. The nurse documents this finding as:

Ecchymosis Rationale: Ecchymosis refers to a large patch of capillary bleeding into the tissues (bruise). The color of such an area changes from red-blue or purple to green, yellow, and brown before the area disappears. Pressure on the area will not cause it to blanch. Psoriasis is noted as scaly erythematous patches with silvery scales on top that usually occur on the scalp, the outsides of elbows and knees, the low back, and the anogenital area. Bilateral edema or edema that is generalized over the entire body is known as anasarca. This finding is indicative of a central problem such as congestive heart failure or kidney failure. Petechiae are tiny purple or red spots that appear on the skin as a result of tiny hemorrhages within the dermal and subdermal areas.

Performing an abdominal assessment, a nurse notes tenderness while lightly palpating a client's right lower quadrant. The nurse determines that this finding is most likely associated with which of the following anatomic structures?

Appendix Rationale: The appendix is located in the right lower quadrant. The spleen is a soft mass of lymphatic tissue located on the posterolateral wall of the abdominal cavity, immediately under the diaphragm. The pancreas is a soft lobular gland located behind the stomach. The liver fills most of the right upper quadrant and extends over to the left midclavicular line.

A nurse is providing instructions to a client who is scheduled to undergo a Papanicolaou (Pap) test in one week. Which statement does the nurse make to the client?

"Avoid intercourse for 24 hours before the scheduled examination." Rationale: The Pap test is used to screen for cervical cancer. It is not performed during menses or if a heavy infectious discharge is present. The woman is instructed not to douche, have intercourse, or insert anything into the vagina in the 24 hours before the test. Telling the client to use tampons, douche before the exam, or obtain a sample of the discharge for inspection is incorrect.

A nurse is describing the procedure for testicular self-examination (TSE) to a male client. Which statement should the nurse make to the client?

"If you notice an enlarged testicle or a lump, you need to notify the physician." Rationale: During a shower or bath is the best time to examine the testes, because warm temperatures make the testes hang lower in the scrotum. The testes should feel round and smooth, without lumps. Self-examination should be performed monthly. The physician is to be notified immediately if any abnormalities are found.

A nurse is conducting an interview with a client who has come to the clinic after finding a lump in her right breast during breast self-examination. The client says, "I am so worried. I know that this must be breast cancer. What am I going to do?" Which response should the nurse give the client? "Tell me what worries you." "Most lumps found in the breast aren't cancer." "Let's talk again after the doctor examines you." "You shouldn't be so worried. After all, if it is cancer, you found it at an early stage."

"Tell me what worries you." RATIONALE: The nurse should always focus on the client's feelings and concerns and respond so that the client is provided an opportunity to discuss feelings. "Tell me what worries you" is the only option that gives the client this opportunity. The other options are nontherapeutic and place the client's feelings on hold. TEST-TAKING STRATEGY: Recall therapeutic communication techniques to answer the question. Remembering that the nurse should always focus on the client's feelings will direct you to the correct option. Review: therapeutic communication techniques.

Dianne tells the nurse that several of her coworkers have lost weight on a fad diet. How should the nurse respond? "Try one of these fad diets if it will help to take off the weight." "You should try a strict vegetarian diet. That will help you lose weight quickly." "You need to eat foods from all food groups and limit fats, oils, and sweets." "Do whatever you can to get the weight off, because your weight is the cause of the high blood pressure and cholesterol."

"You need to eat foods from all food groups and limit fats, oils, and sweets." RATIONALE: The USDA's MyPlate is a guide to daily food choices and portion sizes. The dieting client should be instructed to eat foods from all food groups, especially fruits, vegetables, and whole grains, and to limit consumption of fats, oils, and sweets, as well as salt. Although weight loss on this program may be slower than that with a fad diet, it is a healthier method of weight loss, and the weight loss with such a program is more likely to be permanent. Fad diets are discouraged because they may be harmful to a person's health. It is not necessary to go on a strict vegetarian diet to lose weight, and this type of diet must be well planned to avoid problems resulting from protein deficiency. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that do not include foods from all food groups. Also, note the words "all food groups" in the correct option. Review: appropriate weight-loss diets.

A nurse conducting a physical assessment of a client plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal:

A problem with balance Rationale: The Romberg test, a balance test, is used to assess cerebellar function. The client stands with his or her feet together and arms at the side. Once he or she is in a stable position, the client is asked to close the eyes and hold the position for about 20 seconds. Normally the client can maintain posture and balance, although slight swaying may occur. Hearing acuity, including distant hearing and the ability to discriminate high- and low-pitched sounds, is assessed with the use of the voice and tuning-fork tests.

28. A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. What should the nurse check for when inspecting the ears for cerumen impaction? Redness and swelling of the tympanic membrane An external auditory canal that is longer than normal The presence of edema in the external auditory canal A yellowish or brownish waxy material in the external auditory canal

A yellowish or brownish waxy material in the external auditory canal

A nurse sees documentation in the client's record indicating that the physician has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds are:

Abnormal sounds that should not be heard in the lungs Rationale: Adventitious breath sounds are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused when moving air collides with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds.

11. A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. How should the nurse document this finding? Anasarca Ecchymosis Unilateral edema Increased vascularity of the skin tissue

Anasarca Rationale: Bilateral edema, or edema that is generalized over the entire body, is known as anasarca. This finding is indicative of a central problem such as congestive heart failure or kidney failure. It does not indicate increased vascularity of skin tissue. Ecchymosis is a large patch of capillary bleeding into the tissues (bruise).

A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding as:

A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection?

Ask health history questions while performing the examination and initiating emergency measures Rationale: If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client's immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment.

A 16-year-old girl visits the women's health clinic to obtain information about birth control because she is sexually active and wants to avoid pregnancy. The nurse who is interviewing the client should first:

Assess the client's knowledge of available birth control methods Rationale: Learning occurs more readily when new information complements existing knowledge. Therefore it is important for the nurse to assess the client's level of knowledge of the subject matter. Although the use of written material assists in the learning process, this would not be the first nursing intervention. Telling the client that because of her age and lifestyle birth control pills would be the easiest method of contraception provides advice from the nurse's perspective and does not allow the client the opportunity to make her own decision. Telling the client that birth control methods cannot be discussed unless the client's boyfriend is present is incorrect and nontherapeutic.

The nurse, performing an abdominal examination, inspects the client's abdomen. Which assessment technique does the nurse perform next?

Auscultation Rationale: The assessment techniques used for a physical examination are inspection, palpation, percussion, and auscultation. These techniques are performed one at a time and normally in this order. The exception to this order is an abdominal examination: During the abdominal examination, auscultation is performed after inspection and before palpation and percussion, because palpation and percussion can increase peristalsis, which would yield a false interpretation of bowel sounds.

A nurse reviewing a client's record notes documentation that the client has melena. How does the nurse detect the presence of melena?

By checking the client's stool for blood Rationale: Melena is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.

A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. The nurse interprets this to mean that the client:

Can read at a distance of 20 feet what a client with normal vision can read at 80 feet Rationale: When recording the results of visual acuity testing with the use of the Snellen chart, the nurse would use the numeric fraction noted at the end of the last line on the chart read successfully by the client. The top number (numerator) indicates the distance the client is standing from the chart; the denominator is the distance at which a normal eye could have read that particular line. Therefore a reading of 20/80 means that the client can read at a distance of 20 feet what a client with normal vision can read at 80 feet.. Legal blindness is defined as the best corrected vision in the better eye of 20/200 or worse. Normal visual acuity is 20/20.

A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client?

Complete Rationale: A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting such as a pediatric or family practice clinic, an independent or group private practice, a college health service, a women's healthcare agency, a visiting nurse agency, or a community health agency. An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or one body system. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed.

A nurse inspecting a client's throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which nerve? Cranial nerve V Cranial nerve XII Cranial nerves I and II Cranial nerves IX and X

Cranial nerves IX and X

A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing? Cranial nerve X Cranial nerve V Cranial nerve IX Cranial nerve XII

Cranial nerve XII

Cranial nerve XII Rationale: To test cranial nerve XII (hypoglossal nerve), the examiner inspects symmetry and movement of the tongue. The nurse looks for a forward thrust in the midline as the client sticks out the tongue. The examiner tests the motor function of cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve) by depressing the client's tongue with a tongue blade and noting the pharyngeal movement as the client says "ah." Motor function of these nerves is also tested by touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Eliciting a response from cranial nerve V (trigeminal nerve) tests the muscles of mastication.

A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands that the primary purpose of including cultural information in the health assessment is to:

Determine what the client believes has caused the epilepsy Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican-American culture, epilepsy is seen as a reflection of physical imbalance. Although the nurse may obtain data related to family history (hereditary) and formulate nursing diagnoses, these are not the primary reasons for including cultural information in the health assessment. A nurse gathers assessment data but does not confirm a medical diagnosis.

During a neurological assessment, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing?

Facial Rationale: Assessment of cranial nerve VII (facial nerve) involves noting mobility and symmetry as the client smiles, frowns, closes the eyes tightly (against the nurse's attempt to open them), lifts the eyebrows, shows the teeth, and puffs out the cheeks. Cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) are tested together. Testing the motor function of these nerves entails depressing the client's tongue with a tongue blade and noting pharyngeal movement as the client says "ah" and touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Testing of the abducens, oculomotor, and trochlear nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and testing extraocular movements through the cardinal positions of gaze.

A female client is seen in the clinic for a gynecological examination. The nurse begins collecting subjective data. Which of the following topics does the nurse ask the client about first?

Her menstrual history Rationale: The nurse should begin collecting subjective data by asking the client about her menstrual history, because this information is usually nonthreatening to the client. Questions about sexual history, obstetrical history, and the presence of vaginal discharge would be asked, but this information may be perceived by the client as more sensitive and the questions more threatening.

A nurse performing a musculoskeletal assessment of a client with suspected carpal tunnel syndrome plans to perform the Phalen test. The nurse should ask the client to:

Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds Rationale: In the Phalen test, the nurse asks the client to hold the hands back to back while flexing the wrists 90 degrees. Dorsiflexing or plantarflexing the foot and hyperextending the fingers are not associated with testing for carpal tunnel syndrome. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.

While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which of the following findings does the nurse expect to note when auscultating the client's bowel sounds?

Hyperactive bowel sounds Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hypoactive bowel sounds are low pitched. Hypoactive sounds (or an absence of sounds) follow abdominal surgery or occur with inflammation of the peritoneum.

A nurse performing a physical examination is assessing the client for costovertebral angle tenderness. When the nurse percusses the area, the client complains of sharp pain. The nurse interprets this finding as most indicative of:

Kidney inflammation Rationale: When assessing for costovertebral angle tenderness, the nurse is checking for kidney tenderness. Sharp pain that occurs on percussion of the costovertebral angle indicates inflammation of the kidney or paranephric area. To assess the kidney, the nurse places one hand over the 12th rib, at the costovertebral angle, on the back. The nurse then thumps that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver, or spleen enlargement are not associated with the costovertebral angle.

34. A nurse is preparing to auscultate the breath sounds of a client. The nurse should use which technique? Ask the client to lie prone Ask the client to breathe in and out through the nose Hold the bell of the stethoscope lightly against the chest Listen for at least one full respiration in each location on the chest

Listen for at least one full respiration in each location on the chest Rationale: To best listen to breath sounds, the nurse asks the client to sit, leaning slightly forward, with the arms resting comfortably across the lap. The client is instructed to breathe through the mouth, a little deeper than usual, but to stop if he or she feels dizzy. The flat diaphragm endpiece of the stethoscope is held firmly against the client's chest wall. The nurse listens for at least one full respiration in each location on the chest. Side-to-side comparison is most important in the assessment of breath sounds.

At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she states that:

Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down Rationale: BSE is performed monthly and should be carried out after the menstrual period, on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. A woman who is not having menstrual periods should select a specific day of the month and perform BSE on that day each month. BSE is not the only way to detect early breast cancer. Women should get regular physical examinations and mammograms as prescribed. The woman is taught to inspect the breasts while standing in front of a mirror, to palpate the breasts while in the shower (because soap and water assist in palpation), and, finally, to perform palpation while lying supine.

A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which of the following findings does the nurse expect to note if cholecystitis is present?

Murphy sign Rationale: The Murphy sign is an indicator of gallbladder disease. The client is asked to inhale while the examiner's fingers are hooked under the liver border, at the bottom of the rib cage. Inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed. The Homan sign is pain in the calf area on sharp dorsiflexion of the client's foot. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen. Rebound tenderness is a reliable sign of peritoneal irritation. The McBurney sign is a reaction of the client indicating severe pain and extreme tenderness when the McBurney point (midway between the umbilicus and the anterior iliac crest in the right lower quadrant of the abdomen) is palpated. Such a reaction indicates appendicitis.

A nurse in the emergency department is performing a musculoskeletal assessment of a client. The presence of which of the following conditions would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

Neck trauma Rationale: A nurse performing a musculoskeletal assessment would not test ROM in a client who has sustained neck trauma, which may have resulted in a cervical fracture. If a cervical fracture is present, further movement of the neck could result in spinal cord injury. ROM testing does not need to be avoided if the client is experiencing a headache, sinus infection, or muscle spasms.

A nurse performing a respiratory assessment of a client plans to assess tactile (vocal) fremitus. The nurse performs this assessment by:

Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine" Rationale: Palpation over the lung is used to assess tactile (vocal) fremitus. The nurse begins by palpating over the lung apices in the supraclavicular areas. The nurse compares vibrations from side to side as the client repeats the word "ninety-nine." To palpate for symmetric chest expansion, the nurse places the hands on the anterolateral wall, with the thumbs along the costal margins and pointing toward the xiphoid process. The client is asked to take a deep breath; as he or she does so, the nurse watches his or her thumbs move apart and watches for symmetry. Auscultation of breath sounds over the trachea and larynx is used to assess bronchial breath sounds. Auscultation of breath sounds over the peripheral lung fields is used to assess vesicular breath sounds.

A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by:

Placing a tape measure around the widest point of the lower leg Rationale: The nurse uses a nonstretchable tape measure to measure the calf at its widest point, taking care to measure the opposite leg in exactly the same place, the same number of centimeters down from the patella or other landmark. The descriptions in the incorrect options would not provide an accurate measurement of calf circumference.

A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse take before inserting the otoscope?

Pulling the pinna up and back Rationale: In an adult client, the nurse pulls the pinna up and back to help straighten the S shape of the ear canal. The client's head is tilted slightly away from the examiner, toward the client's opposite shoulder. The nurse holds the pinna gently and firmly until the examination is complete and the otoscope has been removed from the client's ear. The nurse pulls the pinna down when examining an infant or a child younger than 3 years.

44. A nurse conducting a peripheral vascular assessment performs the Allen test. The nurse understands that this test is used to determine the patency of which structures? Capillaries Pedal pulses Femoral arteries Radial and ulnar arteries

Radial and ulnar arteries Rationale: The nurse would perform the Allen test to determine the patency of the radial and ulnar arteries. The nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While the nurse is applying pressure, the client is asked to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used to obtain a blood specimen.

A nurse conducting a peripheral vascular assessment performs the Allen test. The nurse understands that this test is used to determine the patency of the:

A nurse is preparing to check the breath sounds of a client. Over which anatomic area does the nurse place the stethoscope when auscultating for bronchial breath sounds?

Rationale: Bronchial (tracheal) breath sounds are located over the trachea and larynx. Bronchovesicular breath sounds are located over major bronchi. Vesicular breath sounds are located over the peripheral lung fields. The upper sternal area is where main bronchi are located. Breath sounds are normally not heard over the cricoid cartilage.

A nurse is using an otoscope to examine the ears of a client. Which of the following findings indicates to the nurse that the tympanic membrane is normal?

Rationale: The tympanic membrane is shiny and translucent, with a pearly gray color. The appearance of a yellow clump of material indicates the presence of a piece of cerumen in the external meatus. An excessive amount of cerumen in the external auditory canal appears dark and covers a large part of the canal and tympanic membrane. A hole in the tympanic membrane indicates perforation of the membrane.

The nurse is admitting a client to the hospital. Which should be included in a discussion of the client's personal history? Select all that apply. Recent hospitalizations Cause of parents' death Health of the client's siblings Previous history of bipolar disorder Hypersensitivity reactions to medications

Recent hospitalizations Previous history of bipolar disorder Hypersensitivity reactions to medications RATIONALE: The nurse should include recent hospitalizations, previous history of diseases, and hypersensitivity or allergic reactions in a review of the client's personal history. The cause of the client's parents' death and the health of the client's siblings should be included in the client's family history.

A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?

Right lower quadrant Rationale: When auscultating bowel sounds, the nurse uses the diaphragm endpiece, because bowel sounds are relatively high pitched. The nurse holds the stethoscope lightly against the skin, because pushing too hard could stimulate more bowel sounds. The nurse begins auscultating in the right lower quadrant at the ileocecal valve, because bowel sounds are normally always present there. The nurse then listens for bowel sounds in the other quadrants.

37. A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be? Harsh Hollow Tubular Rustling

Rustling Rationale: Vesicular breath sounds are rustling and sound like wind blowing through trees. Bronchial (tracheal) breath sounds are harsh, hollow, tubular sounds.

A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be?

Rustling Rationale: Vesicular breath sounds are rustling and sound like wind blowing through trees. Bronchial (tracheal) breath sounds are harsh, hollow, tubular sounds.

A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct?

Setting the room temperature at a comfortable level Rationale: When preparing the physical environment for an interview with a client, the nurse sets the room temperature at a comfortable level. The nurse also provides privacy and sufficient lighting and removes distracting objects or equipment and noise from the environment. The distance between the client and the nurse should be 4 to 5 feet (twice arm's length). The nurse arranges the seating so that client and nurse are at eye level. Barriers (e.g., facing a client across a desk or table) are avoided.

Shannon tells the nurse that she has never had a mammogram and asks whether she needs one. On the basis of American Cancer Society (ACS) recommendations, which instruction should the nurse provide to Shannon? She will need to start having a yearly mammogram at age 40 Her health care provider will recommend that she have a mammogram done now She will have a baseline mammogram now and another one every 3 years thereafter She will have a baseline mammogram now and then will have one every year thereafter

She will need to start having a yearly mammogram at age 40 RATIONALE: According to ACS recommendations, yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health. Therefore the other options are incorrect.

When conducting a physical examination of an adult client, in what order does the nurse perform the various assessment techniques? Number 1 is the first technique performed and number 4 is the last technique performed.

The correct order is: Inspection Palpation Percussion Auscultation Rationale: The assessment techniques used to perform a physical examination are inspection, palpation, percussion, and auscultation. These activities are performed one at a time and in this order. The exception is abdominal assessment, in which the nurse would inspect and then auscultate, because percussion and palpation can cause peristalsis, which could cause the examiner to make a false interpretation of bowel sounds.

A nurse is examining the peripheral vision of a client using the confrontation test. To carry out this procedure, the nurse:

Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field Rationale: The confrontation test is a gross measure of peripheral vision. It compares the client's peripheral vision with the examiner's vision under the assumption that the examiner's vision is normal. The examiner positions himself or herself at eye level with the client, about 2 feet away. The examiner directs the client to cover one eye with an opaque card and look straight at the examiner with the other. The examiner covers his or her own eye opposite the client's covered one. Next the examiner holds a pencil or flicking finger as a target midline between himself or herself and the client and slowly advances it from the periphery in several directions. The examiner asks the client to say "now" as the target is first seen. This sighting should occur just as the examiner sees the object for the first time. Asking the client to discriminate numbers on a chart composed of colored dots and darkening the room and asking the client to identify colored blocks and shapes that appear in the visual field are both components of testing for color vision.

1. A nurse performing a physical assessment of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data? The client appears anxious. Blood pressure is 170/80 mm Hg. The client states that he has a rash. The client has diminished reflexes in the legs.

The client states that he has a rash.

A nurse performing a physical assessment of a client gathers both subjective and objective data. Which of the following findings would the nurse document as subjective data?

The client states that he has a rash. Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results.

The nurse reviews a client's medical records and notes that vesicular breath sounds were ausculated. The nurse determines this was assessed to determine presence of an abnormality in which area? Major bronchi The xiphoid process The trachea and larynx The peripheral lung fields

The peripheral lung fields Rationale: Vesicular breath sounds are heard over the peripheral lung fields, where air flows through the smaller bronchioles and alveoli. Bronchovesicular breath sounds are heard over the major bronchi. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Breath sounds are not heard over the xiphoid process.

A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse determines that:

The skin temperature is normal Rationale: To assess skin temperature, the nurse would first note the temperature of his or her own hands, then use the backs (dorsa) of the hands to palpate the client's skin bilaterally. The skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. The hands and feet may feel slightly cooler in a cool environment. Giving the client additional fluids, removing the blanket, and checking for a fever are all incorrect responses to this finding.

During a neurological assessment, the nurse asks the client to close the jaws tightly, after which the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of the:

Trigeminal nerve Rationale: To test the motor function of cranial nerve V (trigeminal nerve), the nurse assesses the muscles of mastication by palpating the temporal and masseter muscles as the client clenches the teeth. The nurse tries to separate the jaws by pushing down on the client's chin. Normally the nurse cannot separate the jaws. Testing of the trochlear, abducens, and oculomotor nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and assessing extraocular movements through the cardinal positions of gaze.

A nurse is observing a new nurse employee who is preparing to assess the acoustic nerve during a neurological examination. The nurse determines the new nurse employee is using correct technique if the new nurse uses which method? Uses a tuning fork Asks the client to puff out the cheeks Tests taste perception on the client's tongue Checks the client's ability to clench the teeth

Uses a tuning fork Rationale: Testing of cranial nerve VIII (acoustic nerve) entails checking hearing acuity by assessing the client's ability to hear normal conversation, assessing the client's performance on the whispered voice test, and performing the Weber and Rinne tuning fork tests. Asking the client to puff out the cheeks is used to test the function of cranial nerve VII (facial nerve). Testing of taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve). Checking the client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve).

During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client?

"I need some more information about the discharge. What color is it?" Rationale: If the client says that she has had some vaginal drainage, the nurse should obtain additional data about the discharge. The nurse would ask about the character and color of the discharge, when the discharge began, any factors associated with the discharge, medications being taken, and self-care behaviors. Normal discharge is sparse, clear, or cloudy and is always nonirritating. Unprotected sexual intercourse suggests that the discharge is associated with a STI and would cause more concern on the part of the client. Telling the client not to worry is a nontherapeutic communication technique. Asking about her last gynecological checkup may be an appropriate question but is not related to the subject of the question.

The nurse prepares to listen to Sara's breath sounds. In which area should the nurse place the diaphragm endpiece of the stethoscope to assess bronchial breath sounds?

1 RATIONALE: Bronchial (tracheal) sounds are high-pitched, harsh, hollow, tubular sounds, normally heard over the trachea and larynx. Bronchovesicular sounds are moderately pitched and heard over the major bronchi. Vesicular sounds are low-pitched, with a rustling quality, and heard over the peripheral lung fields.

36. A nurse is preparing to check the breath sounds of a client. Over which anatomic area does the nurse place the stethoscope when auscultating for bronchial breath sounds?

2 Rationale: Bronchial (tracheal) breath sounds are located over the trachea and larynx. Bronchovesicular breath sounds are located over major bronchi. Vesicular breath sounds are located over the peripheral lung fields. The upper sternal area is where main bronchi are located. Breath sounds are normally not heard over the cricoid cartilage.

A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the client's pulse is normal. Which of the following notations would the nurse make in the client's record to document the force of the client's pulse?

2+ Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+, bounding pulse; 3+, increased pulse; 2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the client's pulse as 2+.

A nurse reviewing the medical record of a client with the diagnosis of heart failure notes documentation indicating that the client has deep pitting edema, that the indentation remains for a short time, and that the leg looks swollen. How does the nurse document this finding?

3+ edema Rationale: Edema, the accumulation of fluid in the intercellular spaces, is not normally present. To check for edema, the nurse presses his or her thumbs firmly against the ankle malleolus or the tibia. Normally the skin surface stays smooth. If the pressure leaves a dent in the skin, "pitting" edema is present. Its presence is graded on the following 4-point scale: 1+ denotes mild pitting and slight indentation but no perceptible swelling of the leg, 2+ indicates moderate pitting in which the indentation subsides rapidly, 3+ indicates deep pitting in which the indentation remains for a short time and the leg looks swollen, and 4+ denotes very deep pitting in which the indentation lasts a long time and the leg is very swollen.

A nurse is gathering supplies to perform a physical assessment of a client. Which necessary item does the nurse select to perform the Weber test?

4 Rationale: Tuning fork tests measure hearing by way of air conduction or by bone conduction, in which sound vibrates through the cranial bones to the inner ear. The Weber test is a tuning fork test that is performed when the client reports hearing better with one ear than with the other. In the Weber test, a vibrating tuning fork is placed in the midline of the client's skull and the client is asked whether the tone sounds the same in both ears or better in one. The client should hear the tone by bone conduction through the skull, and it should sound equally loud in both ears. The otoscope, reflex hammer, and stethoscope may be used when performing the physical exam but are not needed to perform the Weber test.

A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data?

A 1 × 2-inch scar is present on the lower right portion of the abdomen. Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client's last menstrual period, and the reported use of medication for headaches are all subjective data.

A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. The nurse, inspecting the ears for cerumen impaction, checks for:

A yellowish or brownish waxy material in the external auditory canal Rationale: Cerumen (ear wax) is a yellowish or brownish waxy secretion produced by vestigial apocrine sweat glands in the external ear canal. It becomes impacted because of the narrow tortuous canal or as a result of poor cleaning methods. Cerumen may partially obscure the eardrum or totally occlude the ear canal. Even when the canal is 90% to 95% blocked, hearing is normal, but when the last 5% to 10% becomes occluded (e.g., when cerumen expands after the client swims or showers), the client experiences sudden hearing loss and a feeling of fullness in the ear. Redness and swelling of the tympanic membrane, edema in the external auditory canal, and an external auditory canal that is longer than normal are not descriptions of cerumen.

35. A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding in which way? Normal egophony Abnormal vesicular breath sounds Abnormal bronchophony Normal whispered pectoriloquy

Abnormal bronchophony Rationale: The quality of voice resonance can be performed by testing for the presence of bronchophony, egophony, and whispered pectoriloquy. In bronchophony, the nurse asks the client to repeat the word "ninety-nine" as the nurse listens to the client's chest with a stethoscope. Normal voice transmission is soft, muffled, and indistinct. The nurse normally hears sound through the stethoscope but cannot distinguish exactly what is being said. A pathologic condition that increases lung density enhances the transmission of voice sounds; in such a case, the nurse will hear "ninety-nine" clearly. Vesicular breath sounds are heard over peripheral lung fields where air flows through smaller bronchioles and alveoli. In egophony, the client's chest is auscultated while the client phonates a long "ee-ee-ee-ee" sound. Normally the nurse hears "eeeeee" through the stethoscope. In whispered pectoriloquy, the client is asked to whisper a phrase such as "one-two-three" as the nurse listens to the chest. The normal response is a muffled, almost inaudible sound.

A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as:

A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding?

Accommodation Rationale: Accommodation is adaptation of the eye for near vision. Movement of the ciliary muscles increases the curvature of the lens. To observe accommodation, the examiner notes convergence (motion toward) of the axes of the eyeballs and pupillary constriction. Myopia is nearsightedness. Hyperopia is farsightedness. Photophobia is abnormal sensitivity to light, especially of the eyes.

A nurse performing a neurological examination is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which of the following actions does the nurse take to test this nerve?

Asking the client to close his or her eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear Rationale: To test the cochlear portion of the acoustic nerve, the nurse has the client close the eyes and indicate when a ticking watch or rustling of the examiner's fingertips is heard as the stimulus is brought closer to the ear. To test the motor component of the trigeminal nerve, the nurse asks the client to clench the teeth and palpates the masseter muscles just above the mandibular angle. To test the sensory component of the trigeminal nerve (cranial nerve V), the nurse has the client identify light and sharp touch on both sides of the face. Asking the client to raise the eyebrows and watching for symmetry is one method of testing the function of the facial nerve (cranial nerve VII).

A nurse performing a neurological assessment is preparing to assess the optic nerve. The nurse performs this examination by:

Assessing visual acuity Rationale: The optic nerve is assessed through the testing of visual acuity and visual fields by means of confrontation. Ptosis, a drooping of the eyelid, can be assessed by means of inspection of the eyelids. Testing of the abducens, oculomotor, and trochlear nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and assessing extraocular movements through the cardinal positions of gaze.

A nurse performing an abdominal assessment is preparing to auscultate for bowel sounds. The nurse:

Begins in the right lower quadrant Rationale: To auscultate for bowel sounds, the nurse uses the diaphragm endpiece, because bowel sounds are relatively high pitched. The stethoscope is held lightly against the skin, because pushing too hard can stimulate more bowel sounds. The nurse begins in the right lower quadrant of the abdomen at the ileocecal valve, because bowel sounds are always present there normally. The nurse should listen for 5 minutes before deciding that bowel sounds are absent.

A nurse reviewing the physical assessment findings in a client's healthcare record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has?

Carpal tunnel syndrome Rationale: The Phalen test is performed to check for the presence of carpal tunnel syndrome. The client is asked to hold the hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen test reproduces the numbness and burning experienced by a client with carpal tunnel syndrome. This test does not reveal the presence of scoliosis, bone deformity, or Heberden nodules, which occur in osteoarthritis.

A nurse is reviewing the healthcare record of a client who has just undergone an examination of the internal genitalia. Which of the following documented findings indicates an abnormality?

Clear secretions with a foul odor are noted on the cervix. Rationale: Normally the cervix is pink, midline, and about 1 inch in diameter. Depending on the day of the menstrual cycle, secretions may be clear and thin or thick, opaque, and stringy. Secretions should always be odorless and nonirritating. Secretions with a foul odor are associated with infection.

31. A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve? Coffee A tuning fork A wisp of cotton An ophthalmoscope

Coffee Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse tests the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a nonnoxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. A tuning fork is used to assess the function of cranial nerve VIII (acoustic nerve). A wisp of cotton is used to assess the sensory function of cranial nerve V (trigeminal nerve). An ophthalmoscope is used to assess the internal structures of the eye.

A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?

A client complains that her skin is redder than normal. The nurse assesses the client's skin, documents hyperemia, and explains to the client that this condition is caused by:

Excess blood in the dilated superficial capillaries Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. A reduced amount of bilirubin in the blood, diminished perfusion of the surrounding tissues, and contraction of the underlying blood vessels are all incorrect explanations for hyperemia.

An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client? Loud music Use of power tools Occupational noise Exposure to cigarette smoke

Exposure to cigarette smoke

A nurse inspecting a client's throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of:

Cranial nerves IX and X Rationale: The motor function of cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) is tested by depressing the tongue with a tongue blade and noting the pharyngeal movement as the client says "ah." Motor function of these nerves is also tested by touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Eliciting a response from cranial nerve V (trigeminal nerve) tests the muscles of mastication. Eliciting a response from cranial nerve I (olfactory nerve) tests the function of smell. Eliciting a response from cranial nerve II (optic nerve) involves eye examinations. In testing cranial nerve XII (hypoglossal nerve), the examiner inspects symmetry and movement of the tongue.

A mother brings her 18-month-old child to the clinic to receive the next scheduled vaccine. The child has previously received the following vaccines: three doses of the hepatitis B vaccine (at birth and 1 and 6 months of age); three doses of the diphtheria/tetanus/acellular pertussis (DTaP) vaccine (at 2, 4, and 6 months of age); four doses of Haemophilus influenzae type b (Hib) conjugate vaccine (at 2, 4, 6, and 12 months of age); three doses of inactivated poliovirus vaccine (IPV) (at 2, 4, and 6 months of age); one dose of measles/mumps/rubella vaccine (MMR) (at 12 months of age); varicella zoster vaccine at 12 months of age; and four doses of pneumococcal vaccine (at 2, 4, 6, and 12 months of age). After reviewing the child's immunization record, which scheduled vaccine does the nurse prepare to administer?

DTaP Rationale: DTaP is administered at 2, 4, and 6 months of age; between 15 and 18 months of age; and between 4 and 6 years of age. Because the child has received only three doses of this vaccine, the DTaP should be administered. Hepatitis B vaccine is administered at birth and at 1 and 6 months of age. Hib is administered at 2, 4, and 6 months of age and between 12 and 15 months. IPV is administered at 2, 4, and 6 months of age and between 4 and 6 years of age. MMR is administered between 12 and 15 months of age and again between 4 and 6 years of age. Varicella zoster vaccine is administered between 12 and 15 months of age. Pneumococcal vaccine is administered at 2, 4, and 6 months of age and at 12 to 15 months of age.

A nurse is preparing to perform a skin examination with the use of a Wood light. In preparing for this diagnostic test, the nurse should:

Darken the room Rationale: A handheld long-wavelength ultraviolet (black) light, or Wood light, is sometimes used during physical examination of the skin. Areas of blue-green or red fluorescence are associated with certain skin conditions. Hypopigmented skin appears more prominent when it is viewed under black light, greatly facilitating the evaluation of pigment changes in fair-skinned clients. Examination of the skin is always carried out in a darkened room. The test is noninvasive, and the nurse should reassure the client that no discomfort is associated with a Wood light examination.

Data related to the respiratory system Rationale: An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals.

A nurse performing a genital examination of a male client notes that the skin of the penis and scrotum is wrinkled. On the basis of this finding, the nurse:

Documents the normal finding Rationale: The penile skin is normally wrinkled and hairless, without lesions. The dorsal vein may also be apparent on inspection of the penis. Scrotal skin also has a wrinkled appearance (rugae). Asymmetry is normal, with the left half of the scrotum usually lower than the right. Wrinkled skin on the penis and scrotum is a normal finding; therefore the nurse would document the finding. The other options are incorrect.

A nurse performing a neurological assessment is inspecting the client's eyelids for ptosis. The nurse checks the client for:

Drooping Rationale: Ptosis, a drooping of the eyelids, can occur as a result of disorders such as myasthenia gravis, dysfunction of cranial nerve III, and Bell palsy. Pupil dilation and constriction are checked with the use of a flashlight. Ocular movements are checked by leading the client's eyes through the six cardinal positions of gaze.

A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expects to note if the bladder is full?

Dull sounds Rationale: Normally a bladder is not percussible until it contains 150 mL of urine. If the bladder is full, dullness is heard over the symphysis pubis. Hyperresonance is present with gaseous distention of the abdomen. Bowel sounds are auscultated, not percussed.

During a physical assessment, the client tells the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing:

Dysphagia Rationale: Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia is a loss of appetite. Eructation is belching. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid.

A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which of the following actions does the nurse take to help ensure the success of the interview? Select all that apply.

Ensuring that the room is private Seeing that distracting objects are removed from the room Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained, that there are no interruptions during the interview, that the room temperature is comfortable, that lighting is sufficient, that ambient noise is reduced, and that distracting objects are removed from the room. The nurse also ensures that the client and nurse are seated comfortably, eye to eye, without a desk or table between them, because a desk or table would act as a barrier. The nurse should maintain a distance of 4 to 5 feet from the client to avoid invading the client's private space, which might create anxiety on the part of the client.

An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?

Exposure to cigarette smoke Rationale: Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include youth (otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. Loud music, the use of power tools, and occupational noise can all cause hearing loss. Hearing loss may occur as a result of an acute loud noise (acoustic trauma) or long-term exposure to loud noise (noise-induced hearing loss).

A nurse performing a cranial nerve assessment is testing the function of the oculomotor, trochlear, and abducens nerves. Which of the following parameters does the nurse check to determine the function of these nerves?

Eye movements Rationale: Testing of the oculomotor, trochlear, and abducens nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation, as well as testing of extraocular movements through the cardinal positions of gaze. Inspection of the tongue for symmetry reveals the function of cranial nerve XII (hypoglossal nerve). Assessment of facial symmetry reveals the function of cranial nerve VII (facial nerve). The corneal reflex reflects the function of the sensory afferent in cranial nerve V (trigeminal nerve) and the motor efferent in cranial nerve VII (facial nerve).

A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope at the:

Fifth left interspace at the midclavicular line Rationale: The mitral valve is located in the area of the fifth left interspace, at the midclavicular line. The pulmonic valve is located in the area of the second left interspace. The aortic valve is located in the area of the second right interspace. The tricuspid valve is located in the area of the left lower sternal border.

A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope at which location on the client's chest? Second left interspace Second right interspace Left lower sternal border Fifth left interspace at the midclavicular line

29. A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal? Firm pressure Pain behind the eyes Pain during palpation Pressure producing an acute headache

Firm pressure Rationale: The client would normally feel a firm pressure as the nurse palpates his or her sinuses. Pain experienced during palpation of the sinuses is an indication of acute sinusitis. Headaches that vary in intensity with position changes or when secretions drain indicate acute sinusitis. An acute headache should not occur with palpation of the sinuses.

A nurse is palpating a client's sinus areas. Which of the following sensations does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?

A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment?

Follow-up Rationale: A follow-up database is compiled to evaluate the status of an identified problem at regular and appropriate intervals. An emergency database calls for rapid collection of the data, often at the same time lifesaving measures are being performed. A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. An episodic database (problem-centered) is compiled for a limited or short-term problem. It is focused mainly on one problem or body system.

A nurse reviewing the healthcare record of a client notes documentation of grade 4 muscle strength. The nurse understands that this indicates:

Full ROM against gravity with some resistance Rationale: Muscle strength is graded on a scale of 0 to 5. A grade of 5 indicates normal strength and is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and full ROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity. Grade 2 indicates poor strength and full ROM with gravity eliminated (passive motion). Grade 1 indicates trace strength and slight contraction. Grade 0 indicates zero strength and no contraction.

A nurse performing a physical examination is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note?

Gurgling sounds Rationale: Bowel sounds are a result of the movement of air and fluid through the small intestine. Depending on the time elapsed since the client has eaten, a wide range of normal sounds may occur. Bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly between five and 30 times a minute. Bowel sounds are hypoactive (low-pitched) or entirely absent after abdominal surgery or with inflammation of the peritoneum.

A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client?

Left lateral Rationale: A female client is placed in the left lateral position for a rectal examination. If the examiner is examining the genitalia as well as the rectum, the woman is placed in the lithotomy position. A male client is placed in the left lateral or standing position. It would be difficult to perform a rectal examination on a client in the supine position.

39. A nurse is assessing a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the nurse obtain data on from the client? Age Ethnicity Hypertension Genetic inheritance

Hypertension Rationale: Risk factors for CAD may be categorized as modifiable and unmodifiable. Unmodifiable risk factors include age, sex, ethnicity, genetic predisposition, and family history of heart disease. Modifiable risk factors include increased concentrations of serum lipids, hypertension, cigarette smoking, obesity, and level of physical activity. Contributing modifiable risk factors include diabetes mellitus and a stressful lifestyle.

A nurse is assessing a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the nurse obtain data on from the client?

A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse determines the client is likely experiencing which disorder? Venous insufficiency Intermittent claudication Sore muscles from overexertion Muscle cramps related to musculoskeletal problems

Intermittent claudication Rationale: Leg pain characteristic of peripheral artery disease is known as intermittent claudication. Usually the client can walk only a certain distance before cramping, burning, muscle discomfort, or pain forces him or her to stop; the pain subsides after rest. When the client resumes walking, he or she can walk the same distance before the pain returns. The pain is reproducible. As the disease progresses, the client walks shorter and shorter distances before pain recurs. Ultimately pain may even occur while the client is at rest. Therefore the other options are incorrect.

A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing:

A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips:

Lateral to the extensor tendon of the big toe Rationale: The dorsalis pedis pulse is palpated lateral to and parallel with the extensor tendon of the big toe. The popliteal pulse is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. The femoral artery is located below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines.

The nurse is observing a new nurse employee assess a client's dorsalis pedis pulse. The nurse realizes the new nurse is using correct technique if the nurse places the fingertips on which part of the client's body? Behind the knee Lateral to the extensor tendon of the big toe In the groove between the malleolus and the Achilles tendon Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines

A nurse is preparing to listen to the breath sounds of a client. The nurse should:

40. A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment in which manner? Palpating the carotid artery in the upper third of the neck Palpating both arteries simultaneously to compare amplitude Listening to the carotid artery, using the bell of the stethoscope to assess for bruits Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery

Listening to the carotid artery, using the bell of the stethoscope to assess for bruits Rationale: To assess the carotid artery, the nurse uses the techniques of palpation and auscultation. The nurse palpates each carotid artery medial to the sternomastoid muscle in the neck. The nurse should avoid putting pressure on the carotid sinus higher in the neck because of the risk of excessive vagal stimulation, which could slow the heart rate. The nurse should palpate one artery at a time to avoid compromising arterial blood flow to the brain. The nurse should auscultate each carotid artery for the presence of a bruit. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally a bruit is not present. The nurse should lightly place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath briefly so that tracheal breath sounds do not mask or mimic a carotid artery bruit.

A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment by:

A nurse is preparing to assist the physician in performing an internal gynecological examination of a client. In which of the following positions does the nurse place the client for this examination?

Lithotomy Rationale: An internal gynecological examination is performed with the client in the lithotomy position. In this position, the client is supine, with the feet in stirrups, the knees apart, and the buttocks at the end of the examining table. The client is draped so that only the vulva is exposed. In the prone position, the client would be lying on her stomach. The Sims position, a left side-lying position, is most often used in administering an enema.

A nurse is performing an abdominal assessment on a client. On auscultation of the abdomen the nurse hears a bruit over the abdominal aorta. Which action should the nurse take as a priority on the basis of this finding?

Notify the healthcare provider Rationale: Detection of a bruit over the aorta on assessment of the abdomen could indicate the presence of an aneurysm. The nurse would notify the healthcare provider of the finding and would not palpate or percuss the abdomen because of the risk of rupture. Although the nurse would document the findings, this is not the priority action.

A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as:

Nystagmus Rationale: Nystagmus is a fine oscillating movement, most notable around the iris. The nurse checks for nystagmus when assessing a client for ocular muscle weakness. Mild nystagmus at extreme lateral gaze is normal; nystagmus at any other position is not. Ptosis is a drooping of the eyelid. Scleral icterus is a yellowing of the sclera, extending up to the cornea, that indicates jaundice. Exophthalmos, a noticeable protrusion of the eyeball, is a characteristic sign of hyperthyroidism.

A nurse is assisting the physician in performing transillumination of a client's scrotum. The nurse prepares for this procedure by:

Obtaining a flashlight and darkening the room Rationale: Transillumination of the testes is a painless procedure that is performed when swelling or a lump is noted on palpation. After the room is darkened, a strong flashlight is shined from behind the scrotal contents. Normal scrotal contents do not appear on transillumination. Instructing the client to drink fluids or to take deep breaths and bear down is not necessary.

A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that the client has normal:

Ocular movements Rationale: Leading the client's eyes through the six cardinal fields of gaze will elicit any muscle weakness during movement. This test assesses the function of the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Near vision is tested with the use of a handheld vision screener that contains various sizes of print. Central vision is measured with the use of a Snellen chart. Peripheral vision is measured with the confrontation test.

A nurse performing a neurological assessment of an adult client asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?

Olfactory Rationale: The olfactory nerve is tested by determining the sense of smell in clients who report loss of smell, those with head trauma, those with abnormal mental status, and those in whom the presence of an intracranial lesion is suspected. The optic nerve is assessed by testing visual acuity and visual fields. The abducens nerve is usually assessed with the oculomotor and trochlear nerves; testing involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and testing extraocular movements through the cardinal positions of gaze. The hypoglossal nerve is assessed through inspection of the tongue.

A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork? On the client's teeth On the client's forehead On the client's mastoid bone On the midline of the client's skull

On the client's mastoid bone

A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork?

On the client's mastoid bone Rationale: In the Rinne test, the base of an activated tuning fork is held first against the mastoid bone, behind the ear, and then in front of the ear canal (0.5 to 2 inches). When the client no longer perceives the sound behind the ear, the fork is moved in front of the ear canal until the client indicates that the sound can no longer be heard. The client reports whether the sound from the tuning fork is louder behind the ear (on the mastoid bone) or in front of the ear canal. In the Weber test, an activated tuning fork is placed on the midline of the skull, the forehead, or the teeth.

A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination:

One week after menstruation begins Rationale: BSE should be performed after the menstrual period, on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. The pregnant woman or menopausal woman who is not having menstrual periods is taught to select a specific day to examine the breasts every month. Therefore the other options are incorrect.

A nurse teaches a client about healthy dietary measures and explains the MyPlate food plan. The nurse determines that the client understands the information if the client says how many of his grains should be whole grains?

One-half Rationale: According to the MyPlate food plan, at least half of grains eaten daily should be whole grains. While it is acceptable to make more than half of your grains whole grains, MyPlate does not require it.

A nurse performing an eye examination uses an ophthalmoscope to best visualize which of the following areas?

Optic disc Rationale: The ophthalmoscope enlarges the examiner's view of the eye so that the media (anterior chamber, lens, vitreous humor) and the ocular fundus (the internal surface of the retina) can be examined. The optic disc is located on the internal surface of the retina. The iris, conjunctiva, and cornea can be examined without the use of an ophthalmoscope.

A nurse reviewing a client's healthcare record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the nurse determine that the client has?

Osteoarthritis Rationale: Osteoarthritis is characterized by hard, nontender nodules of 2 to 3 mm or larger. These osteophytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes. In this disorder, when these nodes occur on the proximal interphalangeal joints they are called Bouchard nodes. Heberden nodes are not associated with scoliosis, rotator cuff lesions, or carpal tunnel syndrome.

Performing an abdominal assessment, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner because:

Palpation and percussion can increase peristalsis Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. The other options identify incorrect reasons for auscultating the abdomen before palpating and percussing it.

A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign?

Percussing at the location of the median nerve Rationale: The Tinel sign is elicited with direct percussion in the location of the median nerve at the wrist. The test produces no symptoms in the normal hand. In the presence of carpal tunnel syndrome, percussion of the median nerve produces burning and tingling along its distribution (Tinel sign). Asking the client to hold the hands back to back while flexing the wrist 90 degrees is the Phalen test, another test for the presence of carpal tunnel syndrome. Testing the strength of each joint and checking for repetitive movements in the joints involve the assessment of muscle strength and range of motion.

A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells the client that this test measures:

Peripheral vision Rationale: The confrontation test is a gross measure of peripheral vision. It compares the client's peripheral vision with the nurse's, assuming that the nurse's vision is normal. The nurse positions himself or herself at eye level with the client, about 2 feet away, then directs the client to cover one eye with an opaque card and look straight at the nurse with the other eye. The nurse covers the eye opposite the client's covered one. The nurse then holds a pencil or flicking finger as the target, midline between the nurse and the client, and slowly advances it from the periphery in several directions. The nurse asks the client to say "now" as the target is first seen. This should occur just as the nurse sees the object. Near vision is tested with a handheld vision screener that contains various sizes of print. Color vision is tested with the use of the Ishihara test, which comprises a series of cards bearing a pattern of dots printed against a background of many colored dots. Distant vision is tested with the use of a Snellen chart.

A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve? Asking the client to stick out his or her tongue and watching the client for tremors Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says "ah." Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

30. A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve? Asking the client to stick out his or her tongue and watching the client for tremors Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says "ah." Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size. The nurse checks that these muscles are equal in strength by asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands. Asking the client to stick out the tongue and watching for tremors is the method for assessing the function of cranial nerve XII (hypoglossal nerve). Assessment of pharyngeal function reveals the function of cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve).

A nurse is preparing to test the function of cranial nerve XI. Which of the following actions does the nurse take to test this nerve?

A nurse is preparing to assess the function of a client's spinal accessory nerve. Which of the following actions does the nurse ask the client to take to aid assessment of this nerve?

Shrugging the shoulders against the nurse's resistance Rationale: To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve).

A nurse conducting an interview with a client collects subjective data. During the interview, the nurse:

Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors Rationale: During an interview, the nurse keeps note-taking to a minimum and tries to focus his or her attention on the client. Any note-taking should be secondary to the dialogue and should not interfere with the client's dialogue. Note-taking during an interview breaks eye contact too often; shifts the nurse's attention away from the client, diminishing his or her sense of importance; interrupts the client's narrative flow; impedes the nurse's observation of the client's nonverbal behaviors; and may be threatening to the client during the discussion of sensitive issues.

A nurse is preparing to screen a client's vision with the use of a Snellen chart. The nurse:

Tests the right eye, then tests the left eye, and finally tests both eyes together Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot with the chart at the client's eye level. The client is positioned on a mark exactly 20 feet from the chart. The client uses an opaque card to shield one eye at a time during the test; after each eye is tested, both eyes are assessed together. The client is asked to read through the chart to the smallest line of letters he or she can discern. The client is encouraged to read the next smallest line as well. Therefore the other options are incorrect.

An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse concludes that:

The client has a normal cardiac output Rationale: In the normal resting adult, the heart pumps between 4 and 6 L of blood per minute throughout the body. This cardiac output equals the volume of blood in each systole (called stroke volume) multiplied by the number of beats per minute. Therefore a cardiac output of 5 L/min is a normal cardiac output. The other options are incorrect interpretations.

A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the nurse places the stethoscope over:

A nurse sees documentation in the client's record indicating that the nurse on a previous shift has noted the presence of adventitious breath sounds. The nurse interprets this information in which manner? These sounds are normally heard in the lungs Hollow sounds heard over the trachea and larynx indicate pneumonia Rustling sounds heard over the peripheral lung fields are associated with bronchitis These are abnormal sounds that should not be heard in the lungs of a healthy client

These are abnormal sounds that should not be heard in the lungs of a healthy client Rationale: Adventitious breath sounds are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused when moving air collides with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds.

A nurse preparing to perform an abdominal assessment asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity?

Tympany Rationale: The nurse expects to primarily note tympany when percussing the abdomen. Tympany should predominate because air in the intestines rises to the surface when the client is supine. Dullness occurs over a distended bladder, adipose tissue, fluid, or a mass. Borborygmus (the term used to describe hyperperistalsis) may be noted on auscultation, not percussion. Hyperresonance is present with gaseous distention.

A nurse is preparing to listen to a client's breath sounds. The nurse should:

Use the diaphragm of the stethoscope, holding it firmly against the client's chest Rationale: The nurse asks the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client is asked to breathe through the mouth a little more deeply than usual but is told to stop if he or she begins to feel dizzy. The nurse uses the flat diaphragm endpiece of the stethoscope, holding it firmly on the chest wall, and listens for at least one full respiration in each location, moving from side to side to compare sounds.

A nurse is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the nurse:

A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat which kind of words? Spoken in a soft tone of voice by the nurse about 5 feet (1.5 meters) in front of the client Whispered by the nurse from the client's side at a distance of 1 to 2 feet (30 to 60 cm) from the ear being tested Spoken by the nurse from the client's side in a normal tone of voice about 10 feet (3 meters) from the ear being tested Whispered at a distance of 20 feet (6 meters) by the nurse while he or she is standing in front of the client.

Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested

A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat words that are:

Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested Rationale: In performing the voice test, the nurse tests one ear at a time while masking hearing in the other ear to prevent transmission around the head. The nurse shields his or her lips so that the client cannot compensate for hearing loss (consciously or unconsciously) by lip-reading or using the "good" ear. The nurse stands 1 to 2 feet from the client's ear, exhales, and slowly whispers some two-syllable words. A client with normal hearing repeats each word correctly.

A nurse performing a skin assessment notes that the client's skin is very dry. The nurse documents this finding as:

Xerosis Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Causes include too-frequent bathing, low humidity, and decreased production of sebum in aging skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin. Seborrhea is one of several common skin conditions in which an overproduction of sebum results in excessive oiliness or dry scales. Actinic keratoses are red-tan scaly plaques that grow over the years, becoming raised and roughened. A silvery-white scale may adhere to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. Actinic keratoses are premalignant and may develop into squamous cell carcinoma.

A 35-year-old female client asks the clinic nurse when she should begin to have yearly mammograms. What does the nurse tell the client?

Yearly mammograms are recommended starting at age 40. Rationale: The American Cancer Society recommends yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Clinical breast exam should be done about every 3 years for women in their twenties and thirties and every year for women 40 and older. Women should know how their breasts normally look and feel and report any breast change promptly to the healthcare provider. Breast self-exam should be done monthly starting when a woman is in her twenties. The American Cancer Society also recommends that some women, because of their family history, a genetic tendency, or certain other factors, be screened with magnetic resonance imaging in addition to mammograms.

A client of Asian American descent tells the nurse he is considering using acupuncture to deal with low back pain due to strained muscles. Which question is most appropriate to ask the client? "Have you considered physical therapy first?" "Are you currently taking any anticoagulants?" "Have you thought about seeing a chiropractor?" "Can you increase your intake of rice and raw fish in your diet?"

"Are you currently taking any anticoagulants?" RATIONALE: Acupuncture involves inserting needles into tissues, therefor to prevent bleeding, it is crucial to know if the client is currently taking anticoagulants. Physical therapy and chiropractor treatments are alternative methods of treating low back pain, but the client has expressed a desire for acupuncture. The nurse should assess what the client believes is causing the illness before suggesting diet changes. TEST-TAKING STRATEGY: Use Maslow's Hierarchy of Needs Theory to support selecting the option that prevents client harm from bleeding. Eliminate the comparable or alike options that recommend another treatment the client may not desire.

A nurse is gathering subjective data from an adult client about the client's daily food intake. Which question should the nurse ask the client first? "Do you do your own shopping?" "Have you ever heard of MyPlate?" "Can you tell me what you ate and drank over the last 24 hours?" "Do you have adequate income to purchase the foods you need?"

"Can you tell me what you ate and drank over the last 24 hours?" RATIONALE: The first question the nurse should ask the client would provide data about the client's typical daily intake. Once this has been determined, the nurse would collect data regarding who shops and prepares the food and whether the client has adequate income to purchase healthy food. The nurse might ask the client about MyPlate before teaching the client about healthy eating habits; however, the nurse would use it as a guide for teaching nutrition regardless of whether the client has heard of it.

The clinic nurse, performing a physical examination of an adult client, is gathering subjective data about the client's lifestyle. When asked about alcohol, the client tells the nurse that he does drink on a daily basis. Based on this finding, which question should the nurse ask next? "What type of alcohol do you drink?" "Have you ever passed out after drinking alcohol?" "Does your drinking affect your work or home life?" "How frequently do you drink, and how much alcohol do you consume?"

"How frequently do you drink, and how much alcohol do you consume?" RATIONALE: Once it has been determined that the client uses alcohol, the nurse should next determine how frequently the client drinks and how much alcohol is consumed. This information will assist the nurse in determining whether the client has a substance abuse problem and provide a baseline for asking the client additional sensitive questions. Asking the client the type of alcohol he drinks, whether he has ever passed out as a result of drinking alcohol or whether his drinking affects his home life may all be appropriate questions, but the nurse would first ask about frequency and amount of alcohol consumed.

A nurse provides information to a client about measures to prevent infection with West Nile virus. Which statement by the client indicates a need for further information? "I need to avoid wooded or swampy areas when I'm outdoors." "I don't need to use insect repellent if my clothes are covering my skin." "I should wear clothing that covers all of my skin, and I should wear a hat." "I should stay indoors at dusk and dawn, when mosquitoes are most active."

"I don't need to use insect repellent if my clothes are covering my skin." RATIONALE: West Nile virus is associated with mosquito bites. The nurse should instruct the client to wear a hat and clothing that covers as much skin as possible when outdoors and to spray insect repellant containing DEET (N, N-diethyl-m-toluamide) on clothes that cover the skin. Mosquitoes are most prevalent in wooded and swampy areas and are most active at dusk and dawn.

A nurse has provided information to a client about measures to prevent cardiovascular disease. Which statement by the client indicates a need for further information? "I need to reduce my salt intake." "I need to cut down on my smoking." "I need to start a regular exercise program." "I need to watch my weight and cut down on my saturated fat."

"I need to cut down on my smoking." RATIONALE: Risk factors associated with cardiovascular disease include increasing age, sex, excessive alcohol intake, cigarette smoking, diabetes mellitus, increased serum lipid concentrations, excessive dietary sodium, obesity, sedentary lifestyle, and stress. Reduction of salt intake, reducing calorie intake, exercise, and cutting down on fat intake are appropriate preventive measures. The risk of cardiovascular disease and resultant death is higher in smokers than in nonsmokers. The client needs to stop smoking, not "cut down" on the smoking.

During her clinic visit, Dianne is instructed to follow the DASH (Dietary Approaches to Stop Hypertension) eating plan and to reduce her intake of sodium and fat. Which of these statements by Dianne indicate a need for further instruction? Select all that apply. "I should avoid milk and milk products." "I'll rinse canned vegetables with water before cooking them." "A packaged food product is safe to eat if it doesn't taste salty." "I don't need to worry about condiments such as ketchup or mustard." "I will try to eat more fresh fruits and vegetables every day." "It doesn't matter whether I choose red meat or poultry, as long as it's lean."

"I should avoid milk and milk products." "A packaged food product is safe to eat if it doesn't taste salty." "I don't need to worry about condiments such as ketchup or mustard." "It doesn't matter whether I choose red meat or poultry, as long as it's lean."

The nurse teaches Shannon about measures to help prevent skin cancer. Which statements by Shannon leads the nurse to conclude that she understands these measures correctly? Select all that apply. "I won't need to wear protective clothing if I wear sunscreen." "I'll examine my body monthly for any changes in my moles." "I'll try to avoid being out in the sun between 9 a.m. and 2 p.m." "I will ask my husband to help me examine the moles on my back." "If I find any changes in my moles, I'll tell the doctor the next time I have an appointment."

"I'll examine my body monthly for any changes in my moles." "I will ask my husband to help me examine the moles on my back." RATIONALE: The most effective means of preventing skin cancer is reducing exposure of the skin to sunlight. Secondary prevention through early detection is also essential. Avoiding sun exposure between the hours of 11 a.m. and 3 p.m., using sunscreen, and wearing protective clothing are all important measures for preventing sunburn. It is important to be aware of one's skin markings and to examine spots, scars, and lesions, including moles, monthly. Assistance with skin inspection should be obtained as needed. Any changes should be reported to the health care provider right away.

The nurse is counseling the parents of a 5 year-old about environmental hazards. Which statement by the parent indicates the need for further information to prevent injury? "We have our water heater's temperature set at 140°F (60° C)." "We always place our child in a safety car seat when we ride in the car." "We frequently check the smoke detectors in our home to be sure that they work." "I've taught my child about the importance of wearing a helmet when riding a bicycle."

"We have our water heater's temperature set at 140°F (60° C)." RATIONALE: A primary nursing responsibility is to teach the parents about environmental hazards and measures to reduce the risk of injury and illness. These measures include using window and stair guards, using car safety seats, wearing helmets and other protective garb when participating in activities that could result in injury, ensuring that smoke detectors are working properly, and maintaining water heater temperature below 120° F to prevent burns.

A nurse is using an otoscope to examine the ears of a client. Which finding indicates to the nurse that the tympanic membrane is normal?

A nurse performing a skin assessment of a client with heart failure notes that the client's ankles are swollen. To assess the severity of the edema, the nurse presses the skin at the ankle. Moderate pitting is present, but the indentation subsides rapidly. How should the nurse document this finding? 1+ edema 2+ edema 3+ edema 4+ edema

2+ edema RATIONALE: Edema is the accumulation of fluid in the intercellular spaces. To check for edema, the nurse presses the thumbs firmly against the ankle malleolus. If the pressure leaves a dent in the skin, pitting edema is present. Edema is graded on a 4-point scale: 1+ indicates mild pitting with a slight indentation, 2+ is moderate pitting in which the indentation subsides rapidly, 3+ represents deep pitting in which the indentation remains for a short time and the ankle is swollen, and 4+ denotes very deep pitting in which the indentation remains for a long time and the ankle is very swollen. TEST-TAKING STRATEGY: Focus on the subject of the question, which is assessment for edema. Noting the words "indentation subsides rapidly" and knowing the grading scale used to assess edema will direct you to the correct option. Review: the grading scale used to assess edema.

A nurse is using a Snellen chart to assess a client's visual acuity. The client stands 20 feet from the chart, and each eye is tested separately. The client is able to read the line comprising the letters P, E, C, F, and D with each eye. The nurse encourages the client to read the next smallest line with each eye, but the client is unable to do so. How does the nurse document the client's vision? 20/40 40/20 20/30 60/20

20/40 RATIONALE: The Snellen chart is placed in a well-lit spot and the client stands 20 feet away, with the chart at eye level. Each eye is tested separately (one eye is covered), and the client is asked to read through the chart to the smallest line of letters possible. The client is also encouraged to read the next smallest line also. Findings are recorded as a comparison between what the client can read at 20 feet and the distance at which a person with normal vision can read the same line. A reading of 20/40 means that the client is able to see at 20 feet from the chart what a healthy eye can see at 40 feet. Normal visual acuity is 20/20. TEST-TAKING STRATEGY: First recall that normal visual acuity is 20/20. Next focus on the subject - the letters the client can read and note the measurement of this line. This will help direct you to the correct option. Review: Snellen chart.

The nurse is preparing to listen to Sara's apical heartbeat. In which area should the nurse place the diaphragm's endpiece to auscultate the area of the mitral valve?

. A nurse reviewing the medical record of a client with the diagnosis of heart failure notes documentation indicating that the client has deep pitting edema, that the indentation remains for a short time, and that the leg looks swollen. How should the nurse document this finding? 1+ edema 2+ edema 3+ edema 4+ edema

A nurse is performing a peripheral vascular assessment. In which anatomic area should the nurse place the fingertips to assess the dorsalis pedis pulse?

4 RATIONALE: The dorsalis pedis pulse is located just lateral and parallel to the extensor tendon of the great toe (the top of the foot). The femoral artery is located in the groin. It extends down the thigh and branches to other arteries. The popliteal artery is located behind the knee. The anterior tibial artery is located on the front of the lower leg and extends from the knee to the ankle area. TEST-TAKING STRATEGY: Focus on the subject - the anatomic location of the dorsalis pedis pulse. Noting the word "pedis" in the question will assist you in determining that the pulse is in the foot. Review: anatomic locations of peripheral pulses.

The nurse has educated Shannon about BSE. The nurse realizes the education was effective if Shannon states that she will perform this examination how frequently? The first day of each month 7 days after the start of menstruation 14 days after the start of menstruation The 10th day of each month

7 days after the start of menstruation RATIONALE: Breast self-examination (BSE) should be performed monthly at a regular time when the breasts are not tender. In premenopausal women, the best time is 7 days after the start of menstruation. At this time, hormonal stimulation of the breasts is at its lowest point. Postmenopausal clients and clients who have undergone hysterectomy should select a specific day of the month and perform BSE each month on that day. First day of each month, 14 days after the start of menstruation, and the 10th day of each month are incorrect times to perform BSE.

A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? The client is allergic to strawberries. The last menstrual period was 30 days ago. The client takes acetaminophen for headaches. A 1 × 2-inch (5 cm) scar is present on the lower right portion of the abdomen.

A 1 × 2-inch (5 cm) scar is present on the lower right portion of the abdomen.

At the end of the breast examination, Shannon tells the nurse that she has several moles and is worried about skin cancer. She states that her father has had "several skin cancers" removed. Which of these lesions would need to be examined more closely for skin cancer? Select all that apply. A scar that has an overgrowth of skin An irregularly shaped, pigmented papule A firm, nodular lesion that is topped with dry, scaly skin A firm, movable flesh-colored nodule that contains liquid A mole that was previously flat but now, the client states, is "larger and bumpy"

A firm, nodular lesion that is topped with dry, scaly skin A mole that was previously flat but now, the client states, is "larger and bumpy" RATIONALE: The ABCD guide can be used to assess a skin lesion for characteristics associated with cancer. In this guide, A stands for asymmetry shape, B represents border irregularity, C stands for color variation within one lesion, and D denotes diameter greater than 6 mm. Every suspicious skin lesion should be examined carefully, and a person who has a lesion with one or more of the ABCD characteristics should be evaluated by a surgeon or dermatologist. An overgrowth of skin over a scar is a keloid, which is benign. Skin lesions that are irregularly shaped or have changed in color, elevation, or size may be cancerous or precancerous. A firm, nodular lesion that is covered with a dry or rough scale may be actinic keratosis, which is a premalignant lesion. A firm, movable flesh-colored nodule that contains liquid is a cyst, which is benign.

What objective assessment would determine that the tympanic membrane finding is normal? A red membrane A white membrane A yellow-amber membrane A shiny, translucent membrane

A shiny, translucent membrane RATIONALE: The normal tympanic membrane is translucent, shiny, and pearly gray. It is free of tears and breaks. A bulging pink or red membrane indicates inflammation. A white membrane denotes the presence of pus behind the membrane. A yellow-amber color indicates serous otitis media.

A nurse performing a breast examination is preparing to palpate the client's breasts. Into which position should the nurse assist the client to perform palpation? A standing position, with the client holding both arms above her head A standing position, with the client holding her hands firmly on her hips A supine position, with the arm on the side being examined positioned across the chest A supine position, with the arm on the side being examined positioned behind the head and a small pillow placed under the shoulder on the same side

A supine position, with the arm on the side being examined positioned behind the head and a small pillow placed under the shoulder on the same side RATIONALE: To palpate the breasts, the nurse assists the client into a supine position and positions the client's arm on the side being examined behind the head. A small pillow is placed under the shoulder on the same side. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall and notes tissue consistency. Palpation is performed systematically, with care taken to ensure that the entire breast and tail are palpated. The other options are not positions that would allow effective palpation of the breast tissue. TEST-TAKING STRATEGY: Eliminate comparable or alike options (standing) are the position for inspection of the breasts. To select from the remaining two options visualize each and select the one that allows for optimal palpation of the breast. Review: clinical breast examination.

22. A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding? Myopia Hyperopia Photophobia Accommodation

Accommodation

A nurse is preparing to administer the diphtheria/tetanus/acellular pertussis vaccine (DTaP) to a 6-month-old infant. Which action should the nurse take to minimize the potential for a local reaction to the vaccine? Using a 1.5-inch (3.8 cm) needle for injection Administering the injection in the deltoid muscle Administering the injection in the vastus lateralis muscle Changing the needle on the syringe after drawing up the vaccine

Administering the injection in the vastus lateralis muscle RATIONALE: To minimize the potential for a local reaction to a vaccine, the nurse selects a needle of adequate length to deposit the vaccine deep into the muscle mass. The vaccine is injected into the vastus lateralis muscle or ventrogluteal muscle (the deltoid may be used in children 18 months of age or older). Changing the needle on the syringe after drawing up the vaccine and before injecting will not decrease the possibility of a local reaction.

5. A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? Collect health history information first, then perform the physical examination Ask health history questions while performing the examination and initiating emergency measures Collect all information requested on the history form, including social support, strengths, and coping patterns Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room

The nurse teaches Shannon how to perform BSE. What is the best way for the nurse to confirm that Shannon understands how to perform the BSE? Asks Shannon to verbalize how to perform the examination Asking Shannon to perform BSE and observing her performance Asking Shannon to read the pamphlet on performing BSE and to write down any questions she might have Asking Shannon to view a computer tutorial on performing BSE and to write down any questions she might have

Asking Shannon to perform BSE and observing her performance RATIONALE: To best determine Shannon's learning and understanding of how to perform a procedure, the nurse would ask her to perform the procedure and observe her performance. Verbalizing how to perform the examination, reading pamphlets and viewing computer tutorials are not the best ways of ensuring that the client knows how to perform BSE.

A clinic nurse is performing a mental status examination of a client. Which action should the nurse take to test the client's remote memory? Asking about the client's first job Asking what time the client left home to come to the clinic Asking what method of transportation the client used to get to the clinic Reciting four unrelated words and asking the client to repeat them at various points later in the assessment

Asking about the client's first job

The nurse has demonstrated the technique for a surgical wound dressing change to the wife of a client who will be discharged after hip replacement surgery. Which action should the nurse take to best confirm that the wife understands the procedure? Asking the wife to perform the dressing change Asking the wife whether she has any questions about the procedure Asking the wife whether she feels comfortable performing the procedure Asking the wife whether she understands what items need to be obtained from the surgical supply store

Asking the wife to perform the dressing change RATIONALE: The nurse would best evaluate the wife's learning by observing the wife's performance of the activity. Although asking the wife whether she has any questions, feels comfortable, or understands the procedure may be appropriate, these questions do not best reveal the wife's ability to perform the dressing change.

The nurse is performing an assessment on a 64-year old client admitted with chest pain who has a history of coronary artery disease, type 2 diabetes mellitus, hypertension, and smoking 1 pack per day for 40 years. The nurse notes the following clinical findings on assessment. MULTIPLE SELECT Select the correct answers. Which actions should the nurse take? Select all that apply. Assess for focal neurological deficits Administer an as needed antihypertensive medication Assess for a history of light-headedness, dizziness, and syncope Discuss with the primary health care provider performing serial troponin levels Initiate a referral for the diabetes nurse educator and outpatient endocrinology follow-up Collaborate with the primary health care provider on prescribing a bilateral carotid ultrasound

Assess for focal neurological deficits Assess for a history of light-headedness, dizziness, and syncope Discuss with the primary health care provider performing serial troponin levels Initiate a referral for the diabetes nurse educator and outpatient endocrinology follow-up Collaborate with the primary health care provider on prescribing a bilateral carotid ultrasound RATIONALE: The carotid arteries are located in the groove between the trachea and sternocleidomastoid muscle, medial to and alongside the muscle. On auscultation, the nurse listens for the presence of a bruit (a blowing, swishing sound), which indicates blood flow turbulence. Normally a bruit is not present, so this finding, whooshing noted over the right carotid artery, necessitates the need for follow-up. Assessing for focal neurological deficits and a history of light-headedness, dizziness, and syncope are important to determine if blood flow to the brain has been compromised as a result of carotid stenosis. A carotid ultrasound should be done due to the detection of a bruit on physical assessment, as well as the risk factors of hypertension, type 2 diabetes mellitus, coronary artery disease, and smoking. Serial troponin levels should be prescribed because of the elevation noted with the first level, as well as consultation with cardiology for further testing to determine if the client experienced a myocardial infarction. The client's serum glucose level and HbA1C indicate poor diabetes control; therefore, the nurse should initiate a referral to the diabetes nurse educator and outpatient endocrinology follow-up. An as needed antihypertensive should not be administered at this time because the blood pressure, although elevated beyond normal levels, is not elevated to the point of requiring additional blood pressure management. TEST-TAKING STRATEGY: Focus on the data in the question and determine if an abnormality exists. Use of clinical judgment is necessary in making the decision regarding blood pressure management. Given the context of other clinical findings, as well as the current blood pressure reading, the safest option would be to hold off on administering as needed blood pressure medication.

The nurse is developing the plan of care for a family of seven who are recently arrived refugees from Central America. The nurse should prioritize the plan of care to take which action immediately? Provide immediate vaccinations for the entire family Assess the three year old child who has a rash, a cough and a high fever Advise the mother with a seven month old child to continue breastfeeding Obtain stool samples to determine if the family has a gastrointestinal illness

Assess the three year old child who has a rash, a cough and a high fever RATIONALE: The nurse should prioritize the assessment of the three year old child who has a rash, a cough and a fever. These could be the symptoms of a communicable disease. Providing vaccinations is important, but the child's current symptoms take priority. Obtaining stool samples may not be necessary as there is no indication of gastrointestinal symptoms. It is important to continue breastfeeding the seven month old child, but this is not as high a priority as the symptoms of rash, a cough and a fever. TEST-TAKING STRATEGY: Utilize knowledge of Maslow's Hierarchy of Needs Theory to answer this question. Actual needs, such as the child with symptoms of rash, a cough and fever, take precedence over potential needs. Vaccinations, breastfeeding instructions and obtaining stool samples are all comparable or alike options which address potential, rather than actual needs.

On a follow-up visit to the clinic, Dianne tells the nurse she has been attending a stress-management program and that it has been extremely helpful in helping her manage stress. Dianne says she feels less fatigued at the end of the workday and that she would like to begin an exercise program. The nurse should tell Dianne that which exercise would best facilitate weight loss? Ask the instructor of the stress-management program Begin walking 20 to 30 minutes at least three times a week Avoid exercise until she loses some weight to avoid stressing her heart Obtain a membership at a health club and hire a personal trainer to help get started in an exercise program

Begin walking 20 to 30 minutes at least three times a week RATIONALE: Regular exercise such as walking or other aerobic movement results in improved circulation, increased release of endorphins, and an enhanced sense of well-being. Exercise is also an effective stress-management technique. Telling Dianne to ask the instructor of the stress-management program places Dianne's question on hold and is a nontherapeutic response. Obtaining a membership at a health club is unnecessary; additionally, Dianne may not have the financial resources to hire a personal trainer. Telling Dianne to avoid exercise until she loses weight is incorrect. Exercise should be combined with dieting for overall effectiveness of weight loss TEST-TAKING STRATEGY: Focus on the strategic word, "best." First eliminate the option that places Dianne's question on hold (asking the instructor). Next eliminate the option that will require money for participation (joining a health club); there is no information in the question regarding Dianne's financial status, and this option may increase Dianne's stress if Dianne is on a limited budget. To choose between the remaining options, recall the importance of combining diet with exercise for weight loss. Review: exercise/diet and stress management

A nurse is preparing an ambulatory male client for a rectal examination. After the examination has been explained to the client, into what position should the nurse assist the client? Sims Supine Left lateral Bending forward resting upper body on exam table

Bending forward resting upper body on exam table RATIONALE: In a rectal examination, the male client is asked to bend forward, with his hips flexed and his upper body resting on the examination table. The lithotomy position may be used for this examination in a woman after examination of the genitalia is complete. A nonambulatory client may be examined while in the left lateral (Sims) position. A rectal examination could not be performed if the client were in the supine position.

The nurse is providing preoperative instructions for day surgery scheduled in a week to a client who speaks Spanish only. Which action is the best way for the nurse to ensure that the client understands the instructions? Calling for a hospital-designated interpreter to communicate with the client Asking a family member who speaks English and Spanish to translate for the client Relying on the use of hand signals and demonstrations to teach the client about the preoperative procedures Writing the instructions on a piece of paper so that an English and Spanish speaking neighbor will be able to translate them for the client

Calling for a hospital-designated interpreter to communicate with the client RATIONALE: Arranging for a hospital designated interpreter is the best practice for communication with a client who speaks a different language. This action will ensure that the client clearly understands the preoperative instructions. Asking a family member or a neighbor is not an appropriate action, because the nurse cannot be sure that the client will receive the correct information. Also, asking a family member or neighbor to translate violates the client's privacy. Likewise, the use of hand signals and demonstrations will not ensure that the client understands the instructions. TEST-TAKING STRATEGY: Note the strategic word "best" in the question. Eliminate the comparable or alike options that violate the client's right to privacy by asking the family member or neighbor to translate. Next remember that a hospital designated translator will be familiar with medical terminology and will be able to explain the instruction accurately in lay terms. Review: the best communication techniques for a client who speaks a different language.

The nurse is volunteering with an outreach program to provide basic health care for people experiencing homelessness. Which finding, if noted, should be addressed first? Blood pressure 154/72 mmHg Visual acuity of 20/200 in both eyes Random blood glucose level of 206 mg/dL (11.77 mmol/L) Complaints of pain associated with numbness and tingling in both feet

Complaints of pain associated with numbness and tingling in both feet RATIONALE: The nurse should address the complaints of pain and numbness and tingling in both feet first with this population. If the client perceives value to the service provided, they will be more likely to return for follow up care. While the blood pressure, blood glucose and vision results are concerning, the client's stated concern should be addressed first. TEST-TAKING STRATEGY: Note the subject, the finding to be addressed, and focus on the strategic word, first. Recalling that adherence is a problem for this population will direct you to the correct option. Also note, the correct option is the only subjective finding.

A nurse conducting a physical assessment is observing the client's balance and performing tests to determine the client's sense of equilibrium. Which cranial nerve is the nurse assessing? Cranial nerve II Cranial nerve IX Cranial nerve VII Cranial nerve VIII

Cranial nerve VIII RATIONALE: Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the client's balance when the client is walking or standing, involve the vestibular portion. The function of cranial nerve II (the optic nerve) is tested by assessing the client's visual acuity. Swallowing ability and taste perception of the posterior portion of the tongue are controlled by cranial nerve IX (the glossopharyngeal nerve). Taste perception on the anterior portion of the tongue and the ability to perform facial and eye movements (e.g., closing the eyes) are controlled by cranial nerve VII (the facial nerve). TEST-TAKING STRATEGY: Focus on the subject - the cranial nerve associated with balance and equilibrium. Recalling that cranial nerve VIII is the acoustic nerve should direct you to this option. Review: functions of cranial nerves.

10. A nurse is preparing to perform a skin examination with the use of a Wood light. Which action should the nurse perform to prepare for this diagnostic test? Darken the room Obtain informed consent from the client Obtain a scalpel and a slide for diagnostic evaluation Obtain medication to anesthetize the skin area before proceeding with the examination

A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which? Data related to follow-up care A complete (total health) database Data related to the respiratory system Data related to the treatment for the cold

7. A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. What is the primary purpose of including cultural information in the health assessment? Confirm the medical diagnosis Make accurate nursing diagnoses Identify any hereditary traits related to the epilepsy Determine what the client believes has caused the epilepsy

The nurse is developing a plan of care for a client who has a severe intellectual disability. The client has recently begun to suck on her right hand, which is becoming red and raw. She is also refusing to eat some of her favorite foods. Which intervention has the highest priority? Wrapping her hand in gauze Determining if the client has a new mouth sore Frequently reminding her it is unsanitary to suck on her hands Giving her a small reward when she does not suck on her hand during meals

Determining if the client has a new mouth sore RATIONALE: The nurse should be aware that altered behavior may be caused by illness. The highest priority should be to investigate any illness that could cause altered behavior. Wrapping her hand in gauze is not a priority if there is an underlying cause of the new behavior. Reminding her it is unsanitary to suck on her hands may not be effective if the individual has a severe intellectual disability. Providing her with a small reward for not sucking on her hands would not be effective if the cause of the behavior is a sore mouth. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that focus on aspects other than addressing an underlying illness. Wrapping the hand in gauze, giving reminders and rewards do not focus on the underlying illness.

The nurse is performing an assessment of a client who is African American. Which question should the nurse ask to elicit information on a health risk associated with this cultural group? Does anyone in your family have arthritis? Does anyone in your family have thalassemia? Does anyone in your family have tuberculosis? Does anyone in your family have hypertension?

Does anyone in your family have hypertension? RATIONALE: The incidence of hypertension varies significantly among races and cultural groups. Hypertension is more prevalent among African Americans than among European Americans. Arthritis, thalassemia and tuberculosis are not health risks specific for the client who is African American

Family History

Family history includes age and health or age and cause of death of blood relatives such as parents, grandparents, and siblings. A genogram (see image above) or family tree may be constructed to chart family health history clearly; this assists the nurse to identify risk factors for illness. The screener should also inquire about the health of close family members such as the client's spouse and children.

The nurse, obtaining subjective data, asks Dianne about her perception of her health. Dianne again tells the nurse that the stress of her job is the reason for her not being able to take good care of herself. After gathering additional information about Dianne's stressful life, what action should the nurse take next? Suggesting that Dianne find another job Telling Dianne to ignore the stress at work Encouraging Dianne to participate in a stress-management program Telling Dianne how important it is for her to forget about her work once the workday is over

Encouraging Dianne to participate in a stress-management program RATIONALE: Assessment of health perception is focused on the client's perceived level of health and well-being and on personal practices for maintaining health. Because Dianne has said that stress is the cause of her health problems, the nurse would suggest and encourage participation in a stress-management program. Finding another job is an unrealistic expectation and could cause even more stress. Although trying to forget about her work at the end of the workday and ignoring stress at work are strategies for alleviating stress, both are easier said than done. This client needs to learn methods for managing the stress.

14. A clinic nurse about to meet a new client and plans to gather subjective data regarding the client's health history. Which actions should the nurse take to help ensure the success of the interview? Select all that apply. Ensuring that the room is private Seeing that distracting objects are removed from the room Having the client sit across a desk or table to give the client some personal space Maintaining a distance of 2 feet (60 cm) or closer between the nurse and client. Switching on a dim light that will make the room cozier and help the client relax

Ensuring that the room is private Seeing that distracting objects are removed from the room Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained, that there are no interruptions during the interview, that the room temperature is comfortable, that lighting is sufficient, that ambient noise is reduced, and that distracting objects are removed from the room. The nurse also ensures that the client and nurse are seated comfortably, eye to eye, without a desk or table between them, because a desk or table would act as a barrier. The nurse should maintain a distance of 4 to 5 feet (1.2 to 1.5 meters) from the client to avoid invading the client's private space, which might create anxiety on the part of the client.

The nurse helps the health care provider perform a Pap test on Shannon. When should the nurse instruct Shannon to receive follow-up testing? Yearly Every 3 years Every 5 years Every 6 months

Every 3 years The American Cancer Society (ACS) recommends that all women begin cervical cancer screening at 21 years of age; screening should be performed every 3 years until age 29. Beginning at age 30, women who have had three normal Pap results in a row may be screened every 5 years along with a human papillomavirus (HPV) test. Women 65 years or older who have had no abnormal Pap results in the preceding 10 years and no pre-cancers such as CIN2 or CIN3 may choose to stop having Pap tests

13. A client complains that her skin is redder than normal. The nurse assesses the client's skin, documents hyperemia, and explains to the client that this condition is caused by which? Contraction of the underlying blood vessels A reduced amount of bilirubin in the blood Diminished perfusion of the surrounding tissues Excess blood in the dilated superficial capillaries

6. A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? Emergency Follow-up Complete (total) Problem-centered

A nurse at a health fair is conducting teaching sessions on dietary measures to help prevent cancer. Which foods should the nurse encourage clients attending the teaching sessions to eat as a means of preventing cancer? Select all that apply. Fruits Red meats Vegetables Foods low in fiber High-nitrate foods

Fruits Vegetables RATIONALE: Dietary factors related to the development of cancer include foods that are high in fat and low in fiber, foods that are high in animal fat, high-nitrate foods, and those that contain preservatives, contaminants, and additives. Therefore, of the options provided, fruits and vegetables are the food items whose consumption should be encouraged as a means of preventing cancer.

The nurse examines Sara's breasts and informs her that no masses were felt. The nurse provides teaching on self-breast examination and recommendations of the American Cancer Society (ACS) for early detection of breast cancer. What should the nurse include in the teaching? Have a yearly mammogram starting at the age of 40 Have had a baseline mammogram performed at the age of 20 Have a yearly breast examination by a health care provider beginning at the age of 40 Perform a monthly breast self-examination and have a baseline mammogram when she reaches the age of 50

Have a yearly mammogram starting at the age of 40 RATIONALE: According to the ACS, yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health. Clinical breast exams (CBEs) are recommended about every 3 years for women in their twenties and thirties and every year for women 40 and older. Breast self-exams (BSEs) should be performed monthly (starting at the age of 20 is an option), and women should know how their breasts normally look and feel and promptly report any changes to a health care provider. The ACS also recommends that some women, because of their family history, a genetic tendency, or certain other factors, be screened with the use of magnetic resonance imaging (MRI) in addition to mammography.

The health care provider recommends that Dianne undergo a physical examination, including laboratory studies, before she starts exercising. Which tests are appropriate for assessment of Dianne's nutritional status? Select all that apply. Hemoglobin Serum creatinine Serum transferrin Serum triglycerides Total thyroxine (T4) Serum glucose level (fasting)

Hemoglobin Serum transferrin Serum triglycerides Serum glucose level (fasting)

The nurse is participating in a planning session for public health services that promote primary prevention. The nurse should guide the group into selecting to focus on which aspects? Select all that apply. Immunizations Pollution control An exercise regimen Cardiac rehabilitation Self-examination practices Diabetes mellitus management

Immunizations Pollution control An exercise regimen Primary prevention activities are those that prevent disease or dysfunction, including health-education programs and wellness activities that maintain or improve health. Examples of primary prevention include immunizations, pollution control, nutrition, and exercise. Secondary prevention activities are focused on clients who are experiencing health problems, on activities such as screening techniques (self-examination practices, mammography, blood pressure screening), and on treatment of disease at an early stage to limit disability. Tertiary prevention is focused on rehabilitation to minimize the effects of a long-term disease and to assist clients in achieving the highest possible level of function. Examples include cardiac rehabilitation and diabetes mellitus management.

A nurse is preparing to perform the Weber test in a client who reports loss of hearing in one ear. In which anatomic area should the nurse place the tuning fork for this test to be performed accurately? In front of the ear In the midline of the skull On the mastoid process At the temporal lobe on the side with hearing loss

In the midline of the skull RATIONALE: In the Weber test, the stem of the vibrating tuning fork is placed in the midline of the client's skull. Normally the client should hear the tone, by way of bone conduction through the skull, equally in the two ears. In the Rinne test, the stem of a vibrating tuning fork is placed on the client's mastoid process. When the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should again hear the sound. Normally the sound is heard twice as long by way of air conduction (near the ear canal) than by way of bone conduction (at the mastoid process). Placing the tuning fork at the temporal lobe on the side with hearing loss is not a component of a tuning fork test. TEST-TAKING STRATEGY: Focus on the subject - the Weber test. Try to visualize both the Weber and Rinne tests to answer correctly. Remember that in the Weber test the stem of the vibrating tuning fork is placed in the midline of the client's skull. Review: the tuning fork tests.

The nurse begins the physical examination by taking Sara's vital signs and her height and weight; on noting that these measurements are within the normal ranges, she proceeds with the physical examination. The nurse assesses Sara's vision and prepares to perform the confrontation test. Sara asks the nurse about the purpose of this test. What should the nurse tell Sara about the test? It is used to assess near vision. It is used to assess color vision. It is used to assess distant vision. It is used to assess peripheral vision.

It is used to assess peripheral vision. RATIONALE: The confrontation test is a measure of peripheral vision in which the client's peripheral vision is compared with the nurse's under the assumption that the nurse's peripheral vision is normal. The client covers one eye and looks straight ahead, and the nurse (positioned 2 feet away) covers his or her own eye opposite the client's covered eye. The nurse advances a finger or another small object in from the periphery from several directions; the client should see the object at the same time the nurse does. Near vision is tested with the use of a hand-held vision screener or by asking the client to read from a magazine or newspaper. The Ishihara chart is a tool used to assess color vision. It reveals the client's ability to distinguish a pattern of color (a number) in a series of color plates. Distant vision is measured with the use of the Snellen eye chart. TEST-TAKING STRATEGY: Focus on the subject - confrontation test. Recall the test that is performed for each vision issue in each option. To answer correctly it is essential to know that the confrontation test assesses peripheral vision. Review: visual testing. QUESTION CATEGORIES:

A nurse performing a musculoskeletal assessment is inspecting the posterior aspect of the client's posture as the client stands. After noting an exaggeration of the posterior curvature of the client's thoracic spine, how does the nurse document this finding? Lordosis Scoliosis Kyphosis Osteoporosis

Kyphosis RATIONALE: Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. Lordosis, or swayback, is an increased lumbar curvature. A lateral spinal curvature is called scoliosis. Loss of height is frequently an early sign of osteoporosis.

A nurse is preparing a client for a Papanicolaou test. Into which position does the nurse assist the client for this examination? Sims Supine Lateral Lithotomy

Lithotomy RATIONALE: A Papanicolaou test (a.k.a. "Pap smear") is performed during the speculum examination of the internal genitalia. In this test, a smear of tissue is obtained and then tested for cervical or vaginal cancer. The client is placed in the lithotomy position for this examination. The positions in the other options would not allow the examiner to perform the speculum examination, which is necessary for the smear to be obtained.

The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk? Lesbian persons Men who have sex with men Women who have sex with women Female to male transgender persons

Men who have sex with men RATIONALE: Men who have sex with men are at a higher risk for HIV and Acquired Immunodeficiency Syndrome (AIDS). Although anyone who is sexually active should be counseled on prevention of sexually transmitted infections, the other populations mentioned are not at increased risk for HIV/AIDS. TEST-TAKING STRATEGY: Eliminate comparable or alike options that mention women, because men who have sex with men are the most likely to contract HIV/AIDS.

20. A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. How should the nurse interpret this data? Normal near vision Normal central vision Normal peripheral vision Normal ocular movements

Normal ocular movements Rationale: Leading the client's eyes through the six cardinal fields of gaze will elicit any muscle weakness during movement. This test assesses the function of the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Near vision is tested with the use of a handheld vision screener that contains various sizes of print. Central vision is measured with the use of a Snellen chart. Peripheral vision is measured with the confrontation test.

The nurse, now performing the abdominal assessment, is listening to Sara's bowel sounds. Which descriptor does the nurse document in the health record after hearing these sounds? Select to listen to the audio clip. Borborygmus Normal sounds Hypoactive sounds Hyperactive sounds

Normal sounds RATIONALE: Normal bowel sounds are high-pitched, gurgling sounds that occur irregularly between 5 and 30 times a minute. Borborygmus, a type of hyperactive bowel sound, indicates hyperperistalsis. Hypoactive, or infrequent, bowel sounds are most often noted after abdominal surgery or with inflammation of the peritoneum. Hyperactive sounds are loud, high-pitched, rushing, tinkling sounds that indicate increased motility

A nurse performing an examination of a male client's genitalia notes the presence of a foul-smelling white discharge from the urethral meatus. Which action is the most appropriate response to this finding? Obtaining a culture of the discharge Informing the client that the discharge is normal Asking the client about the possibility of the presence of an STI Informing the client that his sexual partners will need examinations

Obtaining a culture of the discharge RATIONALE: When a discharge is noted during examination of the male genitalia, a culture of the discharge is obtained. A foul-smelling white discharge from the urethral meatus is not a normal finding. Informing the client that his sexual partners will need an examination is premature; however, if an STI is diagnosed, this will be an important intervention. Asking the client about the possibility of an STI is a component of obtaining subjective data, so this information should have been obtained before objective data were collected. TEST-TAKING STRATEGY: First note the strategic words "most appropriate". Also consider the words "foul-smelling discharge". Realizing that this is not a normal finding should direct you to select the most appropriate action to carry out first. Review: examination of the male genitalia.

After assessing clients and discussing their religious dietary practices, the nurse confers with the dietician to plan meals. The nurse demonstrates understanding of appropriate food plans if which meal recommendations are made? Select all that apply Ensuring no caffeine or alcohol is served to a client who is Buddhist On Fridays during Lent, providing a client who is Catholic a main dish with macaroni and cheese Serving a high protein meal containing hamburger patties with melted cheese to a client who is an Orthodox Jew Ensuring a client who attends the Church of the Latter Day Saints is not served meat on the first Sunday of the month During Ramadan, serving an evening meal after sunset and a morning meal before dawn to a client who practices Islam

On Fridays during Lent, providing a client who is Catholic a main dish with macaroni and cheese During Ramadan, serving an evening meal after sunset and a morning meal before dawn to a client who practices Islam RATIONALE: On Fridays during Lent, a client who is Catholic may be abstaining from meat; macaroni and cheese do not contain meat. During the month of Ramadan, clients who practice Islam may not eat until after sunset and before dawn. Alcohol and caffeine are generally avoided by clients who practice the faith of the Church of Jesus Christ of Latter Day Saints. Buddhists do not have this prohibition. A client who practices the Orthodox Jewish faith does not mix meat and milk at the same meal; a hamburger patty with cheese would not be an acceptable meal. Clients who practice the faith of the Church of Jesus Christ of Latter Day Saints may wish to fast (not just abstain from meat) on the first Sunday of the month. TEST-TAKING STRATEGY: Use knowledge of the subject, religious dietary practices, is helpful to answer this question. Recognize that many clients who are Catholic abstain from meat during Lent. Clients who practice Islam fast from sunup to sun down. Eliminate the comparable or alike options that do not follow common religious dietary practices of various groups.

A client is experiencing a change in vision. The nurse performing an eye examination uses an ophthalmoscope to best visualize which area? Iris Cornea Optic disc Conjunctiva

SEQUENCING Arrange the sequence options in the correct order by assigning each option a number. Order Sequencing Option Palpate Percuss Auscultate Inspect

Order Sequencing Option Inspect Auscultate Palpate Percuss

A nurse is performing an abdominal assessment of a client who complains of right upper quadrant pain. Which technique should the nurse use to palpate the abdomen? Palpating tender or painful areas last Tapping the client's skin with short, sharp strokes Using both hands and knead deeply into the abdomen Starting with deep palpation, then performing light palpation

Palpating tender or painful areas last RATIONALE: In palpation of the abdomen, the nurse starts with light palpation to detect surface characteristics and accustom the client to being touched. The nurse then performs deeper palpation, first asking the client about any tender areas so that these areas may be palpated last. The nurse uses one hand to palpate except when certain organs (e.g., kidneys, uterus, adnexa) are being palpated. The nurse avoids any situation in which deep palpation might cause internal injury or pain. Percussion is the act of tapping the client's skin with the use of short, sharp strokes to assess underlying structures. TEST-TAKING STRATEGY: Focus on the subject, palpation. Eliminate the option that describes percussion, not palpation. Next, eliminate the comparable or alike options that address deep palpation. Review: the procedure for palpating the abdomen.

HEALTH AND WELLNESS Health Screening

Personal History Subjective and objective data on past and current health status are obtained from the client to aid identification of risk factors. Heart disease, hypertension, stroke, diabetes mellitus, blood disorders, cancer, arthritis, allergies, obesity, alcoholism, seizure disorders, kidney disease, tuberculosis, and mental health disorders are all important findings in a health history. The nurse should also obtain data on childhood diseases and immunizations, accidents and injuries, serious or chronic illnesses, hospitalizations and surgeries, obstetric history, allergies, last examination date, current lifestyle practices, and medications, including herbal products, being taken.

A nurse performing a neurological assessment of a client who has sustained a stroke (brain attack) is preparing to check for stereognosis. Which action should the nurse take to perform this assessment? Placing an object in the client's hand and asking the client to identify it Tracing a number on the client's hand and asking the client to identify it Moving the client's finger up and down and asking the client which way it is being moved Making two simultaneous pinpricks on the skin and asking the client to distinguish them

Placing an object in the client's hand and asking the client to identify it RATIONALE: Stereognosis is the client's ability to recognize objects placed in his or her hand. Graphesthesia is the client's ability to identify a number traced on the client's hand. Position sense (kinesthesia) is tested by moving the client's finger or toe up or down and asking the client which way it is being moved. Two-point discrimination is the client's ability to discriminate two simultaneous pinpricks on the skin. TEST-TAKING STRATEGY: Focus on the subject - assessment of stereognosis. Then focus on the description of each option. It is necessary to recall that stereognosis is the client's ability to recognize objects placed in his or her hand to answer the question. Review: stereognosis

The nurse reviews the data from Sara's physical examination (refer "Chart" below). The nurse concludes that which findings are abnormal? Select all that apply. Vital SignsTemperature: 98.9° F (oral)Pulse: 94 beats/min, regular rhythmRespiratory rate: 18 breaths/min, laboredBlood pressure: 122/78 mm Hg Breath SoundsBronchial breath sounds heard over the tracheaBilateral vesicular breath sounds heard over the periphery of the lungsBronchovesicular breath sounds heard posteriorly between the scapulae NeurologicPatellar tendon reflexes: 1+ bilaterallyBabinski reflex: negativeRomberg test: positiveNo muscle weaknessRange of motion: equal bilaterally Positive result on Romberg test Temperature 98.9° F (37.2°C) (oral) Patellar tendon reflexes 1+ bilaterally Respiratory rate of 18 breaths/min, labored Bronchial breath sounds heard over the trachea

Positive result on Romberg test Patellar tendon reflexes 1+ bilaterally Respiratory rate of 18 breaths/min, labored

A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse take before inserting the otoscope? Pulling the pinna up and back Pulling the pinna down and forward Tipping the client's head down and toward the examiner Tipping the client's head down and away from the examiner

Pulling the pinna up and back

The nurse percusses Sara's posterior chest. Which sound does the nurse expect to note over lung tissue in this area if the tissue is normal? Tympany Resonance A dull sound Hyperresonance

Resonance RATIONALE: For percussion of the posterior chest, the client should sit leaning forward with the arms folded. Percussion of the posterior chest should yield resonance (a low-pitched sound) over lung tissue to the level of the diaphragm. Tympany — a drumlike, loud, empty quality — is heard over a gas-filled stomach or intestine and in cases of pneumothorax. A dull sound is heard over areas of abnormal density, as in pneumonia, pleural effusion, atelectasis, or tumor. Hyperresonance is a loud sound, lower-pitched than normal resonance, that is heard over hyperinflated lungs, such as in chronic obstructive pulmonary disease. TEST-T

The nurse is observing a new nurse employee who is performing an abdominal assessment of a client and preparing to auscultate for bowel sounds. The nurse determines the new nurse employee is using correct technique if which part of the abdomen is auscultated first? Left upper quadrant Left lower quadrant Right upper quadrant Right lower quadrant

Right lower quadrant RATIONALE: To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope lightly against the skin, then begins to auscultate in the right lower abdominal quadrant, in the area of the ileocecal valve, because bowel sounds are always present there normally. After auscultating the right lower quadrant, the nurse proceeds with the examination by auscultating the remaining three quadrants.

The nurse prepares to listen to Sara's heart sounds. What heart sound is audible? Select to listen to the audio clip. S1 and S2 Split S2 sound S1 and S2 with a systolic murmur Physiologic S3 4. S1 and S2 with a systolic murmur

S1 and S2 RATIONALE: The pair of heart sounds that are close together ("lub-dup"), the S1 and S2 sounds, are considered normal heart sounds. A split S2 sound, a normal variation, occurs near the end of expiration ("lub-T-DUP"). A physiologic S3, which occurs after the S2 sound, is a dull, soft, low-pitched sound. A murmur is a blowing or swishing heart sound that may be considered "innocent" or may reflect a serious defect of blood flow in the heart. A systolic murmur may occur in a normal heart or accompany heart disease.

18. The nurse is observing a new nurse employee who is examining the peripheral vision of a client using the confrontation test. The nurse determines the new nurse is using correct technique if the nurse performs which action? Asks the client to discriminate numbers on a chart composed of colored dots Darkens the room and asks the client to identify colored blocks and shapes that appear in the visual field Has both the client and nurse cover the right eye, stare at each other's uncovered eye, and bring a small object into the visual field, then repeat the test with the left eye Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field

Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field Rationale: The confrontation test is a gross measure of peripheral vision. It compares the client's peripheral vision with the examiner's vision under the assumption that the examiner's vision is normal. The examiner positions himself or herself at eye level with the client, about 2 feet (60 cm) away. The examiner directs the client to cover one eye with an opaque card and look straight at the examiner with the other. The examiner covers his or her own eye opposite the client's covered one. Next the examiner holds a pencil or flicking finger as a target midline between himself or herself and the client and slowly advances it from the periphery in several directions. The examiner asks the client to say "now" as the target is first seen. This sighting should occur just as the examiner sees the object for the first time. Asking the client to discriminate numbers on a chart composed of colored dots and darkening the room and asking the client to identify colored blocks and shapes that appear in the visual field are both components of testing for color vision

15. A nurse conducting an interview with a client collects subjective data. During the interview, which action should the nurse take? Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors Takes a great deal of notes to allow the client to continue at his or her own pace as the nurse records what he or she is saying Takes notes because this allows the nurse to break eye contact with the client, which may increase the client's level of comfort Takes notes to allow the nurse to shift attention away from the client, which may make the nurse more comfortable

A nurse collects subjective and objective data from a client who underwent surgery after sustaining a leg fracture in a motor vehicle accident and is now in skeletal traction. The nurse identifies which findings as objective data? Select all that apply. Temperature is 99.9° F (37.2°C). The client complains of leg pain. Blood pressure is 128/86 mm Hg. Pin sites are red but without drainage. The client tells the nurse that he feels warm.

Temperature is 99.9° F (37.2°C). Blood pressure is 128/86 mm Hg. Pin sites are red but without drainage. RATIONALE: Subjective data are the things the client says about himself or herself or what a family member or significant other says about the client during history-taking. Objective data are the findings collected by the nurse while inspecting, percussing, palpating, and auscultating. Objective data also include information from the client's health record and the results of laboratory and diagnostic studies. The client's temperature and blood pressure readings are objective data, as is the nurse's observation of the pin sites. The other options constitute subjective data.

16. A nurse is preparing to screen a client's vision with the use of a Snellen chart. Which action should the nurse take? Tests the right eye, then tests the left eye, and finally tests both eyes together Assesses both eyes together, then assesses the right and left eyes separately Asks the client to stand 40 feet (12 metres) from the chart and read the largest line on the chart. Asks the client to stand 40 feet (12 metres) from the chart and read the line that can be read 200 feet (60 metres) away by someone with unimpaired vision.

Tests the right eye, then tests the left eye, and finally tests both eyes together Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot with the chart at the client's eye level. The client is positioned on a mark exactly 20 feet (6 metres) from the chart. The client uses an opaque card to shield one eye at a time during the test; after each eye is tested, both eyes are assessed together. The client is asked to read through the chart to the smallest line of letters he or she can discern. The client is encouraged to read the next smallest line as well. Therefore the other options are incorrect.

A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. How should the nurse interpret this data? The client is legally blind The client has normal vision The client can read at a distance of 20 feet (6 meters) what a client with normal vision can read at 80 feet (24 meters). The client can read at a distance of 80 feet (24 meters) what a client with normal vision can read at 20 feet (6 meters)

The client can read at a distance of 20 feet (6 meters) what a client with normal vision can read at 80 feet (24 meters). Rationale: When recording the results of visual acuity testing with the use of the Snellen chart, the nurse would use the numeric fraction noted at the end of the last line on the chart read successfully by the client. The top number (numerator) indicates the distance the client is standing from the chart; the denominator is the distance at which a normal eye could have read that particular line. Therefore a reading of 20/80 means that the client can read at a distance of 20 feet (6 meters) what a client with normal vision can read at 80 feet (25 meters). Legal blindness is defined as the best corrected vision in the better eye of 20/200 or worse. Normal visual acuity is 20/20.

A nurse performing a neck assessment of a client is testing the status of cranial nerve XI. Which of the following best indicates that the client has adequate function of this nerve? The client can smile. The client can lift the eyebrows. The client can stick out the tongue. The client can shrug the shoulders against resistance.

The client can shrug the shoulders against resistance. RATIONALE: Cranial nerve XI (spinal accessory nerve) is tested by asking the client to shrug the shoulders against the resistance of the nurse's hand and to turn the head to each side as the nurse tries to resist the client's movement. Cranial nerve VII (the facial nerve) is tested by asking the client to smile, frown, close the eyes tightly against the resistance of the nurse, lift the eyebrows, show the teeth, and puff the cheeks. Cranial nerve XII (the hypoglossal nerve) is tested by inspecting the tongue as the client sticks out the tongue. TEST-TAKING STRATEGY: Focus on the subject of the question, which is assessment of cranial nerves. Eliminate the comparable or alike options that are tests of the facial nerve. To select from the remaining options, recalling that cranial nerve XI is the spinal accessory nerve will direct you to the correct option. Review: the procedure for testing cranial nerve XI. QUESTION CATEGORIES:

A nurse preparing to perform a respiratory assessment of an adult client is reading the client's medical record. The nurse sees that the health care provider noted resonance on percussion of the client's posterior chest. What interpretation does the nurse make of this finding? The client has normal, healthy lungs. The client may have a pneumothorax. The client most likely has a lung tumor. An excessive amount of air is present in the lungs.

The client has normal, healthy lungs. RATIONALE: Resonance on percussion predominates in healthy adult lung tissue. Hyperresonance is noted when too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. A dull note on percussion indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or in the presence of a tumor. TEST-TAKING STRATEGY: Use the process of elimination. Eliminate comparable or alike options. Excessive air in the lungs will produce hyperresonance while pneumothorax will also produce the same tone as excess air is trapped in the pleural space. To select from the remaining options, recall that dullness would be noted in the presence of an abnormal density such a lung tumor. Review: normal and abnormal percussion tones.

A nurse has collected subjective and objective data from an African-American client who is at risk for cardiovascular disease. The client tells the nurse that he is a cigarette smoker, drinks "a beer or two" every day, and enjoys sitting around watching sports on television. Which piece of data does the nurse identify as an unmodifiable risk factor? The client is African-American. The client is a cigarette smoker. The client drinks beer every day. The client sits around watching television.

The client is African-American. Modifiable risk factors are those that can be modified or eliminated to prevent the development of disease. In the case of cardiovascular disease, these include hypertension, obesity, diabetes mellitus, increased serum lipid concentrations, tobacco use, and physical inactivity. Unmodifiable risk factors, those that cannot be modified or eliminated, include age, sex, and heredity

A nurse performing a physical assessment of a client is checking the client's mouth and throat. As part of the assessment, the nurse plans to assess the function of cranial nerve XII. Which of the following best indicates adequate functioning of this nerve? The client is able to frown. The client is able to show the teeth. The client is able to stick out the tongue. The client is able to say "ah" as the tongue is depressed with a tongue blade

The client is able to stick out RATIONALE: To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the client to stick out the tongue. The nurse then notes the forward thrust in the midline as the client protrudes the tongue. The nurse also asks the client to verbalize certain words and then listen for clear, distinct speech. The motor function of cranial nerves IX (the glossopharyngeal nerve) and X (the vagus nerve) is tested by depressing the client's tongue with a tongue blade and noting pharyngeal movement as the client says "ah." To test cranial nerve VII (the facial nerve), the nurse asks the client to frown or show his teeth. TEST-TAKING STRATEGY: Focus on the subject of the question, which is assessment of cranial nerves. Eliminate comparable or alike options that both test the facial nerve. To select from the remaining options, recalling that cranial nerve XII is the hypoglossal nerve will direct you to the correct option. Review: the procedure for testing cranial nerve XII.

A nurse has taught a young adult male client about testicular self-examination. Which statement indicates to the nurse that the teaching was effective? The client states he will perform the self-examination at least every 2 weeks. The client indicates the need to use both hands and palpate both testes at the same time. The client states that it is important to contact the health care provider immediately if any lumps are felt. The client states that he should always perform the self-examination just before getting into the shower.

The client states that it is important to contact the health care provider immediately if any lumps are felt. RATIONALE: Testicular self-examination should be performed monthly, starting during puberty. Because men are at greatest risk for testicular cancer between the ages of 18 and 38 years, teaching should be targeted to this age group. Men should be taught to hold the scrotum in one hand and examine each testicle and spermatic cord separately by gently rolling the testicle between the thumb and fingers of the other hand. The client is taught to perform the examination on the same day of each month. Examination is performed after a warm bath or shower, when the testicles are relaxed, descended, and easier to palpate.

A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. What does the nurse determine? The client has a fever The skin temperature is normal The client needs to drink additional fluids The client needs to have the blanket removed

The nurse completes Sara's physical examination and plans to assist the health care provider in performing a vaginal examination and obtaining a regular Papanicolaou test. The nurse explains the vaginal examination to Sara, informs her that all of the examination findings have been normal, and says that the health care provider will call her when the results of the Pap test are returned. Sara tells the nurse that she has never had this test and asks how frequently the Pap test must be performed. How should the nurse respond? The test should be performed yearly. The test should be performed every 6 months. The test does not need to be performed again if the results are normal. The test may be performed every 5 years because Sara has no family history of cervical cancer.

The test should be performed yearly. RATIONALE: The Papanicolaou (Pap) smear is a painless screening test for cervical cancer. The test is simple, with no side effects. All women should begin cervical cancer screening about 3 years after they begin having vaginal intercourse but no later than 21 years of age; screening should be performed every year with the regular Pap test or every 2 years if the newer liquid-based test is being used. Beginning at age 30, women who have had three normal Pap results in a row may be screened every 2 to 3 years. Women older than 30 may also be screened every 3 years with the use of either the conventional or liquid-based Pap test, plus the human papillomavirus (HPV) test.

A nurse conducting a physical examination of a Chinese-American client is gathering subjective data about the client's health care practices. What is the nurse's primary reason for asking the client about the use of herbal products and dietary supplements? To determine whether these are acceptable forms of treatment To determine whether the client's health care provider approves of their use To determine whether they have been approved by the U.S. Food and Drug Administration To determine whether they will interact adversely with medications being prescribed for the client

To determine whether they will interact adversely with medications being prescribed for the client RATIONALE: Regardless of their cultural origins, many people use cultural remedies such as herbal products and dietary supplements in addition to prescription medications to treat their medical illnesses. Problems may arise when prescription medications interact with these substances. Therefore, it is most important for the nurse to ask the client about the use of any other substances. The nurse must be culturally sensitive to the needs and beliefs of the client, and if the client uses an alternative remedy to treat a problem, this remedy needs to be a component of the plan of care if possible. Although the other options may be considerations for the plan of care, the primary reason for asking the client about the use of herbal products and dietary supplements is to determine whether any might interact adversely with medications being prescribed for the client. TEST-TAKING STRATEGY: The nurse note the strategic word "primary" in the query of the question. Recalling that herbal products and dietary supplements may have side effects or interact adversely with prescription medications will direct you to the correct option. Also use Maslow's Hierarchy of Needs theory. The correct option relates to physiological integrity. Review: adverse effects of herbal products.

A nurse is administering the hepatitis B vaccine to a newborn. Which anatomic site should the nurse select for the injection? Deltoid Dorsogluteal Rectus femoris Vastus lateralis

Vastus lateralis RATIONALE: Vaccines administered intramuscularly are given in the vastus lateralis muscle in newborns and in the deltoid for older infants and children. The dorsogluteal area is avoided because the site has been associated with low antibody seroconversion rates, indicating a reduced immune response. Also, it is generally recommended that the dorsogluteal site be avoided until a child has been walking for at least 1 year. The rectus femoris is not an acceptable site for injections.

9. A nurse performing a skin assessment notes that the client's skin is very dry. How should the nurse document this finding? Xerosis Pruritus Seborrhea Actinic keratoses

Which type of data base is the most appropriate for the nurse to utilize when collecting information from Sara? Focused Complete Follow-up Emergency

complete RATIONALE: A complete database consists of a complete health history, including physical examination findings. It describes the client's current and past health status and serves as a baseline against which all future changes may be measured. A focused database is constructed to address a limited or short-term problem (e.g., one problem or body system). A follow-up database is focused on evaluating a client's progress. An emergency database comprises a rapid collection of information that is often obtained during lifesaving measures. Because Sara has not been examined by a health care provider in 10 years and this is her first visit to the clinic, the nurse would collect a complete database. TEST-TAKING STRATEGY: Note the use of the strategic words "most appropriate". Recall the information in the case study. Knowing that Sara has not been examined by a health care provider in 10 year should direct you to the correct option, a complete databa

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