Module Exam 1: (1+2)
A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment in which manner? alpating 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
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
3+ edema
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 in which way? At the onset of menstruation Every month during ovulation Weekly, at the same time of day One week after menstruation begins
One week after menstruation begin
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-quarter One-third One-half Two-thirds
One-half
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
Optic disc
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? Scoliosis Osteoarthritis Rotator cuff lesions Carpal Tunnel Syndrome
Osteoarthritis
A nurse performing a respiratory assessment of a client plans to assess tactile (vocal) fremitus. The nurse performs this assessment by performing which action? 1. Palpating for symmetric chest expansion 2. Auscultating the breath sounds over the trachea and larynx 3. Auscultating the breath sounds over the peripheral lung fields 4. Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine"
Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine"
Performing an abdominal assessment, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason? It is less painful for the client Palpation and percussion can increase peristalsis It identifies any potential areas of abdominal tenderness It gives the client more time to become comfortable with the examiner
Palpation and percussion can increase peristalsis
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? Testing the strength of each muscle joint Percussing at the location of the median nerve Checking for repetitive movements in the joints Asking the client to hold the hands back to back while flexing the wrist 90 degrees
Percussing at the location of the median nerve
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
Peripheral lung fields
A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells the client that this test measures which aspect of vision? Near vision Color vision Distant vision Peripheral vision
Peripheral vision
A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure in which manner? 1. Placing a tape measure around the widest point of the lower leg 2. Measuring 2 inches (5 cm) above the knee and placing the tape measure around the client's leg at this point 3. Measuring 2 inches (5 cm) above the ankle and placing the tape measure around the client's leg at this point 4. Measuring 2 inches (5 cm) below the patella and placing the tape measure around the client's leg at this point
Placing a tape measure around the widest point of the lower leg
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
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
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
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? "When was your last gynecological checkup?" "Have you been engaging in unprotected sexual intercourse?" "Don't worry about the discharge. Some vaginal discharge is normal." "I need some more information about the discharge. What color is it?"
"I need some more information about the discharge. What color is it?"
A nurse has described the procedure for testicular self-examination (TSE) to a male client. Which statement by the client indicates understanding of this procedure? "A good time to examine the testicles is just before I take a shower." "If I notice an enlarged testicle or a lump, I need to notify the physician" "The testicle is egg-shaped and movable. It feels firm and has a lumpy consistency." "I should perform a testicular exam at least every 2 months to detect early signs of testicular cancer."
"If I notice an enlarged testicle or a lump, I need to notify the physician."
A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? "Yes, your infant is protected from all infections." "If you breastfeed, your infant is protected from infection." "The transfer of your antibodies protects your infant until the infant is 12 months old." "The immune system of an infant is immature, and the infant is at risk for infection."
"The immune system of an infant is immature, and the infant is at risk for infection."
A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the client's pulse is normal. Which notation would the nurse make in the client's record to document the force of the client's pulse? 4+ 3+ 2+ 1+
2+
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.
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 which disorder? Loss of hearing acuity A problem with balance A problem with distant hearing A problem discriminating high and low-pitched sounds
A problem with balance
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 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
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 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
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
Ask health history questions while performing the examination and initiating emergency measures
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 raise his or her eyebrows and looking for symmetry Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face 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
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
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 take which action first? Assess the client's knowledge of available birth control methods Inform the client that birth control methods cannot be discussed unless the client's boyfriend is present Tell the client that for her age and lifestyle, birth control pills would be the easiest method of contraception Give the client written material about various birth control methods and ask her to read them and to call if she has any questions
Assess the client's knowledge of available birth control methods
A nurse performing a neurological assessment is preparing to assess the optic nerve. The nurse performs this examination by which method? Assessing visual acuity Inspecting the eyelids for ptosis Assessing pupil constriction Assessing ocular movements
Assessing visual acuity
The nurse, performing an abdominal examination, inspects the client's abdomen. Which assessment technique does the nurse perform next? Percussion Auscultation Light palpation Deep palpation
Auscultation
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 urine for blood By checking the client's stool for blood By checking the client's urine for a decrease in output By checking the client's bowel movements for diarrhea
By checking the client's stool for blood
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? The cervix is pink. The cervix is midline. The cervix is about 1 inch (2.5 cm) in diameter. Clear secretions with a foul odor are noted on the cervix
Clear secretions with a foul odor are noted on the cervix
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
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? Episodic Follow-up Emergency Complete
Complete
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? Scoliosis Bone deformity Heberden nodules Carpal Tunnel Syndrome
Carpal Tunnel Syndrome
A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz (2.9 kg). The nurse notes that the infant now weighs 13 lb (5.9 kg). Which action should the nurse take? Tell the mother that the infant's weight is increasing as expected Tell the mother to decrease the daily number of feedings because the weight gain is excessive Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate
Tell the mother that the infant's weight is increasing as expected
A nurse is observing a new nurse employee perform an abdominal assessment. The nurse determines the new nurse employee requires additional instruction if which action is performed? Uses the bell end of the stethoscope Holds the stethscope lightly against the skin Auscultates prior to using the palpation technique Listens for 5 minutes before determining that bowel sounds are absent
Uses the bell end of the stethoscope
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
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 Problem-centered
Follow-up
A nurse reviewing the healthcare record of a client notes documentation of grade 4 muscle strength. The nurse makes which determination regarding this client's range of motion? Full range of motion (ROM) with gravity Full ROM against gravity with some resistance Full ROM with gravity eliminated (passive motion) Full ROM against gravity with full resistance
Full ROM against gravity with some resistance
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
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
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
Lateral to the extensor tendon of the big toe
A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client? Supine Standing Lithotomy Left lateral
Let lateral
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? Hib IPV MMR DTaP
DTaP
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
Darken the room
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
Data related to the respiratory system
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
Determine what the client believes has caused the epilepsy
A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? Suspect the presence of hydrocephalus Suggest to the pediatrician that a skull x-ray be performed Tell the mother that the infant is growing faster than expected Document these measurements in the infant's health-care record
Document these measurements in the infant's health-care record
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 takes which action? Document the normal finding Checks for penile discharge, because this finding indicates infection Palpates for a mass in the scrotum, because wrinkling indicates the presence of one Obtains additional subjective data from the client, focusing on the scrotal abnormality
Documents the normal finding
A nurse performing a neurological assessment is inspecting the client's eyelids for ptosis. The nurse checks the client for which finding? Drooping Pupil dilation Pupil constriction Deviation of ocular movements
Drooping
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 Hyperresonance sounds Hypoactive bowel sounds An absence of bowel sounds
Dull sounds
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 which disorder? Pyrosis Anorexia Eructation Dysphagia
Dysphagia
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 in which manner? Psoriasis Anasarca Petechiae Ecchymosis
Ecchymosis
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
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
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
Excess blood in the dilated superficial capillaries
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 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? Tongue symmetry Eye movements Facial symmetry Corneal reflex
Eye movements
During a neurological assessment, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing? Vagus Facial Abducens Oculomotor
Facial
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
Fifth left interspace at the midclavicular line
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 Hypoactive sounds :Low-pitched sounds An absence of sounds
Gurgling sounds
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 sexual history Her menstrual history Her obstetrical history The presence of vaginal discharge
Her menstrual history
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 perform which action? Dorsiflex the foot Plantarflex the foot Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds Hyperextend the fingers with the palmar surfaces of the hands touching, holding the position for 60 seconds
Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds
While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds? Hypoactive bowel sounds Low-pitched bowel sounds Hyperactive bowel sounds An absence of bowel sounds
Hyperactive bowel sounds
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
A nurse has provided instructions to a client who is scheduled to undergo a Papanicolaou (Pap) test in one week. Which statement by the client indicates understanding of the instructions? "If I am menstruating, I'll use pads instead of a tampon." "I'll need to avoid intercourse for 24 hours before the scheduled examination." "I'll get a douching kit from the pharmacy and douche 2 hours before the examination." "If I am having a vaginal discharge, I'll obtain a sample of the discharge for inspection."
I'll need to avoid intercourse for 24 hours before the scheduled examination."
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 disorder? Liver cirrhosis Spleen rupture Pancreatic dysfunction Inflammation of the appendix
Inflammation of the appendix
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
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 which disorder? Liver enlargement Ovarian infection Spleen enlargement Kidney inflammation
Kidney inflammation
A nurse is preparing to assist the health care provider in performing an internal gynecological examination of a client. In which of the following positions does the nurse place the client for this examination? Prone Left side-lying Sims Lithotomy
Lithotomy
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 makes which statement? BSE must be performed every other month BSE is performed on the day menstruation begins Monthly BSE is the only way to ensure early detection of breast cancer Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down
Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down
A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which finding does the nurse expect to note if cholecystitis is present? Homan sign Murphy sign Blumberg sign McBurney sign
Murphy sign
A nurse in the emergency department is performing a musculoskeletal assessment of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine? Headache Neck trauma SInus infection Muscle spasms
Neck trauma
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
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? Document the finding Palpate the area for a mass Notify the HCP Percuss the abdomen to check for tympany
Notify the HCP
A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. How should the nurse document this finding? Ptosis Nystagmus Scleral icterus Exophthalmos
Nystagmus
A nurse is performing transillumination of a client's scrotum. The nurse prepares for this procedure in which manner? Obtaining a flashlight and darkening the room Instructing the client to drink three glasses of water Instructing the client to take several deep breaths and bear down Telling the client that the procedure is very uncomfortable but that the discomfort will only last for a few moments
Obtaining a flashlight and darkening the room
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? Optic Abducens Olfactory Hypoglossal
Olfactor
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 providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, what should the nurse tell the group about the infants? Rely on the fact that their needs will be met Tolerate a great deal of frustration and discomfort to develop a healthy personality Ignore needs for short periods to develop a healthy personality Experience frustration to allow an infant to cry for a while before meeting his or her needs
Rely on the fact that their needs will be met
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? LUQ LLQ RUQ RLQ
Right lower quadrant (RLQ)
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
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 Placing a chair for the client across from the nurse's desk Providing seating for the client so that the client faces a strong light Setting up seating so that the client and nurse are not at eye level
Setting the room temperature at a comfortable level
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
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
Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors
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
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).
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 interprets the findings in which way? The client has a low cardiac output The client has a high cardiac output The client has a normal cardiac output The client will need a blood transfusion
The client has a normal cardiac output
A nurse is preparing to assess the function of a client's spinal accessory nerve. Which assessment finding indicates the client's spinal accessory nerve function is adequate? The client is able to smile without drooping The client is able to clench the teeth without difficulty The client is able to shrug the shoulders against the nurse's resistance The client is able to identify by taste a substance placed on the back of the tongue
The client is able to shrug the shoulders against the nurse's resistance
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 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 skin temperature is normal
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
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 which cranial nerve? Trochlear nerve Abducens nerve Trigeminal nerve Oculomotor nerve
Trigeminal nerve
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? Dullness Tympany Borborygmus Hyperresonance
Tympany
A nurse is preparing to listen to a client's breath sounds. The nurse should use which technique? Ask the client to lie down Listen to the right lung, then the left lung Ask the client to take shallow rapid breaths through the mouth Use the diaphragm of the stethoscope, holding it firmly against the client's chest
Use the diaphragm of the stethoscope, holding it firmly against the client's chest
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
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 (30 to 60 cm) from the ear being tested
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
Xerosis
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 25. Yearly mammograms are recommended starting at age 40. Yearly mammograms are not necessary unless there is a family history of breast cancer. Yearly mammograms are recommended starting at the age of 20 and continuing until menopause begins
Yearly mammograms are recommended starting at age 40
