nclex

The nurse is preparing to interview a client to collect data about the client's health history. The nurse should take which actions to make sure that the physical environment is ready? Select all that apply.

1,2,5

The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action?

4

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition?

3

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for?

3

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination?

3

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve?

3

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client?

3

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve?

3

A 52-year-old male client is seen in the health care provider's (HCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet, 8 inches (173 cm) and his weight is 220 pounds (99.8 kg). Vital signs are as follows: temperature, 98.6°F (37°C) orally; pulse, 86 beats/minute; and respirations, 18 breaths/minute. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first?

4

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?

4

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest?

4

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema?

4

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique?

4

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds?

4

A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used.

Stands 2 to 3 feet (60 to 90 cm) in front of and faces the client Asks the client to cover 1 eye Examiner covers eye opposite to the eye covered by the client The examiner brings in an object gradually from periphery Asks the client to report when object is first noted

The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse should next ask the client to take which action?

2

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test?

4

The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action?

4

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the health care provider (HCP)?

3

In what area of the chest would the nurse expect to auscultate these breath sounds?

3

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?

4

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply.

2-5

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client?

3

A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching?

3

After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds?

3

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive?

3

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location?

2

A clinic nurse is performing a cardiovascular assessment on a client and auscultates the chest over the apex of the heart. The nurse should document this finding as which sound?

2

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion?

2

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?

2

The nurse is performing a physical examination on a hospitalized client. On abdominal assessment, the nurse listens to the bowel sounds and hears these sounds. The nurse documents that which sound is heard?

2

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply.

2,3,5

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply.

2-5

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area?

1

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

1

The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment of the client's smoking history?

1

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action?

1