NCLEX Practice Health Assessment

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?

A blowing or swooshing noise

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective?

"This is mostly used in a walk-in clinic or emergency department."

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site?

Mitral area

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?

That the best time for the examination is after a shower

A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6º F (37º C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. 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?

"When was the last time you had your blood pressure checked?"

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.

-Auscultating lung sounds -Obtaining the client's temperature -Obtaining information about the client's respirations

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.

-Muscle strength graded 5/5 -Symmetrical movements bilaterally -Increased muscle size on the dominant arm -A 1-cm hypertrophy of the right upper arm

The nurse is instructing a client how to perform a testicular self-exam (TSE). The nurse should explain that which is the best time to perform this exam?

After a shower or bath

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?

Ask the client to give permission for a family member to stay during the interview.

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

Ask the client to shrug the ahoulders against the nurse's resistance.

The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time?

At a specific day of the month and on that same day every month thereafter

The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)?

Elevate the shoulders.

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

Pulsation between the umbilicus and the pubis

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?

Number of pack-years

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?

One week after menstruation begins

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?

Plan short sessions with the client to obtain data.

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?

Separate the client's jaw by pushing down on the chin.

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?

Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal.

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

Supine with the head raised slightly and the knees slightly flexed

The nurse is preparing to perform a Weber test on a client who reports a loss of hearing in 1 ear. To perform the test, the nurse places the tuning fork in which area?

Top of head

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?

The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.

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?

The major bronchi

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?

The right eye is tested, followed by the left eye, and then both eyes are tested.

The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test?

Cloves, peppermint, and soap

The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area?

Left shoulder