NCLEX Practice Health Assessment 2

The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction?

"It is best to do TSE first thing in the morning before a bath or shower."

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test?

"I will tell you when the small object is in my visual field."

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data?

Ask the client to follow the flashlight through the 6 cardinal positions of gaze.

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?

Just under the left clavicle

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

A physical obstruction to the transmission of sound waves

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation?

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

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?

Difficulty walking

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action?

Focus on a distant object.

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?

Holding the sides of the client's great toe and, while moving it, asking what position it is in

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

Identify an object placed in the client's hand.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the primary health care provider (PHCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry?

It is painless and safe.

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? 0:05

Normal bowel sounds

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?

Over the fifth intercostal space in the left midclavicular line

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take?

Page an interpreter from the hospital's interpreter services.

The nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The client complains of discomfort at the intravenous (IV) site, and the nurse notes that the site is cool, pale, and swollen and that the solution is infusing slowly. What action should the nurse take first?

Stop the IV infusion.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

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

After a shower or bath

The clinic nurse is performing an assessment for a client who is complaining of shortness of breath. The client admits to smoking 1 pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack-years? Fill in the blank.

10 pack-years

The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client?

"You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)."

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply.

-Set the room temperature at a comfortable level. -Remove distracting objects from the interviewing area. -Ensure comfortable seating at eye level for the client and nurse.

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.

-Tongue -Nail beds -Mucous membranes

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?

Pleural friction rub

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

Redness and swelling in the ear canal

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Wheezes