Nursing Health Assessment - ATI Health Assess 2.0 Questions

A nurse is providing teaching to a client who reports acne on their face and chest. Which of the following client statements indicated an understanding of the teaching?

" I should wash the areas frequently with warm water and soap."

A nurse is discussing a client's tobacco usage during a health history interview. Which of the following questions should the nurse ask to maintain nurse-client rapport? "You are worried about the amount that you smoke, right?" "Did you know that smoking can lead to a decreased lung recoil, which results in hyperinflation and dyspnea?" "Would you like any information on smoking cessation?" "Why do you think that you are smoking so much?"

"Would you like any information on smoking cessation?" This question empowers the client to make their own decisions regarding their health care without implying judgement.

A nurse is performing a head to toe assessment of a client. Which of the following findings indicate the client might be experiencing respiratory difficulty?

> the client is sitting in tripod position > the client is using pursed lipped breathing > the client appears confused

a charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub?

>coarse grating tone >heard on inspiration and expiration >pain with breathing

a nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient setting. At which of the following times should the nurse plan to collect information about the client's general appearance?

>during an interview about the client's health history >when introducing themselves to the client > while collecting the client's vital signs.

a nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during the assessment?

>instruct the client to swallow >apply downward pressure and ask the client to shrug their shoulders >request the client to move their head forward and backward and then side to side

a nurse is preparing to perform a head-to-toe assessment on a client. Which of the following tools should the nurse plan to gather?

>penlight >stethoscope >sphygmomanometer

a nurse is assessing a client's radial pulse rate. Which of the following information should the nurse collect while performing this action?

>regularity of the pulse > strength of the pulse

A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which step of the nursing process should the nurse perform first?

Assessment

A nurse is caring for a client who reports palpable lymph nodes under one axilla. The nurse can see small nodules under the skin in the area the client describes. Which of the following should the nurse identify as a potential cause of the client's lymph node enlargement? A. A supernumerary nipple B. Infection C. Increased adipose tissue D. Psychotropic medication use

B. Infection Rationale: The nurse should recognize that an infection of the hand, breast, or arm can cause lymph nodes in the axillae to enlarge so that they become palpable, and sometimes they can even be visible upon inspection.

A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect?

Beefy red tongue

A nurse is preparing to perform light palpation of a clients abdomen. In what order should the nurse perform the following steps? (Move steps into correct order). 1. use the finger pads of one hand to palpate 2. place the clients arms at their side 3. depress the clients abdomen using a dipping motion 4. moving fingers across the clients abdomen moving clockwise 5. palpate painful areas

CORRECT ORDER: 1. place the clients arms at their side 2. use the finger pads of one hand to palpate 3. depress the clients abdomen using a dipping motion 4. moving fingers across the clients abdomen moving clockwise 5. palpate painful areas

A nurse is auscultating heart sounds. Identify the location where the apical pulse is auscultated

D

A nurse is performing a breast inspection on a client. Which of the following findings should the nurse report to the provider? A. Striae B. Flat, brown nevi C. Visible capillaries beneath the skin surface bilaterally D. Dimpling

D. Dimpling Rationale: The nurse should identify that dimpling, warmth, or a rash on the client's breast are unexpected findings that should be reported to the provider for further evaluation.

A nurse is inspecting a client's axillae. Which of the following should the nurse identify as an expected finding? A. Skin is deeply pigmented B. Presence of plaques C. Fixation of tissue during arm movement D. Skin has a uniform consistency

D. Skin has a uniform consistency Rationale: The nurse should identify that the client's axillae should be smooth and intact.

A nurse is assessing an older adult client's mouth. The nurse should identify that which of the following is an expected variation for this client?

Darkening of mucosa

A nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a result of vomiting. Which of the following findings should the nurse expect?

Defined reddened area of the sclera

A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress?

Discuss the benefits of meditation with the client

A nurse is preparing to irrigate the client's leg wound. Which pieces id personal protection equipment should the nurse wear while performing this task?

Goggles N95 mask Gloves Gown Surgical cap

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions?

Have the client lay supine with the head of the bed at a 45° angle.

A nurse is assisting a client with ambulating around the nurses' station. Which step of the nursing process is the nurse performing?

Implementation

A nurse has just received report on a newly admitted clement who reports abdominal tenderness in the lower right quadrant. What is the first step the nurse should perform during the abdominal assessment?

Inspection

A nurse is admitting a client who has had a stroke. Which of the following actions should the nurse take?

Keep the clients bed in the lowest position

A nurse is performing a pre-admission assessment in a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse?

Maintain a fair distance between self and client

A nurse is conducting a health history interview and asks the client to describe the pain that they are experiencing. This is an example of what type of question? Leading question Closed-ended question Direct question Open-ended question

Open-ended question Open-ended questions ask a general question about a topic and allows the client to express their thoughts. They encourage the client to provide a thorough and detailed response.

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect?

Pale Mucosa

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease?

Palpable dorsalis pedal pulse

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which action should the nurse take?

Palpate the tender areas of the abdomen last The cleint relorted abdominal tenderness. So rhe nurse should palpate tender areas last because tense muscles make the assessment mkre difficult for the client

A nurse is preparing to perform a skin assessment on a client. Which of the following tools should the nurse plan to use?

Penlight

The nurse is preparing to assess a newly admitted client. Which pieces of equipment does the nurse need to begin the inspection part of the physical examination?

Penlight Tape measure Tongue depressor

A nurse is planning on obtaining orthostatic blood pressure from a client who has syncope. In what order should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Place the client in a supine position and allow them to rest is the first step. The nurse should place the client in the supine position and have them rest for at least 3 min. Take the client's blood pressure in the supine position is the second step. The nurse should take the client's baseline BP and pulse reading while the client is supine. Keep the cuff in place and assist the client to a seated position is the third step. The nurse should keep the cuff in place and assist the client to a seated position. Take the client's blood pressure in a seated position is the fourth step. The nurse should take the client's blood pressure and pulse while they are in a seated position. Assist the client to stand and obtain their blood pressure is the fifth step. The nurse should assist the client to stand and take a standing blood pressure and pulse reading. Orthostatic hypotension is indicated by a drop in systolic pressure of greater than 20 mm Hg or in diastolic pressure of greater than 10 mm Hg after the client stands.

A nurse is teaching a young adult about risk factors for developing melanoma. Which of the following client statements indicates an understanding of the teaching?

The blistering sunburns I had as a child increase my risk for melanoma as an adult.

A nurse is palpating a client's extremities and notes the lower left leg is cooler to the touch than the client's right leg or arms. How should the nurse interpret this finding?

The client might have a blood clot.

a charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene?

The nurse is auscultating through the client's gown

A nurse is performing an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye?

The nurse should identify that the transparent layer that covers the iris and pupil is the cornea.

A nurse is reviewing the medical record of a client who was assessed as having a barrel chest resulting from COPD. Which of the following images shows a client who has a barrel chest?

The top answer (the anterior/posterior to transverse diameter is equal, and the ribs, normally in a downward slope, lay horizontal. The client might sit in a tripod position to obtain adequate oxygen exchange

A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect?

White patches on the tongue

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which of the following quadrants should the nurse listen to first? a. RLQ b. LLQ c. RUQ d. LUQ

a. RLQ

A nurse is preparing to obtain information regarding a client's abdominal health history. Which of the following questions should the nurse ask? (SATA) a. are you experiencing abdominal pain? b. do you take any medications? c. have you noticed a change in your appetite? d. when was your last BM? e. have you had any changes in your urinary output?

a. are you experiencing abdominal pain? b. do you take any medications? c. have you noticed a change in your appetite? d. when was your last BM?

A nurse is preparing to inspect a clients abdomen who has liver disease. Which of the following manifestations should the nurse expect? a. dilated veins b. stretch marks c. purple striae d. rash

a. dilated veins

A nurse is performing an assessment of a client's abdomen. Which of the following actions should the nurse take?

auscultate bowel sounds prior to palpating

A nurse is preparing to assess a clients abdomen. Upon palpation, which of the following findings should the nurse report to the provider? a. nontender b. involuntary rigidity c. relaxed muscles d. adipose tissue

b. involuntary rigidity

A nurse is auscultating a client's abdomen for the presence of bowel sounds. Which of the following findings should the nurse expect for hypoactive bowel sounds? a. absent after 5 min b. every 5-30 sec c. every 3 sec d. after 2 min

d. after 2 min

A nurse is assessing a client spinal range of motion. Which of the following motions is the nurse assessing by asking the client to bend backwards as far as it can go? a.) flexion b.) rotation c.) lateral flexion d.) hyperextension

d.) hyperextension

A nurse is assessing a client head and neck. Which of the following findings should the nurse report to the provider? a.) C-7 is the most prominent vertebrae b.) Clicking is noted in the temporomandibular joint c.) the muscles of the neck are firm d.) there is locking of the jaw joint

d.) there is locking of the jaw joint

a nurse is assessing a client's posterior and lateral chest. Which of the following actions should the nurse take?

observe for the use of accessory muscles during inspiration

A nurse is assessing a client who has a lump on their neck. Which of the following questions should the nurse ask the client? (Select all that apply.)

"Are you experiencing difficulty breathing?" "How long has the lump been on your neck?" "Is the lump causing you discomfort?" "Are you having difficulty swallowing?"

A nurse is conducting a health history interview. Which of the following questions should the nurse ask when gathering information about a client's cardiac and peripheral vascular system? (Select all that apply.) "Have you experienced any chest pain, tightness or discomfort?" "Have you had any changes in your appetite or food intolerances?" "Have you noticed any swelling in your hands, feet or ankles?" "Do you feel short of breath during the day or while sleeping?" "When did you last have a screening test for tuberculosis?"

"Have you experienced any chest pain, tightness or discomfort?" is correct. Alterations in the function of a client's cardiovascular system can present as chest pain, tightness, or discomfort. The nurse should ask the client if they have experienced these manifestations when reviewing their cardiac and peripheral vascular system. "Have you noticed any swelling in your hands, feet or ankles?" is correct. Alterations in the function of a client's cardiovascular system can present as edema in the extremities. The nurse should ask the client if they have experienced these manifestations when reviewing their cardiac and peripheral vascular system. "Do you feel short of breath during the day or while sleeping?" is correct. Alterations in the function of a client's cardiovascular system can present as shortness of breath with exertion or while sleeping. The nurse should ask the client if they have experienced these manifestations when reviewing their cardiac and peripheral vascular system.

A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client to obtain a focused history of the ears? (Select all that apply.)

"Have you had trouble with your hearing?" "Do you ever lose your balance?" "Have you ever used hearing aids?" "Do you have ringing in your ears?"

A nurse is conducting a review of systems with a client during a health history interview. Which of the following responses by the client requires additional investigation? "I had a rash from poison ivy on my arms last week, but it's gone now." "I wear a hearing aid." "I had a negative tuberculosis screening test last month." "I have a cough."

"I have a cough." A review of systems evaluates the client's overall health and identifies unexpected manifestations. A report of a cough requires further investigation by the nurse. The nurse should inquire about the type and frequency of the cough, the presence, and characteristics of the sputum, and if there are any other accompanying manifestations.

A nurse is collecting data from a client about their skin and nails. Which of the following statements by the client should the nurse identify as needing further assessment?

"I notice that my fingernails have changed recently"

A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make?

"The penlight will allow me to look at the pulses in your neck."

A nurse is collecting biographic data from a client who reports they are seeking health care due to a persistent cough. The client states they identify as transgender. Which of the following questions should the nurse ask? "How does your family feel about your gender identity?" "What pronouns do you use?" "When did you transition?" "Are you planning to ever have surgery to change your biological sex?"

"What pronouns do you use?" The nurse should determine what pronouns the client prefers. This will assist with the provision of patient-centered care. Additional information the nurse should gather includes the client's assigned sex at birth and what gender they identify as.

A nurse is providing teaching about the prevention of sexually transmitted infections (STIs) to a 19 year old client who is sexually active and reports having multiple partners. Which of the following client responses demonstrates an understanding of the teaching? a.) I should plan on getting tested each year for sexually transmitted infections b.) Taking my birth control pills will prevent me from getting an infection c.) Because I am at a low risk for HIV, I only need to get tested every other year d.) Since I got Hepatitis B vaccine, I am protected from sexually transmitted infections.

- "I should plan on getting tested each year for sexually transmitted infections." It is recommended that all sexually active females who are under the age of 25 receive a yearly screening for chlamydia, gonorrhea, and syphilis infections. - "Taking my birth control pills daily will prevent me from getting an infection." Birth control pills will not prevent the exchange of bodily fluids, which can lead to the transmission of an STI. Condoms provide a physical barrier and prevent the transmission of STIs. - "Because I am at a low risk for HIV, I only need to get tested every other year." It is recommended that clients who have a low risk of contracting HIV/AIDS get tested at least once as part of their routine health care. Clients who are at a high risk should be tested annually. High-risk clients include individuals who have multiple sexual partners, men who have sex with men, past or present use of injectable substances, and clients whose sexual partners have HIV, are bisexual, or have a history of using injectable substances. - "Since I got the Hepatitis B vaccine, I am protected from sexually transmitted infections." Hepatitis B is a viral infection that can be spread through contact with blood, semen, and bodily fluids. While the vaccine can prevent development of the infection if exposed to the virus, it does not provide protection against other STIs.

A nurse is collecting a health history from a client. Which the following client statements requires further investigation? a.) I urinate a lot when I get up int he morning b.) I have a bowel movement every morning after breakfast c.) I have noticed that it burns when I urinate d.) I empty my bladder several times a day

- "I urinate a lot when I get up in the morning." This is an expected response and does not require further investigation. Reports of awakening at night to void would require further investigation. - "I have a bowel movement every morning after breakfast." This is an expected response and does not require further investigation. Reports of constipation, diarrhea, or changes in the color or consistency of the stool would require further investigation. - "I have noticed that it burns when I urinate." A burning sensation when voiding can be an indication of a urinary tract infection (UTI). Other manifestations of a UTI can include an urgent sensation to void and changes in the appearance of the urine, such as blood, cloudiness, or a foul odor. - "I empty my bladder several times a day." This is an expected response and does not require further investigation. Reports of increased frequency or urgency of voiding would require further investigation.

A nurse is providing education to a male client about health promotion screenings. Which of the following information should the nurse include in the teaching? a.) a digital rectal examination can detect enlargement of the prostate gland. b.) the prostate-specific antigen (PSA) test evaluates semen for the presence of cancer cells c.) testicular self-examination should be performed when the client is sitting in a cool environment d.) a client who has an average risk for colorectal cancer should have a colonoscopy every 2 years.

- A digital rectal examination can detect enlargement of the prostate gland. A digital rectal examination can assess the size of the prostate gland and the presence of any tenderness or nodules. - The prostate-specific antigen (PSA) test evaluates semen for the presence of cancer cells. The PSA test is a blood test that detects the presence of a small protein that is produced only in the prostate gland. An elevation of this protein can be due to cancer, infection, noncancerous growth, or recent ejaculation. Clients should be instructed to abstain from ejaculation for 2 days prior to the PSA blood test. - Testicular self-examination should be performed when the client is sitting in a cool environment. Testicular self-examination is best performed when the client is in a standing position and after a warm bath or shower. This allows the scrotal skin to be warm and relaxed to better examine the testicles. - A client who has an average risk for colorectal cancer should have a colonoscopy every 2 years. It is recommended that a colonoscopy be performed once every 10 years, beginning at age 50 for clients who have no manifestations of colorectal cancer and no first-degree relatives who have had colorectal cancer.

A nurse is inserting a urinary catheter for a female adolescent. Which of the following findings should the nurse report to the provider? a.) a membrane at the vaginal opening b.) an area of tenderness on the labia majora c.) lack of pubic hair on the medial thigh d.) labia minora is a darker skin tone than overall coloring

- A membrane at the vaginal opening The hymen is a membrane that can partially occlude the opening of the vagina. The presence of a hymenal membrane is an expected finding and does not need to be reported to the provider. - An area of tenderness on the labia majora A palpable, fluid-filled area with swelling, tenderness, or other manifestations of inflammation on the labia majora could be a Bartholin gland abscess and should be reported to the provider. - Lack of pubic hair on the medial thigh A lack of pubic hair on the medial thigh is an expected finding in an adolescent. This finding does not need to be reported to the provider. - Labia minora is a darker skin tone than overall coloring Darker coloring of the labia minora and the posterior labia majora is an expected finding in a female client. This finding does not need to be reported to the provider.

A nurse is providing a bed bath for an older adult client who is immobile. Which of the following findings should the nurse report to the provider? a.) a pendulous scrotal sac b.) an inability to retract the foreskin c.) sparse pubic hair d.) left testicle is positioned lower than the right one

- A pendulous scrotal sac In an older adult client, it is an expected finding for the scrotal sac to become more pendulous as the testes decrease in size. - An inability to retract the foreskin The prepuce, or foreskin, should be retractable in an uncircumcised male. Phimosis, a narrowed opening of the foreskin, is an unexpected finding and should be reported to the provider. - Sparse pubic hair In an older adult client, it is an expected finding for the pubic hair to become thinner and grayer in color. - Left testicle is positioned lower than the right one This is an expected finding in an older adult client due to the increased length of the left spermatic cord.

A nurse is inspecting a client's rectal area and noted the presence of bulging red tissue that encompasses the entire anal opening. Which of the following should the nurse suspect? a.) anal fissure b.) rectal prolapse c.) external hemorrhoid d.) pilondial sinus

- Anal fissure An anal fissure is a painful tear in the superficial mucosa in the rectal area. Fissures can occur as a result of constipation, trauma, and obesity. - Rectal prolapse A rectal prolapse appears as a moist, red, circular protrusion of the rectal mucus membranes through the anal opening. This can occur due to straining if the client has weak pelvic muscular support. - External hemorrhoid An external hemorrhoid is a dilated vein that is covered in anal skin. They are usually soft and painless unless they become irritated or thrombosed from a lack of blood flow due to a blood clot. When that occurs, the hemorrhoid becomes swollen, painful, and bluish in color. - Pilonidal sinus A pilonidal sinus is an opening along the spinal tract in the sacral or coccyx area. It could contain hair or have an erythemic ring surrounding the opening.

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (Select all that apply.)

- Auscultate the apical pulse - Ask the client if they experience shortness of breath - check the color of the clients skin - inspect the extremities for the presence of edema

A nurse is providing education to a female client who has expressed a desire to use a natural method of contraception. Which of the following methods should the nurse recommend? (select all that apply) a.) condoms b.) withdrawal c.) fertility track with periodic abstinence d.) spermicidal sponge e.) tubal ligation

- Condoms is incorrect. A condom is a barrier method of contraception and also protects against the transmission of sexually transmitted infections. - Withdrawal is correct. Withdrawing the penis from the vagina prior to ejaculation is considered a natural method of contraception. - Fertility tracking with periodic abstinence is correct. Fertility tracking involves an understanding of the reproductive cycle and monitoring for subtle clues that are present during fertile times. This is a natural method of contraception. - Spermicidal sponge is incorrect. A contraceptive sponge containing spermicide is considered a pharmacological method of birth control. - Tubal ligation is incorrect. A tubal ligation is a permanent surgical option of contraception. The procedure involves cutting or tying the fallopian tubes.

A nurse is preparing to assess a client's genitalia. Which of the following actions should the nurse plan to take? a.) ensure the client has a full bladder b.) use a firm, deliberate touch when palpating c.) apply sterile gloves prior to touching the genitalia d.) remove the drape from the lower half of the cleint's body.

- Ensure the client has a full bladder. The client should empty their bladder prior to an examination of the genitalia to decrease discomfort during palpation. - Use a firm, deliberate touch when palpating. The nurse should use a gentle, firm, deliberate touch when palpating a client's genitals. - Apply sterile gloves prior to touching the genitalia. The nurse should apply clean gloves prior to inspecting a client's genitalia. - Remove the drape from the lower half of the client's body. The nurse should expose only the body part that is currently being inspected. Maintaining privacy and keeping other body parts covered during the examination can assist in decreasing the unease that clients often experience when having their genitalia examined.

A nurse is preparing to perform palpation of a client's shoulder. In what order should the nurse perform the following steps? (move the steps into the right box of the right, placing them in the order of performance. Use all the steps.) - From the back, palpate the greater tubercle of the humerus - Face a client and palpate along the clavicle - From the back, palpate the scapula - Face the client and palpate the acromioclavicular joint

- Face a client and palpate along the clavicle - Face the client and palpate the acromioclavicular joint - From the back, palpate the scapula - From the back, palpate the greater tubercle of the humerus

A nurse is preparing to assess a client for the presence of a hernia. Which of the following areas should nurse plan to inspect? (select all that apply) a.) femoral area b.) inguinal area c.) rectal area d.) length of the shaft e.) the circumference of the glans

- Femoral area is correct. The nurse should inspect the bilateral areas of the femoral canal for the presence of any bulges, swelling, or asymmetry that can indicate the occurrence of a femoral hernia. A femoral hernia occurs when loops of bowel descend through the femoral canal; it can present a surgical emergency. - Inguinal area is correct. The nurse should inspect the bilateral areas below the symphysis pubis, on either side of the penile shaft, for the presence of any bulges, swelling, or asymmetry that can indicate the occurrence of an inguinal hernia. An inguinal hernia occurs when loops of bowel descend through the inguinal canal. - Rectal area is incorrect. This is not an area the nurse should inspect for a hernia. A hernia occurs when loops of bowel descend through the femoral or inguinal canals. - Length of the shaft is incorrect. This is not an area the nurse should inspect for a hernia. - The circumference of the glans is incorrect. This is not an area the nurse should inspect for a hernia.

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (Select all that apply.)

- Full, bounding pulse noted bilaterally in the carotid arteries upon palpation is correct. - Distention of the jugular vein on one side of the neck is correct. -The left carotid artery pulse is weak is correct

A nurse is caring for a male client who reports the presence of yellow discharge from the meatus and burning with urination. Which of the following infections should the nurse suspect? a.) Human papillomavirus (HPV) b.) Urinary tract infection (UTI) c.) Syphillis d.) gonorrhea

- Human papillomavirus (HPV) An HPV infection will cause the development of genital warts. They present as painless, soft, fleshy growths on the penile shaft or at the base of the glans. - Urinary tract infection (UTI) Manifestations of a UTI include dysuria, frequency, urgency, and suprapubic pain. If untreated, fever and hematuria can occur. There is no meatus discharge associated with a UTI. - Syphilis A syphilis infection presents as a single small ulceration on the penis. While it begins as a papule, it then changes to become an ulcerated area with yellow serous drainage. - Gonorrhea The reported manifestation of yellow discharge from the meatus and dysuria are associated with a gonorrhea infection. The edges of the meatus can also appear inflamed and edematous.

A nurse is caring for a client who has a stage 1 pressure injury. Which of the following information should the nurse include when documenting the characteristics of the wound? (Select all that apply)

- Location of the pressure injury - Size of the injury in centimeters - Integrity of the skin surrounding the wound

A nurse is caring for an older adult client who has an enlarged prostate and reports difficulty voiding. Which of the following actions should the nurse take? (select all that apply) a.) perform a bladder scan within 60 minutes of the client voiding b.) ensure that the client's intake is significantly greater than output c.) inspect the client's suprapubic area for distention d.) notify the provider if the bladder scan residual volume is greater than 100ml e.) ask the client if they are experiencing pain or a burning sensation when voiding

- Perform a bladder scan within 60 min of the client voiding is incorrect. A bladder scan should be performed within 5 to 15 min of the client voiding to determine the amount of urine left after the client empties their bladder. - Ensure that the client's intake is significantly greater than output is incorrect. Urine output is an indicator of kidney and bladder function, as well as fluid and electrolyte balance. A urine output that is significantly less than the client's intake requires further investigation. - Inspect the client's suprapubic area for distention is correct. Clients who have an enlarged prostate can experience difficulty or an inability to pass urine due to an obstruction at the bladder outlet. A full bladder can be noted by inspecting the suprapubic area for distention and when the client reports lower abdominal discomfort. - Notify the provider if the bladder scan residual volume is greater than 100 mL is correct. A post-void residual is expected to be less than 100 mL. The nurse should notify the provider if the volume is greater than 100 mL. - Ask the client if they are experiencing pain or a burning sensation when voiding is correct. Clients who have difficulty emptying their bladder can develop a urinary tract infection (UTI) due to urinary stasis. Manifestations of a UTI can include a burning sensation when voiding, frequent voiding of small volumes, urgency, suprapubic pain, fever, and bloody urine.

A nurse is preparing to assist the provider with an assessment of a female client's genitourinary system. Which of the following actions should the nurse plan to take? a.) position the client supine with the head of the bed elevated b.) avoid conversation while the provider is performing the assessment c.) instruct the client to position their knees inward d.) position the client's arms above their head

- Position the client supine with the head of the bed elevated. The client should be positioned supine with the head of the bed elevated 45° or with their head on a pillow so that the provider can maintain eye contact with the client throughout the examination. - Avoid conversation while the provider is performing the assessment. Communicating with the client throughout the examination helps to establish a dialogue and can decrease the client's level of unease during the procedure. Each step of the examination should be explained to the client prior to proceeding. - Instruct the client to position their knees inward. The client should be positioned with their thighs flexed and abducted so that the provider can inspect and perform the internal assessment. - Position the client's arms above their head. The client should be positioned with their arms at their sides or folded across their chest. Placing the client's arms above their head will tighten the abdominal muscles and affect the examination.

A nurse is conducting a healthy interview with a client about their urinary system. The nurse should recognize that which of the following client reports could indicate the presence of declining kidney function? (select all that apply) a.) recent weight gain b.) hematuria c.) shortness of breath d.) swelling in the ankles e.) difficulty starting a urine system

- Recent weight gain is correct. If kidney function declines, the body is less able to excrete fluid, leading to extracellular volume overload. This alteration in fluid balance can result in weight gain, edema, and shortness of breath. - Hematuria is incorrect. The presence of blood in the urine is associated with cancer of the bladder or prostate, or an infection in the kidneys or bladder. Hematuria is not associated with kidney failure. - Shortness of breath is correct. If kidney function declines, the body is less able to excrete fluid, leading to extracellular volume overload. This alteration in fluid balance can result in weight gain, edema, and shortness of breath. - Swelling in the ankles is correct. If kidney function declines, the body is less able to excrete fluid, leading to extracellular volume overload. This alteration in fluid balance can result in weight gain, edema, and shortness of breath. - Difficulty starting a urine stream is incorrect. Difficulty initiating a urine stream is associated with an obstruction at the bladder outlet, such as from an enlarged prostate.

A nurse is inspecting the genitalia of an older adult female client. For which of the following findings should the nurse notify the provider? a.) sparse pubic hair b.) atrophy of the mons pubis c.) dry vaginal membranes d.) labial ulcerations

- Sparse pubic hair With menopause, the ovaries stop producing estrogen, which leads to physical changes in the appearance of the reproductive tract. These expected changes include thinning of the pubic hair and atrophy of the mons pubis, labia, and clitoris. As the vaginal lining atrophies, it becomes thinner and drier. - Atrophy of the mons pubis With menopause, the ovaries stop producing estrogen, which leads to physical changes in the appearance of the reproductive tract. These expected changes include thinning of the pubic hair and atrophy of the mons pubis, labia, and clitoris. As the vaginal lining atrophies, it becomes thinner and drier. - Dry vaginal membranes With menopause, the ovaries stop producing estrogen, which leads to physical changes in the appearance of the reproductive tract. These expected changes include thinning of the pubic hair and atrophy of the mons pubis, labia, and clitoris. As the vaginal lining atrophies, it becomes thinner and drier. - Labial ulceration Redness, swelling, or ulcerations in the genital area are always unexpected findings and should be reported to the provider.

A nurse is preparing to assist with a prostate examination. Which of the following actions should the nurse plan to take? a.) supply sterile gloves for the provider b.) provide the supplies for a specimen culture c.) position the client standing, facing the examination table d.) darken the lighting in the room.

- Supply sterile gloves for the provider. The provider should use clean gloves and lubricant when examining a client's prostate gland. - Provide the supplies for a specimen culture. An examination of the prostate is performed by palpating the gland and noting symmetry, size, texture, mobility, and the presence of any tenderness. There is no specimen collection for culture included in this assessment. - Position the client standing, facing the examination table. An ambulatory client can be positioned standing with the examination table supporting their upper body. Alternately, the provider might prefer the client to be positioned on their left side with the hip and knee flexed to stabilize their position and enable adequate visualization of the area. - Darken the lighting in the room. The nurse should ensure that there is adequate lighting to allow the provider to visualize the anus and perianal area.

A nurse is providing education to a young adult about the human papillomavirus (HPV) vaccine. Which of the following information should the nurse include in the teaching? a.) the HPV vaccine is only recommended for female clients b.) an HPV infection can lead to the development of cancer c.) the HPV vaccine should be administered before age 18 to be effective d.) immunization to prevent an HPV infection requires a single injection

- The HPV vaccine is only recommended for female clients. The HPV vaccine is recommended to be administered to all clients beginning between ages 9 to 11 years. - An HPV infection can lead to the development of cancer. HPV infections are associated with the development of genital, rectal, and oropharyngeal cancers. - The HPV vaccine should be administered before age 18 to be effective. Current recommendations for the administration of the HPV vaccine include adults up to age 26 years. However, guidelines are now expanding to include some adults up to age 45. - Immunization to prevent an HPV infection requires a single injection. The HPV vaccine is a series of two or three injections over a 6-month period. Young adolescents only require two injections, while older adolescents and adults require a three-injection series to achieve immunity against the virus.

A nurse is inspecting the genitals of an adult male client. Which of the following should the nurse identify as expected findings? (select all that apply) a.) visible dorsal vein on the underside of the penile shaft b.) bilateral pea-sized (1cm), soft testes c.) Meatus located on the dorsal side of the glans d.) absence of public hair on the penile shaft e.) testes that are easily moveable during palpation

- Visible dorsal vein on the underside of the penile shaft is correct. The dorsal vein might be visible on the penile shaft. This is an expected finding. - Bilateral pea-sized (1 cm), soft testes is incorrect. It is expected that the testes are oval, firm, larger than 3.5 cm in diameter, and the same size bilaterally. Small, soft testes indicate atrophy. This is not an expected finding. - Meatus located on the dorsal side of the glans is incorrect. The meatus, or urethral opening, is expected to be located in the center of the glans. A meatus located on the top of the dorsal side of the glans or penile shaft is termed an epispadias. This is not an expected finding. - Absence of pubic hair on the penile shaft is correct. Pubic hair is expected to be present only at the base of the penis. This is an expected finding. - Testes that are easily movable during palpation is correct. It is an expected finding that the testes are freely movable. Testes that are not movable should be reported to the provider.

A nurse is preparing to perform palpations on a clients knees. In which order shut the nurse perform the following steps? (move the steps into the right box of the right, placing them in the order of performance. Use all the steps.) - assist the client in a sitting position with the legs dangling at the edge of the examination table - palpate the tibiofemoral joint where the femur and tibia meet - palpate the quadriceps muscles above the knee - follow the lower edge of the patella and locate the tibiofemoral joint - palpate the hollows on either side of the patella with a thumbs

- assist the client in a sitting position with the legs dangling at the edge of the examination table - palpate the quadriceps muscles above the knee - palpate the hollows on either side of the patella with a thumbs - follow the lower edge of the patella and locate the tibiofemoral joint - palpate the tibiofemoral joint where the femur and tibia meet

A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of the teaching? (Select all that apply.)

-"I am going to start walking several times a week." -"I plan to join a support group to help me stop smoking." -"I will be sure to have my blood pressure checked at least every year."

A nurse is assessing a client's respiration and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings? -Tachypnea -Bradypnea -Apnea -Hyperventilation

-Bradypnea

A nurse is completing an initial assessment checklist on an older adult client. The client is accompanied by their caregiver. For which of the following indicators should the nurse observe when assessing for potential maltreatment of the client? (Select all that apply.) -Dirty clothing -Unexplained physical injuries -Oriented to person, place, and time -Able to express coherent thoughts -Malnourished appearance

-Dirty clothing -Unexplained physical injuries -Malnourished appearance

A nurse is preparing the conduct an initial survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take? -Have an informal conversation with the client before beginning observations of client -Complete all focused assessments prior to formulating thoughts regarding the client's general health status -Engage in active listening with the client and allow the client to express concerns early in the assessment process -Sit on client's bedside with them to have close contact and maintain eye contact

-Engage in active listening with the client and allow the client to express concerns early in the assessment process

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement? -Fasciculation -Spasticity -Tic -Myoclonus

-Fasciculation

A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (Select all that apply.)

-Instruct the client to sit with their legs uncrossed. - Encourage the client to avoid tobacco products. - Instruct the client to cleanse the area with mild soap - Instruct the client to wear shoes when ambulating

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? -Temperature 95° F, the client is hypothermic -Pulse rate indicates tachycardia -Oxygen saturation 96% on oxygen 2 L/min via nasal cannula -Blood pressure 108/65 mm Hg in left arm

-Oxygen saturation 96% on oxygen 2 L/min via nasal cannula

A nurse is assessing a client's skin color. Which of the following findings should the nurse report to the provider?(Select all that apply)

-Pinpoint areas of purplish-red coloration across the abdomen - Pale-colored nailbeds

The nurse should identify that which of the following factors can interfere with obtaining a pulse oximetry reading? -Hypertension -Fever -Recent scan with contrast dye -Thin, brittle nails

-Recent scan with contrast dye

If client is unable to hold oral probe which alternative should be used? -Axillary -Temporal -Tympanic -Rectal

-Rectal

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings? -Bradycardia -Tachycardia -Atrial fibrillation -Pulse deficit

-Tachycardia

A nurse is caring for a client who is reporting pain as 4 on a scale of 0 to 10. Upon further assessment, which of the following findings should the nurse identify as manifestations of chronic pain? (Select all that apply.) -The client reports that the pain has been present for approximately 4 years. -The client reports never feeling total relief from pain. -The client's pain can be attributed to an acute injury or illness. -The client reports that the pain is recurring and does not always originate in the same location. -The client describes the pain as transient.

-The client reports that the pain has been present for approximately 4 years. -The client reports never feeling total relief from pain. -The client reports that the pain is recurring and does not always originate in the same location.

A nurse is conducting a general survey on a client who is being admitted to a long-term care facility. The nurse is assessing the client's emotional state. Which of the following findings should the nurse record as a subjective, unexpected finding? -The client is sitting in a relaxed posture -The client asks for a tissue and used it to wipe away an occasional tear -The client tells the nurse that visits from their friends and family make them smile -The client reports they feel sad and lonely most of the time

-The client reports they feel sad and lonely most of the time

A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory rate? -The client has been a chronic smoker for 10 years. -The client takes narcotic pain medication for chronic pain. -The client reports anxiety due to being in the hospital. -The client has a history of anemia.

-The client takes narcotic pain medication for chronic pain.

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure? (Select all that apply.) -Time of day -Obesity -Diuretic medication -Height -Smoking

-Time of day -Obesity -Diuretic medication -Smoking

A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information should the nurse include in the documentation? SATA -Current medication list -Past medical history -Use of assistive devices -Height and Weight -Behavior and mood

-Use of assistive devices -Height and Weight -Behavior and mood

A nurse is auscultating a client's heart sounds. Place the nursing actions for auscultation of the heart in the correct order. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. Elevate the head of the bed 30° and instruct the client to breath normally is the first step. 2. Visualize the anatomy of the heart is the second step. 3. Place the stethoscope to the right sternal border at the second intercostal space is the third step. 4. Place the stethoscope close to the sternal border at the fourth intercostal space is the fourth step. 5. Auscultate the apical pulse for 1 min is the fifth step.

a nurse is preparing to assess the status of a client's upper extremities. Which of the following actions should the nurse take?

> inspect the condition of each fingernail > compare the amplitude of the radial pulses bilaterally > palpate the shoulder, elbow, wrist, and finger joints

a nurse is preparing to auscultate a client's posterior and lateral chest. In which order should the nurse perform the following actions?

>expose the posterior chest with the client sitting with their arms folded across their chest >auscultate 8cm to one side of the spine around c7, then auscultate the other side of the spine in the same location >auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine is reached >auscultate the lateral sides slightly below the axillary area, then down to the seventh or eighth rib

a nurse is preparing to care for a group of clients in an acute care setting. Which of the following assessments should the nurse plan to perform on every client?

>lung sounds >bowel sounds > pedal pulses > mental status

a nurse is assessing a client who is dark-skinned. In which of the following areas of the client's body should the nurse assess the client for adequate oxygenation?

>nail beds >oral mucosa >lips

a nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation?

>numbness and tingling of extremities >lightheadedness >chest pain

a nurse is an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should the nurse inspect when performing a general survey of the client?

>nutritional status > hygiene >posture

a nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data?

>report from client says they sleep while propped on two pillows at night >client says they quit smoking 2 years ago > client states: being short of breath all of the time is making me depressed

a nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use?

>smoking is linked to various forms of cancer >it might take several attempts to finally stop smoking >there are pharmacological therapies that can help a person stop smoking

a nurse is auscultating the breath sounds of a client who has pneumonia and hears bronchial crackles. In which of the following areas of the chest is the nurse auscultating?

A (heard to the right and left of the trachea and larynx. They can only be heard on the anterior chest

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report?

A forceful chest movement at the midclavicular line in the fourth intercostal space

A nurse is teaching a group of newly licensed nurses about routine mammography screenings for female clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A. "A 55-year-old client should receive mammography screenings at least every 2 years." B. "Clients can discontinue routine mammography screenings when they are 65 years old." C. "Clients should begin routine mammography screenings when they are 35 years old." D. "A 45-year old client should receive mammography screenings at least every 5 years."

A. "A 55-year-old client should receive mammography screenings at least every 2 years." Rationale: Mammography guidelines recommend routine mammography screenings every 1 to 2 years for female clients between 40 to 75 years old. Therefore, this statement indicates an understanding of the teaching.

A nurse is reviewing breast self-examination techniques with a client. Which of the following client statements indicates an understanding of the techniques? A. "I will use circular motions to feel the texture of my breast tissue." B. "I will use the palmar surface of my hands to perform breast palpation." C. "I will lie down and put one hand behind my head to examine the breast on the opposite side of my body." D. "I will examine my breasts after bathing and drying thoroughly."

A. "I will use circular motions to feel the texture of my breast tissue." Rationale: The client should use small, circular motions to palpate the breast and underlying tissue. Therefore, the nurse should identify this statement as an indication that the client understands breast self-examination techniques.

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation?

An adolescent who has an s3 heart sound

A nurse is providing teaching to a client who reports extremely dry skin. Which of the following interventions should the nurse recommend?

Apply alcohol-free lotion

A nurse is preparing to assess a client's conjunctiva. Identify the sequence the nurse should follow when taking the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Apply exam gloves instruct the client to look up Place the thumbs below each of the client's lower eyelids Gently pull the client's skin down to the top edge of the bony orbital rim Inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions

A nurse is gathering information during a health history interview from a client who reports they have type 1 diabetes mellitus. Which of the following actions should the nurse take? Assess the client's blood glucose level. Ask the client for additional information regarding the management of their diabetes. Encourage the client to join a diabetic support group. Provide education for the client on the management of diabetes.

Ask the client for additional information regarding the management of their diabetes. A health history gathers subjective information from the client about their past and current state of health. It is a screening tool to provide information about the client's positive health actions and potential problems and concerns. The nurse should complete the information gathering stage before moving to other actions.

A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind; I do not want to have this surgery." Which ethical principal is the client using?

Autonomy

A nurse is caring for a male client who was recently diagnosed with gynecomastia. Which of the following should the nurse identify as a potential cause of this condition? A. Presence of the BRCA1 gene B. Medication adverse effects C. Decreased estrogen levels D. Decreased thyroid hormone levels

B. Medication adverse effects Rationale: The nurse should identify that gynecomastia, or a swelling of the breast tissue in males, can be caused by medication adverse effects. This condition can also be caused by hormonal changes or weight gain.

A nurse is performing a breast inspection during a client's routine physical examination. Which of the following findings should the nurse report to the provider? A. Areolas are oval-shaped B. Scaley skin at the border of one areola C. Small bumps visible on each areola D. Areolas have darker pigment than the surrounding skin

B. Scaley skin at the border of one areola Rationale: The nurse should identify that the presence of scaley skin on the breast is an unexpected finding. The nurse should report this finding to the provider for further evaluation.

A nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash. The nurse should identify that which of the following findings indicates the client might have a skull fracture?

Bloody Drainage

A nurse is teaching a newly licensed nurse about nipple inspection. Which of the following should the nurse include as an example of an expected variation of the nipple? A. A client reports recent serosanguinous nipple discharge B. A client reports that one nipple has begun to point in a different direction C. A client's nipple has remained inverted since childhood D. A client's nipple has a small crust present on the tip

C. A client's nipple has remained inverted since childhood Rationale: The nurse should include nipple inversion since puberty as an example of an expected variation in breast appearance. Nipples are inverted at birth and usually begin to protrude during puberty.

A nurse is teaching a group of female clients about breast self-awareness. Which of the following instructions should the nurse include? A. Breasts are the least tender during the first 3 days of the menstrual cycle. B. Females can discontinue breast self-examination after menopause. C. Menstruating females should examine their breasts about 5 days after their menstrual cycle begins. D. Benign breast nodules are less prominent during the premenstrual phase.

C. Menstruating females should examine their breasts about 5 days after their menstrual cycle begins. Rationale: The nurse should instruct the client to perform breast self-examination 4 to 7 days after the onset of their menstrual cycle. This time is optimal because breasts are at their smallest and least congested. Before onset of menstruation, breasts tend to swell and are more nodular from increasing levels of estrogen.

A nurse is performing a physical assessment of a client. In which of the following positions should the nurse place the client prior to inspecting the client's breasts? A. Standing upright with their arms held straight out to their sides B. Bending over at the waist with hands reaching toward the toes C. Sitting straight up with arms relaxed and close to the body D. Lying supine with hands clasped together at the umbilicus

C. Sitting straight up with arms relaxed and close to the body Rationale: Prior to inspecting the client's breasts, the nurse should place the client in a seated position with their arms relaxed at their sides. The nurse should also drape the client's gown at waist-level to allow for visualization of the anterior chest.

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider?

Capillary refill of 3 seconds

A nurse is performing a focused assessment on a client who reports having difficulty swallowing and a continuous headache. The nurse should identify that these findings can indicate which of the following conditions?

Central nervous system disorder

a nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing?

Cheyne-Stokes breathing

A nurse is performing a breast examination on a client and notices that the client's right arm is edematous. Which of the following should the nurse identify as a potential cause of this condition? A. Adverse effect of beta-blocker medication B. Recent onset of menopause C. Arterial occlusion on the right side D. Recent surgery on the right side

D. Recent surgery on the right side Rationale: Surgery on the client's right side, such as a mastectomy, can disrupt the flow of lymphatic drainage, which can cause edema. Therefore, the nurse should identify that recent surgery might be the cause of the client's condition.

A nurse is preparing to perform a physical examination on a client. Which intervention should the nurse perform to ensure client privacy?

Do not expose any more of the client's body than required at a time.

A nurse is collecting information about a client's spirituality using the FICA Spiritual History Tool. Based on this tool, which of the following information should the nurse gather? (Select all that apply.) Does the client identify spiritual or religious beliefs that are of importance to them? What impact does the client's spiritual or religious beliefs have on their health care decision making? Are there any spiritual or religious practices that should be included when planning the client's care? What is the address of the client's identified religious or spiritual gathering place? Is there a spiritual or religious group that the client identifies as having an importance in their life?

Does the client identify spiritual or religious beliefs that are of importance to them? is correct. The FICA Spiritual History Tool highlights 4 areas to discuss with the client: Faith/beliefs, Influence/importance, Community, and Address/preferences. Determining if the client assigns importance to spiritual or religious beliefs is an important assessment when planning health care. What impact does the client's spiritual or religious beliefs have on their health care decision making? is correct. The FICA Spiritual History Tool highlights 4 areas to discuss with the client: Faith/beliefs, Influence/importance, Community, and Address/preferences. Determining the impact or influence of the client's spiritual/religious beliefs is an important assessment when planning health care. Are there any spiritual or religious practices that should be included when planning the client's care? is correct. The FICA Spiritual History Tool highlights 4 areas to discuss with the client: Faith/beliefs, Influence/importance, Community, and Address/preferences. The nurse should determine if there are spiritual/religious practices that can affect the delivery of health care. Is there a spiritual or religious group that the client identifies as having an importance in their life? is correct. FICA Spiritual History Tool highlights 4 areas to discuss with the client: Faith/beliefs, Influence/importance, Community, and Address/preferences. Determining if the client derives support from a specific spiritual/religious group can be helpful when planning client care.

A nurse is performing a head and neck assessment on a client. The client reports a high-pitched ringing in their ears. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding?

Encounter

A nurse is planning to conduct a health history interview with a client. Which of the following actions should the nurse plan to take? (Select all that apply.) Gather supplies to take notes. Review the client's medical record at the conclusion of the interview. Conduct the interview in an open area such as the reception area or hallway. Select a position that is 0.6 to 0.9 m (2 to 3 feet) from the client during the interview. Ensure face-to-face contact is at eye level.

Gather supplies to take notes is correct. Taking brief notes during the interview process will assist to ensure correct information is recorded. Select a position that is 0.6 to 0.9 m (2 to 3 feet) from the client during the interview is correct. The nurse should plan to position themselves 0.6 to 0.9 m (2 to 3 feet) from the client throughout the interview process. This distance enables conversation, eye contact, and observation of the client during the interview. Ensure face-to-face contact is at eye level is correct. The nurse should plan to sit at the same level as the client throughout the interview. This position facilitates conversation and avoids the impression of superiority over the client.

A nurse is preparing to collect a health history from a client. Which of the following should the nurse plan to assess as a component of a functional assessment? (Select all that apply.) The reason that the client is seeking health care If the client is experiencing abuse or human trafficking The environment in which the client resides The client's use of substances Client's ability to perform activities associated with daily living

If the client is experiencing abuse or human trafficking is correct. A functional assessment determines the client's ability to care for themselves, their lifestyle choices, and the environment in which they live. Determining if the client is subjected to abuse or human trafficking should be investigated during a functional assessment. The environment in which the client resides is correct. A functional assessment determines the client's ability to care for themselves, their lifestyle choices, and the environment in which they live. Collecting information about the client's living arrangements and community can provide insight as to social determinates of health which can impact the client's health. The client's use of substances is correct. A functional assessment determines the client's ability to care for themselves, their lifestyle choices, and the environment in which they live. Collecting information about the client's personal lifestyle choices regarding tobacco, alcohol, and other substance use is included in a functional assessment. Client's ability to perform activities associated with daily living is correct. A functional assessment determines the client's ability to care for themselves, their lifestyle choices, and the environment in which they live. Determining how a client spends their day and if they are able to care for themselves independently or require assistance is included in a functional assessment.

A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration. In which of the following locations should the nurse perform the assessment?

Inferior to the collar bone

A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Which of the following interventions should the nurse plan to include?

Limit elevation of the head of the bed to 30° or less.

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include?

Limit sodium intake to less than 3,000 mg/day.

A nurse has collected biographic data from a client. Which of the following findings in the client's community is considered a social determinant of health that can negatively impact the client's health? Limited access to convenience foods A park available within walking distance from the client's residence Limited access to a pharmacy A neighborhood population that has a high rate of obesity and smoking

Limited access to a pharmacy Limited access to health care facilities and pharmacies is considered a social determinant of health that can have a negative impact on the client's health and treatment of illness.

A nurse is assessing a client's skin color. Which of the following areas should the nurse check to determine the presence of pallor?

Mucous membranes

A nurse is assessing a client's head. Which of the following should the nurse identify as an unexpected finding? (Select all that apply.)

Oval white patches in the client's hair A lesion on the client's scalp Protrusion of the client's head Edema around the client's eyes

A nurse is collecting information about a client's family history. The nurse should plan to collect information about the health of which of the following client relatives? (Select all that apply.) Parents Siblings Aunts and uncles Cousins Grandparents

Parents is correct. The nurse should plan to collect health information about three generations of the client's immediate blood relatives. This information includes the client's parents' ages, health status, and cause of death, if applicable. Siblings is correct. The nurse should plan to collect health information about three generations of the client's immediate relatives. This information includes the client's siblings' ages, health status, and cause of death, if applicable. Grandparents is correct. The nurse should plan to collect health information about three generations of the client's immediate blood relatives. This information includes the client's grandparents' ages, health status, and cause of death, if applicable.

A nurse is preparing to palpate a client's sinuses. Identify the sequence the nurse should follow when taking the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the client's frontal sinuses Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes Ask the client if they detect tenderness or pain Position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses Apply firm, upward pressure and ask the client if they detect tenderness or pain

A nurse is gathering information about a client's personal lifestyle choices. Which of the following information should the nurse seek to gather while investigating substance use? (Select all that apply.) Prescription medications taken for recreational purposes Determination of when the client last had an alcoholic drink Frequency of consumption of over-the-counter (OTC) medications Adverse reactions to medications and environmental substances Highest level of schooling completed

Prescription medications taken for recreational purposes is correct. Inquiring if the client has taken prescription medications for nontherapeutic reasons should be included when assessing the client's personal lifestyle habits. This information is a component of a functional assessment. Determination of when the client last had an alcoholic drink is correct. Asking the client when they last had an alcoholic drink should be included when assessing the client's personal lifestyle habits. This information is a component of a functional assessment.

A nurse is preparing to conduct a health history interview. Which of the following actions should the nurse plan to perform during the closing stage of the interview? Document client data. Provide an opportunity for the client to ask questions. Explain the reason for the interview. Greet client with an introduction.

Provide an opportunity for the client to ask questions. During the closing stage of the interview, the nurse should provide adequate time for the client to verbalize any questions that they have.

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which action should the nurse take to display empathy towards the client?

Put themselves in the client's situation to understand the client's anxiety.

A nurse is obtaining a past health history for a client prior to a breast examination. Which of the following questions should the nurse ask while obtaining the client's past health history? Select all that apply. A. "Have you ever had breast disease?" B. "Have you experienced breast trauma?" C. "Have you had breast surgery?" D. "Do you perform breast self-examinations?" E. "Has anyone in your family had breast cancer?"

Rationale: "Have you ever had breast disease?" is correct. The nurse should ask whether the client has ever had breast disease, such as fibrocystic disease or cancer, while obtaining the client's past health history. "Have you experienced breast trauma?" is correct. The nurse should ask whether the client has ever experienced breast trauma while obtaining the client's past health history. "Have you had breast surgery?" is correct. The nurse should ask the client whether they have had breast surgery while obtaining the client's past health history. Breast surgery can cause atypical hyperplasia of breast tissue, which increases the risk for breast cancer. "Do you perform breast self-examinations?" is correct. The nurse should ask whether the client performs breast self-examinations while obtaining the client's past health history. It is important for the client to perform breast self-examinations to increase the chance for early detection of a lump.

A nurse is preparing to review health promotion recommendations for breast health with a client. Which of the following actions should the nurse plan to take when reviewing health promotion recommendations for breast health? Select all that apply A. Ask the client to describe the process for breast self-examination at the end of the teaching. B. Document instructions provided in the client's medical record. C. Provide the client with information about the human papilloma virus (HPV) vaccine. D. Review recommendations for mammography based on risk with the client. E. Begin the teaching by listing national guidelines for breast screening.

Rationale: Ask the client to describe the process for breast self-examination at the end of the teaching is correct. The nurse should ask the client to describe the process for breast self-examination at the end of the teaching to validate their understanding of the information. Document instructions provided in the client's medical record is correct. The nurse should document any education provided or reinforced with the client in the medical record as part of accurate documentation. Review recommendations for mammography based on risk with the client is correct. The nurse should review recommendations for breast screenings, such as mammography, with the client based on their risk factors.

A nurse is discussing breast cancer with a group of male clients. The nurse should include that which of the following findings is a potential indication of breast cancer? (Select all that apply.) A. Dilation of the hair follicles B. Bilateral tissue enlargement C. Nipple retraction D. A small bulging nodule lateral to one breast E. Palpable Montgomery glands

Rationale: Dilation of the hair follicles is correct. The nurse should include that dilation of the hair follicles of the breast, also known as peau d'orange, is a potential indication of possible breast cancer that should be reported to the provider. Nipple retraction is correct. The nurse should include that nipple retraction is a potential indication of breast cancer that should be reported to the provider. The client should also report the presence of nipple discharge. A small bulging nodule lateral to one breast is correct. The nurse should include that a small bulging nodule lateral to one breast is a potential indication of breast cancer that should be reported to the provider.

A nurse is teaching a client about performing a breast self-examination at home. In which order should the nurse instruct the client to perform the steps of breast self-examination?

Rationale: Look at the breasts in front of a mirror with hands placed on hips is the first step. The nurse should instruct the client to first look at their breasts in front of a mirror with their hands placed on their hips. This position contracts the muscles of the chest wall, which makes it easier to observe changes in breast tissue. Inspect the breasts for changes in shape, color, or contour is the second step. After positioning themselves in front of a mirror, the client should then look for changes in the shape, color, or contour of their breasts. Inspect the nipples for a rash or drainage is the third step. Next, the client should inspect their nipples for a rash or drainage. Lie down and prepare to palpate breasts with the pads of the second, third, and fourth fingers is the fourth step. Next, the client should lie down and prepare to palpate the breasts using the pads of the second, third, and fourth fingers. Palpate each breast from the outer edge, moving from top to bottom across the breast is the fifth step. Lastly, the client should palpate each breast from the outer edge, moving from top to bottom across the breast using light, medium, and firm palpation.

A nurse is completing documentation in a client's medical record. Which action should the nurse take?

Record the client's most recent assessment results

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with the effectiveness with the client during the initial assessment process?

Request assistance from an interpreter during the assessment

A nurse is performing a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has difficulty reading fine print. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding?

Review of systems

A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular disease?

Sibling who has hypertension

A nurse is examining a lesion on a client's back. Which of the following characteristics should the nurse identify as a possible indication of a malignant skin lesion?

Size of a pencil eraser

A nurse is preparing to perform palpation on a client during a physical assessment. Which finding is the nurse assessing during palpation?

Skin temperature, moisture, and abnormalities

A nurse is collecting a health history from a client who is accompanied by an interpreter. Which of the following actions should the nurse take? Speak directly to the client throughout the interview. Ensure the interpreter is positioned behind the client for privacy. Ask the interpreter to summarize a group of questions for the client. Use accurate medical terminology when gathering information.

Speak directly to the client throughout the interview. The nurse should focus on the client and address all questions to the client throughout the interview.

A nurse is inspecting the fingernails of an older adult client. Which of the following findings should the nurse report to the provider?

Spongy nail base

A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this pet of the assessment?

Stethoscope

A nurse is performing an assessment on a client. The client states, "I have a dry cough every morning when I wake up." Which is the type of data the nurse is collecting?

Subjective data

A nurse is conducting a health history interview with a client. Which of the following is accurate about a directive interview technique? This technique consists of mostly closed-ended questions. This technique enables the client to control the pace of the interview. This technique is used to gather general information about a client's condition. This technique is effective for determining a client's emotional responses.

This technique consists of mostly closed-ended questions. Directive interview techniques are highly structured and often contain a list of specific, essential questions. This technique provides limited opportunity for the client to express questions or concerns.

A nurse is performing a head-to-toe assessment on a client and notes a lump on the anterior portion of their neck. The nurse should identify that this finding can indicate which of the following conditions?

Thyroid Disorder

A nurse is examining the texture of an older adult client's skin. Which of the following findings should the nurse report to the provider?

Velvety Skin

A nurse is evaluating assessment findings of a client's skin. The nurse should identify that which of the following findings is associated with a possible infection?

Vesicles

A nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations performed on a regular basis? (Select all that apply.)

Vision Screening every year Dental exam every 6 months

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect?

Yellow Sclera

A nurse is performing a skin assessment on a client. Which of the following findings should the nurse report to the provider?

Yellow discoloration of the palms

a nurse is providing discharge instructions to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make?

You should make every effort to receive a flu vaccine every year

A nurse is preparing to inspect a MALE clients abdomen. Which of the following findings should the nurse identify as an unexpected finding? (SATA) a. everted umbilicus b. purple striae c. rash d. healed scars e. mole

a. everted umbilicus b. purple striae c. rash

A nurse is providing teaching to a client about screening prevention for colorectal cancer. Which of the following tests should the nurse include? (SATA) a. fecal occult test b. flex sigmoidoscopy c. colonoscopy d. barium enema with contrast e. bronchoscopy

a. fecal occult test b. flex sigmoidoscopy c. colonoscopy d. barium enema with contrast

A nurse is preparing to inspect a clients abdomen. Which of the following variations should the nurse expect to find? (SATA) a. silver striae b. rash c. taut skin d. healed scars e. mole

a. silver striae d. healed scars e. mole

A nurse is preparing to perform an assessment on a clients abdomen. Which of the following pieces of equipment should the nurse use? (SATA) a. stethoscope b. watch c. tape measure d. reflex hammer e. tuning fork

a. stethoscope b. watch c. tape measure

A nurse is preparing to inspect the umbilicus of a clients abdomen. Which of the following findings should the nurse identify as an unexpected finding? a. swelling b. mole c. extraversion d. scar

a. swelling

A nurse is preparing a community program about injury prevention for a group of adults. Which of the following information should the nurse include? (select all that apply) a.) Do not text and drive b.) Maintain spinal alignment when working at a desk c.) Remove loose rugs from the home d.) Use the back muscles when lifting objects e.) Wear a helmet when riding a bicycle

a.) Do not text and drive b.) Maintain spinal alignment when working at a desk c.) Remove loose rugs from the home e.) Wear a helmet when riding a bicycle

A nurse is performing range of motion exercises on a clients feet. The nurse should provide which of the following instructions to the client to assess plantar flexion of the feet? a.) Point your toes toward the floor b.) Turn the soles of your feet out, from the body c.) Pointing your toes up toward your nose d.) Turn the bottoms of your feet in, toward the midline

a.) Point your toes toward the floor

A nurse is recommending sources of food with high calcium content to a client. Which of the following foods should the nurse recommend? (select all that apply) a.) milk b.) apples c.) mustard greens d.) corn e.) legumes

a.) milk c.) mustard greens d.) legumes

A nurse is providing dietary teaching to a client about the purpose of incorporating fiber in their diet. Which of the following information should the nurse include? a. fiber can be found in most diary products b. fiber allows larger stool to soften and pass easier c. fiber decreases peristalsis to prevent diarrhea d. fiber promotes the growth of good bacteria in the intestinal tract

b. fiber allows larger stool to soften and pass easier

A nurse is providing teaching to a client who has osteoporosis about the adequate intake of calcium. Which of the following intake amounts should the nurse recommend? a.) 500 to 1,000 mg daily b.) 1,000 to 1,200 mg daily c.) 1,500 to 2,000 mg daily d.) 2,000 to 2,200 mg daily

b.) 1,000 to 1,200 mg daily

The nurse is providing teaching about adequate daily intake of vitamin D to a client. Which of the following intake amount of the nurse recommend? a.) 500 IU daily b.) 800 IU daily c.) 1,500 IU daily d.) 1,800 IU daily

b.) 800 IU daily

A nurse is assessing flexion I have a client's elbows. The nurse should provide which of the following instructions to the client? a.) Start with your arms straight out in front of you with the palm facing the floor then twist at your elbow so your palms are facing up toward the ceiling b.) Start with your arms straight out in front of you then bend your elbows up and bring your fingers toward your shoulders c.) Start with your arms straight out in front of you with palms facing the ceiling then twist at your elbow so your palms are facing down to where the floor d.) Start with your elbows bent and fingers at your shoulders then straighten your arms out in front of you

b.) Start with your arms straight out in front of you then bend your elbows up and bring your fingers toward your shoulders

A nurse is preparing to auscultate a client's abdomen. Which of the following should the nurse expect if the client is experiencing borborygmus? a. hypoactive bowel sounds b. absent bowel sounds c. hyperactive bowel sounds d. normoactive bowel sounds

c. hyperactive bowel sounds

A nurse is teaching a client about the use of probiotics and incorporating them in their diet. Which of the following information should the nurse include? a. probiotics increase peristalsis to prevent constipation b. probiotics allow larger stools to soften to pass c. probiotics promote the growth of good bacteria in the clients intestinal tract d. probiotics remove fats and waste products from the body

c. probiotics promote the growth of good bacteria in the clients intestinal tract

A nurse is caring for a client who has a traumatic injury to a lower extremity. Which of the following action should the nurse take? a.) Apply heat therapy after the first 24 hours following the injury b.) Place an ice pack directly on the injured area c.) Apply compression to the injured area of the extremity d.) Encourage the client to use the extremity as much as possible

c.) Apply compression to the injured area of the extremity

A nurse is taking a health history from a client. Which of the following statements by the client requires further questioning by the nurse? a.) The bruises on my leg is from running into the base of a chair b.) I'm sleeping better since I gave up caffeine in the afternoon c.) For some reason I have been experiencing falls d.) I no longer have back pain since I started walking 2 miles every day

c.) For some reason I have been experiencing falls

A nurse is assessing a clients wrist and hands. Which of the following findings indicates the client may have arthritis? (select all the apply) a.) Uneven skin tone b.) Slate extension of the wrist c.) Nodules on the joints d.) A large mound below the thumb e.) Fingers deviated toward the ulnar

c.) Nodules on the joints e.) Fingers deviated toward the ulnar

A nurse is assessing the range of motion of a clients hands. The nurse should provide which of the following instructions to assess abduction and adduction of a client fingers? a.) Bend them into where the palm of the hand and then move it back out b.) Make a face and then straighten the fingers c.) Spread the fingers apart and then move them back together d.) Bend them to touch the tip of each finger

c.) Spread the fingers apart and then move them back together

A nurse is assessing an older adult client while they walk. Which of the following findings should the nurse report to the provider? a.) The client walks with small steps b.) The client walks with her legs spread out c.) The client walks with a shuffling gait d.) The client walks with a forward bent posture

c.) The client walks with a shuffling gait

A nurse is performing range of motion exercises on a clients hips. The nurse is assessing which of the following motions by instructing a client to bend the knee and bring it up to where the chest? a.) external rotation of the hip b.) adduction of the hip c.) flexion of the hip d.) hyperextension of the hip

c.) flexion of the hip

a nurse is evaluating an older adult client for an alteration in orientation. Which of the following questions should the nurse ask the client?

can you tell me what month it is

a nurse is assessing a client's vital signs. while counting the number of respirations. which of the following information should the nurse collect?

characteristics of the respirations

a charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

clubbing of the fingers indicates a chronic state of impaired perfusion

A nurse is providing teaching to a client about health promotion to prevent constipation. Which of the following instructions should the nurse include? a. limit vegetables to 10% of daily intake b. drink 32 oz of water per day c. eliminate legumes from your diet d. consume foods that are high in whole grains

d. consume foods that are high in whole grains

A nurse is preparing to palpate a client's abdomen. Which of the following should the nurse expect? a. involuntary rigidity b. voluntary guarding c. boardlike d. nontender

d. nontender

A nurse is performing a musculoskeletal and neurological assessment. Which of the following action should the nurse take? a.) Perform the assessment from the toes to the head b.) Assess the extremities from distal to proximal c.) Performed passive range of motion before active range of motion movements d.) Inspect for symmetry and both sides of the body

d.) Inspect for symmetry and both sides of the body

A nurse is assessing the range of motion of the Queens head and neck. The nurse should provide which of the following instructions to assess hyper extension? a.) Turn the head from side to side and look back over your shoulders b.) Bend the neck to the side and bring your ear close to the shoulder c.) Lower the chin to the chest and raise it back up d.) Tilt the head back and look up at the ceiling

d.) Tilt the head back and look up at the ceiling

a nurse is inspecting the anterior chest of a client. Which of the findings should the nurse report to the provider?

distended veins in one breast

a nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?

elevate the head of the client's bed

a nurse is performing an assessment of a client's lower extremities. Which of the following actions should the nurse include in this assessment?

inspect the pattern of hair distribution

a charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation?

inspiratory wheeze auscultated at left lateral chest

A nurse is caring for a client who had a suspected stroke. Which of the following actions should the nurse take? (Select all that apply.)

make the client NPO Assess the clients orientation Obtain the clients vital signs

a nurse is preparing an assessment on a client who reports ear pain. Which of the following actions should the nurse take?

palpate the mastoid area for pain

a nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor-vehicle crash. Which of the following findings is an indication of pneumothorax?

the client is experiencing unequal movement of the posterior chest

a nurse is planning to complete a physical assessment on a client. which of the following actions should the nurse plan to include?

use quotation marks when documenting client statements

a nurse is auscultating the lateral lobes of a client who has bronchitis. The nurse should document the sound of as which of the following?

wheeze