Unit 1 - Health History/General Survey

The nurse is performing an abdominal assessment and has just completed auscultation. Which technique would the nurse correctly choose to use next in this assessment? 1. Percussion. 2. Palpation. 3. Transillumination. 4. Auscultation.

1

The nurse is using an ophthalmoscope to assess the optic disc in a client. The nurse would suspect hemorrhage of the optic disc is present when which color is visualized through the red-free filter of the ophthalmoscope? 1. Green. 2. Black. 3. Red. 4. Yellow.

2

The nurse is developing a plan of care for a recently admitted client to the medical-surgical unit. Which is the basis for the plan and implementation of the client's care? 1. The nursing diagnosis. 2. The objective data. 3. The subjective data. 4. Client goals.

1

The nurse is obtaining a family health history when the client reports that a grandparent had type 1 diabetes. Where should the nurse document this information? 1. Family pedigree. 2. Health practices. 3. Past medical history. 4. Present health/illness.

1

A client is brought to the emergency department (ED) by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which finding would indicate the need for a more detailed neurological assessment of this client? 1. Asymmetry of the client's smile. 2. Grimacing with movement. 3. Talking in a loud voice. 4. Inability to follow directions.

1

During step 3 of the nursing process, which activity is performed? 1. Statement of client goals. 2. Collection of subjective data. 3. Performance of care activities. 4. Review of client goal achievement.

1

The nurse is admitting a client to a mental health unit for an exacerbation of bipolar disorder. When conducting the health history for this client, which is important to keep in mind regarding the client's confidentiality? 1. Confidentiality means that information sharing is limited to those directly involved in the client care. 2. Complete client confidentiality means that all members of the health care team may have access to the chart. 3. The Health Insurance Portability and Accountability Act (HIPAA) helps to maintain client confidentiality and dictates who is to be communicating with the client. 4. The medical records are open to any hospital employee, including administration.

1

The nurse is caring for a client diagnosed with breast cancer who underwent a left-sided mastectomy two days prior. The nurse has delegated vital signs on this client to the unlicensed assistive personnel (UAP). What specific instructions should the nurse provide to the (UAP) in delegating this task? 1. Take the blood pressure on the right arm. 2. No special instructions are needed. 3. Take the blood pressure on the left arm. 4. Take the blood pressure on both arms for a baseline.

1

The nurse is caring for a client who is recovering from abdominal surgery. Which goal statement is most appropriate for the nurse to include in this client's plan of care? 1. The client will verbalize pain relief using an intensity rating in 4 hours. 2. The client will state that he feels fine in 4 hours. 3. The nurse will observe fewer signs of pain in the client's demeanor. 4. The nurse will reevaluate the client's pain level every 2 hours.

1

The nurse is completing a focused interview. Which piece of information would the nurse include during this interaction? 1. Identify new nursing diagnoses after clarifying previously obtained data. 2. Review information collected during client's previous health screening activities. 3. Obtain biographic data about the client. 4. Review data from previous medical records.

1

The nurse is reviewing a client's medical records and notes various forms of information. Which is an example of subjective data from this client's medical record? 1. The client states, "My abdomen hurts on the left side after eating." 2. The nurse notes the client's abdomen is tender on the left side during palpation. 3. The CAT scan reveals a large mass in the left lower quadrant of the abdomen. 4. The client's hemoglobin is 14.1 gm/dL.

1

The nurse is using a Doppler ultrasonic stethoscope to assess a client's pulse in the lower extremity and is unable to locate the pulse. Which action by the nurse is appropriate in this situation? 1. Checking the pressure applied to the probe. 2. Adding more gel to the end of the probe. 3. Informing the healthcare provider immediately. 4. Sending the equipment for repair.

1

The nurse observes the client walking into the room and climbing up on the exam table. The nurse notes this activity to obtain data related to which item? 1. Mobility status. 2. Subjective assessments related to ambulation. 3. Activity tolerance. 4. Strength of upper and lower extremities.

1

The nurse wants to assess the client's self-esteem and emotional state. Which question is most appropriate for the nurse to ask this client? 1. "Can you describe the image that you see when looking in the mirror?" 2. "Tell me about your financial status?" 3. "How often do you have a bowel movement?" 4. "Have you ever contracted a sexually transmitted infection?"

1

Which documentation is appropriate after assessing head, neck, and lymphatics? 1. Occasional headaches relieved by acetaminophen. No history of injury, seizure, tremor, dizziness. No neck swelling. 2. Denies hearing problems, never had specific exam. Nose patent, no injury, sense of smell intact, clear drainage with cold. No trouble eating or swallowing. Dental exam annually, last exam one month ago. Brushes and flosses twice daily. 3. Denies problems. "My bowels move every day with no problem. I get diarrhea when I'm nervous sometimes." Active bowel sounds present in all quadrants. Abdomen soft and non-tender to palpation. 4. Denies problems. No history of UTI. I pass urine five or six times a day and more if I drink more.

1

Which is the purpose of a health history when admitting a client into the hospital with an exacerbation of a chronic disease process? 1. Documenting the client response to health concerns. 2. Documenting the client's dietary history. 3. Documenting the client's stress management skills. 4. Documenting the client's social interactions.

1

Which statement best describes the active role of the professional nurse as an educator? 1. Nurses must consider learning needs, goals, objectives, content, teaching methods, and evaluation when carrying out client education. 2. Teaching plans are developed for informal teaching when distinct needs are identified or when common needs are recognized. 3. In the role of educator, the nurse should refer the client to other health care providers who specialize in the area of need. 4. Teaching is to be delegated to the advanced practice nurse specialist or the nurse educator.

1

While conducting a physical assessment for a client with asthma, the nurse notes that the client is wheezing and documents this finding in the medical record. Which phase of critical thinking is represented by this nurse's actions? 1. Collection of information. 2. Evaluation. 3. Generation of alternatives. 4. Analysis of the situation.

1

The nurse is completing an admission assessment. The assessment form allows for the separation of subjective and objective data. Which data is considered subjective? Select all that apply. 1. The client's mother informs the nurse that her daughter has not been sleeping due to pain. 2. The client states, "I have pain in my belly that is 7 out of 10." 3. Abdominal assessment reveals a firm, hard abdomen. 4. The client is weak and looks very pale. 5. The client appears nervous during the data collection period.

1, 2

The nurse is preparing to assess an adult client who presents to the emergency department (ED) after falling down some steps at home. The client complains of left ankle pain and has open abrasions to the left knee and shin. Which should the nurse incorporate into the physical assessment of this client? Select all that apply. 1. Washing hands in the presence of the client. 2. Putting on nonsterile gloves to examine the client. 3. Ensuring that the client has an empty bladder before beginning the physical assessment. 4. Instructing the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam. 5. Assessing only the left lower extremity since this is the injured body part.

1, 2

When is it appropriate for the nurse to use an otoscope during a physical assessment? Select all that apply. 1. Inspecting the nose. 2. Funneling light into the ear canal. 3. Inspecting the internal structures of the eye. 4. Assessing pulses that are not palpable. 5. Detecting fungal infections of the skin.

1, 2

The nurse educator is observing the student nurse take a blood pressure on an older adult client. When is it appropriate for the nurse educator to intervene during this assessment? Select all that apply. 1. The student nurse ushers the client into the exam room and immediately assesses the client's blood pressure. 2. The student nurse places the blood pressure cuff on the client's arm over a lightweight, long-sleeved sweater. 3. The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure. 4. The student nurse has the client sit in a chair and supports the client's arm on a table at the level of the heart. 5. The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery.

1, 2, 3

The nurse is preparing to interview the hospitalized client. Which statements by the client's nurse indicate that the interview should be postponed? Select all that apply. 1. "I can't seem to get her pain under control this morning." 2. "I just gave her morphine sulfate through her IV for pain about 20 minutes ago." 3. "She was anxious earlier and received some lorazepam." 4. "She's been oriented to 'self' only since admission." 5. "I gave her some ibuprofen about 1 hour ago."

1, 2, 3, 4

Which are appropriate focuses for the health history collected by the nurse? Select all that apply. 1. Physical status. 2. Patterns of daily living. 3. Wellness practices. 4. Self-care activities. 5. Medical diagnoses.

1, 2, 3, 4

The nurse is performing a focused interview with the client. Which behaviors indicate that the client may be feeling anxious? Select all that apply. 1. While seated, the client begins to wiggle his foot back and forth quickly. 2. The client leans back in his chair and seems to move away from the nurse. 3. The client crosses his arms and becomes very quiet. 4. The client leans forward in the chair and uncrosses his legs. 5. The client seems to be distracted and is no longer making direct eye contact with the nurse.

1, 2, 3, 5

The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session? Select all that apply. 1. The stethoscope works by blocking out environmental sounds. 2. Short tubing provides the listener with the most accurate sounds. 3. The bell of the stethoscope is used for high-pitched sounds, such as lung sounds. 4. Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection. 5. The binaurals should fit snugly in the ears.

1, 2, 5

When creating a pedigree, which items would the nurse consider as red flags? Select all that apply. 1. Known genetic conditions. 2. Multiple family members with the same disease. 3. Late age of disease onset. 4. Death from chronic illness. 5. Multiple pregnancy losses.

1, 2, 5

The school nurse provides care for a child who fell on the school playground and sustained multiple abrasions to the lower extremities. Which actions by the school nurse are appropriate when caring for this child? Select all that apply. 1. Putting on nonsterile gloves prior to assessing the child's injuries. 2. Disposing of blood-soaked gauze in the office trash bin. 3. Performing handwashing before touching the child. 4. Asking the child permission to assess the injuries. 5. Wearing a mask while washing the child's abrasions.

1, 3, 4

The nurse is gathering client data from secondary sources. Which sources would the nurse utilize to collect this data? Select all that apply. 1. The client's past medical records. 2. The client. 3. The history and physical. 4. The client's physical therapist. 5. The client's spouse.

1, 3, 4, 5

The nurse is preparing the care plan for a client who admitted to the unit after an abdominal hysterectomy to manage endometriosis. Which goal statements reflect the need for further development by the nurse? Select all that apply. 1. The nurse will assess the vital signs every 2 hours. 2. The client will walk Q2h on the first postoperative day. 3. The client will report feeling better. 4. The client will begin a clear liquid diet on the first postoperative day. 5. The healthcare provider will prescribe oral analgesics on the first postoperative day.

1, 3, 5

The student nurse is preparing to perform a health history interview. Which statements indicate that the student nurse requires further education regarding the purpose of the health history? Select all that apply. 1. "As the nurse, I will mainly focus on the course of the client's illness." 2. "The client's health history can be gathered during the initial interview." 3. "I realize that the client is sick, but I also need to perform a wellness assessment." 4. "The healthcare provider's and nurse's assessments should be almost identical with the same focus." 5. "The nurse typically has a more holistic point of view regarding the client's health."

1, 4

The nurse is caring for a newly admitted client with Methicillin-resistant Staphylococcus Aureus (MRSA). Which are appropriate goals for the initial health assessment? Select all that apply. 1. Determine the client's current state of health and ongoing health-promotion activities. 2. Predict risks to current health status. 3. Use only objective data to determine client allergies. 4. Determine how frequently the client is able to change positions. 5. Identify health-promoting activities.

1, 5

A client has a reddened area on the left forearm. Which assessment technique should the nurse use to assess this area? 1. Percussion. 2. Light palpation. 3. Moderate palpation. 4. Deep palpation.

2

A young adult client notes height as "5 feet 11 inches" and weight as "200 lbs." Upon assessment, the client is found to be 5 feet 9 inches tall with a weight of 225 lbs. Which is the most likely cause of this discrepancy? 1. The client does not have a scale at home. 2. The client may have an image of self that is inconsistent with actual findings. 3. The client did not want to tell the truth. 4. The client is trying to hide a chronic illness.

2

A young adult client presents to the clinic complaining of a sore throat, swollen glands, and fever following oral surgery for extraction of impacted wisdom teeth. In order to complete the initial assessment of this client, the nurse needs to obtain the client's temperature. Which method should the nurse choose for this assessment? 1. Oral. 2. Tympanic. 3. Rectal. 4. Axillary.

2

During an interview with an older adult client, the nurse notes the client is confused as to day and time. The nurse documents this finding as an indicator of which item? 1. Affect and mood. 2. Orientation. 3. Cooperation. 4. Level of anxiety.

2

During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which action by the nurse is the most appropriate? 1. Document this as abnormal. 2. Wet the chest hair before auscultating the chest. 3. Place the diaphragm on top of the client's shirt. 4. Switch from the diaphragm to the bell.

2

In obtaining a past history as part of a history of present illness (HPI), the nurse asks the client about allergies to drugs, animals, insects, and other environmental agents. In addition to this information and asking about how the reaction is treated, which is the most important allergy-related information that the nurse should inquire about? 1. The location where the reaction occurred. 2. The type of reaction that occurred with exposure. 3. Exactly how long the symptoms lasted. 4. Immediate and extended family members with the same allergy.

2

The health care organization is planning to change the type of documentation done on the client care units. The nurses have requested a system that will reduce time spent writing out routine tasks and will still allow for documentation of exceptions. Which type of documentation will best meet the needs of the nursing staff? 1. Focus documentation. 2. Flow sheets. 3. SOAP charting. 4. APIE charting.

2

The novice nurse working on a medical-surgical unit is preparing a plan of care for a client admitted for irritable bowel syndrome. The goal statement is, "The client will resume normal bowel elimination patterns." When reviewing the plan of care with the novice nurse, which statement by the preceptor is the most appropriate? 1. "This plan of care has an appropriate goal statement which meets criteria." 2. "This goal statement requires a time frame to be appropriate." 3. "This goal statement is not reflective of the client's admitting diagnosis." 4. "This care plan is accurate and will be placed in the client's medical record."

2

The nurse conducts a health history while admitting a client to the acute care facility. When collecting primary subjective data, which is an appropriate source for the nurse to use? 1. The client's physical assessment. 2. The client's self-reports. 3. The client's healthcare provider. 4. The client's significant other.

2

The nurse educator is discussing Healthy People 2020 with a group of nursing students. One of the students questions the instructor how this work will impact hospitalization. Which response by the educator is the most appropriate? 1. "Healthy People 2020 is a tool for the healthcare providers to offer information to their clients." 2. "Healthy People 2020 seeks to improve health and prevent illness, disability, and premature death." 3. "The purpose of Healthy People 2020 is to reduce health care costs for hospitalized clients." 4. "Healthy People 2020 is seen as a tool by hospitals to reduce length of stay."

2

The nurse educator is observing a student nurse who is performing cervical palpation on an adult client. Which technique is appropriate for this assessment? 1. Downward pressure of 1-2 cm using the finger pads. 2. Side to side pressure of ½-1 cm using the finger pads. 3. Downward pressure of 2-4 cm using the palmar surface of the fingers 4. Light pressure using the base of the fingers (metacarpophalangeal joints).

2

The nurse educator is presenting information about the nursing process to a group of students. Which statement by a student reflects the appropriate sequence when implementing the nursing process? 1. "The correct order of the nursing process is diagnosis, assessment, planning, implementation, evaluation." 2. "The correct order of the nursing process is assessment, diagnosis, planning, implementation, evaluation." 3. "The correct order of the nursing process is planning, assessment, diagnosis, implementation, evaluation." 4. "The correct order of the nursing process is assessment, planning, diagnosis, implementation, evaluation."

2

The nurse in the clinic is assessing an adult client who has 2+ ankle edema, crackles throughout the lung fields, and dyspnea on exertion. The nurse concludes that the client will need lifestyle-change teaching. Which is an important area for the nurse to assess next during the health history? 1. The client's family history. 2. If the client eats foods high in salt. 3. How many children the client has. 4. If the client is married or divorced.

2

The nurse is assessing a client who presents in the emergency department (ED) with abdominal pain, nausea, and vomiting. Vital signs are within normal limits. The client's health history indicates pelvic inflammatory disease, mitral valve prolapse, and childbirth. When analyzing the available data, what items should be clustered together? 1. Vital signs, complaints of pain, history of childbirth. 2. Abdominal pain, nausea, vomiting, and history of pelvic inflammatory disease. 3. Gender, history of mitral valve prolapse, and vital signs. 4. History of pelvic inflammatory disease, mitral valve prolapse, and pain scale reports.

2

The nurse is assessing an adult client when suddenly the client refuses to continue the examination. Which action by the nurse is the priority? 1. Give the client a short break and then resume the assessment. 2. Document what was done and what was refused. 3. Summon another nurse to the room to serve as a witness. 4. Enlist the assistance of the client's family to encourage the rest of the assessment.

2

The nurse is assessing an anxious-appearing client who is experiencing abdominal pain. Which technique is appropriate for the nurse to use when assessing this client's abdomen? 1. Palpating known painful areas first. 2. Touching each area lightly before applying deeper palpation. 3. Performing the exam as quickly as possible. 4. Refraining from conversation during the assessment.

2

The nurse is conducting an assessment of a client with right lower quadrant abdominal pain. Which action by the nurse is appropriate when palpating this client's abdomen? 1. Assessing the painful area first using moderate palpation. 2. Assessing the painful area last using deep palpation. 3. Assessing the painful area last using light palpation. 4. Assessing the painful area first using deep palpation.

2

The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. Which action by the nurse is the most appropriate? 1. Report the lack of achievement of the goals to the healthcare provider. 2. Review the data and modify the plan. 3. Reformulate the nursing diagnosis to a more realistic one. 4. Request a consult for the client to be seen by a pulmonologist.

2

The nurse is obtaining information about a client's past medical history. Which source would provide the nurse with this data? 1. Medication list. 2. Immunization records. 3. Average amount of hours of sleep each night. 4. Marital status.

2

The nurse is planning to perform a physical assessment on an adult client. Before beginning this phase of the client's health assessment, which action by the nurse is the most appropriate? 1. Provide a gown for the client to change into. 2. Explain to the client what will happen during the examination. 3. Obtain a written consent. 4. Wash hands in the presence of the client.

2

The nurse is preparing to assess a client's mental status within the general survey. Which data should the nurse use to assess this status? 1. Noting of the number of times the client looks to significant other while answering interview questions. 2. Asking the client to describe elements of his health history. 3. Studying the client's clothing selections. 4. Noticing the client's ability to make eye contact during the examination.

2

The nurse is unable to palpate a client's pedal pulses. Which item will the nurse use to assess this client's pedal pulses? 1. Stethoscope. 2. Doppler. 3. Transilluminator. 4. Goniometer.

2

The nurse manager is reviewing SOAP entries in the medical record for a novice nurse. Which entry indicates that the nurse needs further instruction concerning documentation? 1. S: The client states, "I am so nauseated." 2. O: The client reports feeling fatigued. 3. A: Bowel sounds are high-pitched in all abdominal quadrants. 4. P: The client will remain NPO.

2

The nurse says to the client, "Before the healthcare provider comes in to see you, we will need to spend about 30 minutes talking about your current problem and any other health issues that might impact how you are feeling right now." The nurse is participating in which phase of the health assessment interview? 1. Pre-interaction. 2. The initial interview. 3. The focused interview. 4. Closure of the interview.

2

Which information would the nurse include in the assessment category when using SOAP to documents in the medical record? 1. The client's blood pressure was 177/93. 2. The recent loss of employment and insurance has prevented the client from being able to afford prescription medications. 3. The client reports having lost her job and insurance 3 months ago. 4. Referrals have been made to social services to determine financial assistance programs available.

2

While conducting a health history, a client states, "I am healthy, I don't know why I have to be here to get a check-up." However, the client reports, type 2 diabetes mellitus and an unhealed ulcer on the left foot. Based on this information, which statement by the nurse is the most appropriate? 1. "I feel that you are in denial about your health status." 2. "Tell me about your definition of being healthy." 3. "Do you understand what diabetes is?" 4. "Is there anything else you are not telling me?"

2

While percussing a client's lung area the nurse notes a resonance. What does the tone indicate? 1. The nurse is percussing over a bone. 2. A normal finding. 3. The lungs are solidified. 4. Air is trapped in the lungs.

2

The nurse is assessing an adult client. Which observations should the nurse include when documenting the general survey of this client? Select all that apply. 1. Blood pressure 112/68, pulse 68, 98.6°F, respiratory rate 16. 2. Thin, well-nourished male client, appears younger than stated age. 3. Client moves about exam room without difficulty. 4. Abdomen flat, nondistended, bowel sounds present, nontender on palpation. 5. Pain rating of 3 on a 0 to 10 scale.

2, 3

The client has been diagnosed with an early stage of wide-angle glaucoma. The nurse is performing a wellness assessment during the client's initial interview. Which statements by the client may be elicited during this portion of the health history? Select all that apply. 1. "My mom was diagnosed with glaucoma when she was 60 years old." 2. "I pay attention to the foods that I eat, because I want my body to stay well." 3. "I think I do a good job of managing stress with yoga every day and running three times a week." 4. "My husband and I have three couples that we would classify as our very good friends." 5. "Sometimes, my eyes feel very tired and sort of ache."

2, 3, 4

The nurse educator is presenting information about the APIE method of charting as it will be implemented by the facility in a few weeks. Which statements by the participants indicate an appropriate understanding of this method of charting? Select all that apply. 1. "I will only need to chart by exception with this method." 2. "Only subjective data are included in the assessment portion." 3. "The 'P' refers to the chief problem of the client." 4. "The activities implemented to manage the client's needs will be documented in the 'I' section." 5. "The 'E' refers to the evaluation that occurs after an intervention is implemented."

2, 3, 4, 5

The student nurse is preparing a care plan for an assigned client. When writing the nursing diagnose for this client, which elements are required? Select all that apply. 1. Medical diagnosis. 2. Risk or related factors. 3. Defining characteristics. 4. A diagnostic label. 5. A definition.

2, 3, 4, 5

The nurse is preparing to perform a complete health assessment on a client. Which actions by the nurse are appropriate just prior to the examination? Select all that apply. 1. Putting on nonsterile gloves. 2. Providing an opportunity for the client to void. 3. Washing hands in the presence of the client. 4. Turning on soft music to relax the client. 5. Ensuring adequate light in the room.

2, 3, 5

The nurse is reviewing flow chart entries for a client experiencing pain. Which chart entries represent subjective data? Select all that apply. 1. The client's leg is red and swollen. 2. The client complains of leg tenderness. 3. The client's white blood cell count is 5.6. 4. The client demonstrates guarding behaviors during the assessment of the affected extremity. 5. The client complains leg cramps.

2, 5

A client has a visible pulsation in the middle of his abdomen. Which assessment technique is appropriate for the nurse to use to assess this pulsation? 1. Percussion. 2. Light palpation. 3. Moderate palpation. 4. Deep palpation.

3

A client has been brought to the emergency department (ED) by a family member. The client is speaking incoherently. To obtain information about the client's current health status, what should the nurse do? 1. Call the client's healthcare provider. 2. Call the Medical Records department to obtain other records for the client. 3. Discuss the situation with the family member who brought the client to the hospital. 4. Conduct a thorough physical assessment and document the health history as "unable to obtain."

3

During the course of a health history the nurse would like to review a client's medications. Which question is most important to ask when gathering the medication history? 1. "Can you tell me how much the co-pay is for your medications?" 2. "Do you carry health insurance?" 3. "Can you tell me about any over-the-counter or prescription medications that you take?" 4. "Where do you store your medications in your home?"

3

During the pre-interaction stage, the nurse is preparing for the initial interview. Which setting is the least appropriate setting for the initial interview? 1. The client has been admitted to the hospital with pneumonia. The nurse is preparing to interview the client in the client's private hospital room. 2. The client lives at home. The nurse is preparing to interview the client in the client's living room. 3. The client lives at home. The nurse is preparing to interview the client at a small coffee shop not far from the client's home. 4. The client lives at home. The nurse is preparing to interview the client in the client's backyard.

3

The nurse is assessing a 15-month-old toddler client. Which site is the most appropriate for the nurse to use when assessing the pulse? 1. Radial artery. 2. Brachial artery. 3. Apical site. 4. Carotid artery.

3

The nurse is assessing a client's abdomen. Which sound is expected when percussion is used during the assessment? 1. Loud, low-pitched. 2. Soft, high-pitched. 3. Drum-like. 4. Abnormally loud.

3

The nurse is assessing a client's right lower extremity and notes an area of redness. Which part of the hand will the nurse use to further assess the client's skin? 1. Fingertips. 2. Metacarpophalgeal joints. 3. Dorsal surface. 4. Ulnar surface.

3

The nurse is assessing a toddler when the child's mother states that the child has had a fever for the past two days. When the nurse asks the mother what the temperature has been, the mother replies that she hasn't actually taken it but the child's skin has felt very warm. Which response by the nurse is appropriate in this situation? 1. "When our skin feels warm, it means our blood vessels are constricted." 2. "The only reliable indicator of body temperature is by feeling the forehead." 3. "Our skin temperature changes when our surroundings change temperature." 4. "The temperature of the skin is not related to what is happening inside our bodies."

3

The nurse is assessing an adult client's pulse. Which method will is appropriate for the nurse to initially use? 1. Monitoring for a full 2 minutes. 2. Monitoring for 1 complete minute. 3. Monitoring for 30 seconds and multiply by 2. 4. Monitoring for 15 seconds and multiply by 4.

3

The nurse is conducting a workshop on wellness and health promotion using the initiatives of Healthy People 2020. After the session, which statement by a participant indicates an understanding of the initiatives? 1. "It will allow health care providers to lobby legislators for more funding." 2. "The primary goal of Healthy People 2020 is to assist health care providers in determining risk factors for premature birth." 3. "Healthy People 2020 seeks to promote health, prevent illness, disability, and premature death." 4. "The initiatives will outline standards of care for providers in managing diseases."

3

The nurse is entering the room to assess a newly admitted client. Which best describes the purpose for a general survey that is conducted prior to beginning the physical assessment? 1. Allows for vital signs prior to starting exam. 2. Provides an opportunity for the client to relax before the exam. 3. Yields information to guide the physical assessment. 4. Provides the information necessary for the diagnosis.

3

The nurse is examining a client with congestive heart failure who takes propranolol and furosemide. The client complains of fatigue and an inability to finish tasks. Which conclusion by the nurse is the most appropriate? 1. The medication needs adjustment. 2. The client has not been exercising. 3. The client is experiencing expected manifestations of the disease process. 4. The client should be hospitalized.

3

The nurse is inspecting a client's chest and upper extremities. Which would be the appropriate method for the nurse to assess these body areas? 1. Examine the right arm, the chest, and then the left arm. 2. Examine the left arm, the chest, and then the right arm. 3. Examine the left arm, the right arm, and then the chest. 4. Examine the chest, and then examine the arms at the conclusion of the exam, as the client is re-dressing.

3

The nurse is interviewing an older African American client and determines that a teaching plan should be implemented. Based on the client's race, which statement by the client may prompt the nurse to plan develop a teaching plan? 1. "My hands and feet are always cold." 2. "I do not take calcium replacements." 3. "My blood pressure is high most of the time." 4. "I'm worried that my bones may be weak."

3

The nurse is obtaining the initial vital signs on a client in the emergency department (ED) with seizure activity of unknown etiology. Which method is most appropriate for the nurse to use when assessing the client's temperature? 1. Axillary. 2. Oral. 3. Rectal. 4. Tympanic.

3

The nurse is preparing a teaching plan for a client diagnosed with hypertension. Which objective is appropriate when addressing the psychomotor domain for the client? 1. The client will discuss measures to take when experiencing dizziness. 2. The client will describe signs and symptoms of an elevated blood pressure. 3. The client will demonstrate how to monitor own blood pressure. 4. The client will define the dimensions of hypertension.

3

The nurse is preparing to percuss the lower lobes of a client's lungs. Which percussion technique is the most appropriate for the nurse to use during this assessment? 1. Direct percussion. 2. Blunt percussion. 3. Indirect percussion. 4. Any of the percussion techniques.

3

The nurse is reviewing a client's medical record while planning care. Which data from the medical record is an example of objective data? 1. "I hurt my head." 2. "I am 6 years old and I'm here because I fell." 3. "Six-year-old Hispanic female sitting on examination table holding a towel to her forehead." 4. "Client states that she fell at the playground."

3

The nurse needs to take a blood pressure on a very thin client, and the only cuff available is a standard size. Which type of blood pressure reading does the nurse expect? 1. An accurate reading. 2. A falsely elevated reading. 3. The reading will depend on the overall health of the client. 4. A false low reading.

4

When using Leavall and Clark's model as a framework for preparing a community health program, which program objective best reflect the concepts presented by this model? 1. The participants will recognize health as the absence of disease. 2. The participants will verbalize the role of self-actualization achievement in relation to health. 3. The participants will define health as the interrelationships between the agent, host, and the environment. 4. Internal harmony is the foundational basis for health achievement.

3

Which is the priority when assessing the client's sexual history? 1. Determining sexual health. 2. Asking about sexual orientation. 3. Establishing rapport. 4. Assessing age of secondary sex characteristics.

3

Which piece of information will the nurse collect when assessing the client's past medical history? 1. Name. 2. Marital status. 3. Childhood illnesses. 4. Reason for seeking care.

3

While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. Which nursing action is most appropriate? 1. Informing the client of "the abnormality." 2. Stopping the assessment and referring the client to the healthcare provider immediately. 3. Bring in another examiner to assess the finding. 4. Documenting the finding and reassessing at the client's next visit.

3

The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure reading of 172/98 mmHg. Which factors may be applicable in this situation? Select all that apply. 1. Arteriosclerosis decreases the ventricular force necessary for ejection of blood. 2. Arteriosclerosis increases blood vessel elasticity. 3. Arteriosclerosis decreases blood vessel compliance. 4. Age decreases blood vessel elasticity. 5. Arteriosclerosis plays no role in the blood pressure of this client.

3, 4

The nurse is developing a pedigree. Which pieces of information can be used to help identify the widowed female? Select all that apply. 1. A square is used to denote the female. 2. A circle is used to denote the male. 3. A horizontal line connects the circle and the square in the middle. 4. A line above the circle and square that is linked on the top of each shape. 5. The square has a diagonal line through the square from bottom left to upper right corner.

3, 5

A novice nurse is conducting a focused interview on an older adult client who is being admitted for a urinary tract infection (UTI). Which action by the novice nurse is appropriate? 1. Obtaining a urine sample to send for a urinalysis. 2. Monitoring the client's vital signs. 3. Questioning the client about dietary preferences. 4. Assessing the characteristics of the client's pain.

4

The community health nurse is preparing to conduct a program for a group of nursing students concerning health and wellness. Which statement by a participant indicates the most comprehensive and accurate understanding of health? 1. "Health is the absence of illness, disease, and symptoms." 2. "Health is a state of well-being and the use of every power the person possesses to the fullest extent." 3. "Health is the state when a person is viewed as a holistic being." 4. "Health is a state of complete physical, mental, and social well-being."

4

The nurse educator is preparing an in-service on pain management for the staff. One of the staff nurses asks, "What is the most important part of a pain assessment?" Which response by the nurse educator is the most appropriate? 1. "Pain is only partially subjective and primarily a physiologic experience, so vital signs are the most important assessment." 2. "A client's response to pain is always based on the underlying cause, so the client's admitting diagnosis is important." 3. "Vital signs are not reliable indicators of acute pain, because only some clients are able to elicit a change in blood pressure or pulse rate." 4. "The response to pain is unique and based on numerous factors, which need to be assessed."

4

The nurse is developing a handout for clients in a healthcare provider's office. The nurse includes which focus area in this handout to emphasize current changes in the health care delivery system? 1. Class recommendations for diabetics concerning insulin administration A2.Guidelines from the Centers for Disease Control outlining plans to manage outbreaks of disease, eradicating the use of toxins. 2. Guidelines from the Centers for Disease Control outlining plans to manage outbreaks of disease, eradicating the use of toxins. 3. Resources available to treat chronic pain. 4. Class listings for exercise classes available in the community.

4

The nurse is developing the plan of care for a client who is recovering from abdominal surgery. Which intervention is most appropriate to address this client's pain? 1. The healthcare provider will prescribe additional analgesics. 2. The client will have reduced pain after administration of analgesics. 3. The client will vocalize reduced levels of pain within 3 hours. 4. Assist the client with guided imagery to manage pain levels.

4

The nurse is gathering information regarding the client's psychosocial history. Which question would be included in this assessment? 1. "How did your father die?" 2. "Have you had any major surgeries?" 3. "Have you noticed any change in your vision?" 4. "How long have you worked for your current employer?"

4

The nurse is preparing to assess the sinuses of an adult client using direct percussion. Which technique is the most appropriate for this assessment? 1. Using the hyperextended middle finger of the nondominant hand. 2. Using the closed fist of dominant hand. 3. Using the palm of the nondominant hand. 4. Using the fingertips of the dominant hand.

4

The nurse is preparing to examine several clients in the clinic setting. Which client would need the greatest degree of special consideration during a physical examination? 1. An adult client with flu symptoms. 2. A preschool-age client in for a well check-up. 3. An adolescent client who complains of fatigue. 4. An older adult client with chronic lung disease.

4

While auscultating a client's lungs, the nurse identifies more than one sound. Which action by the nurse is the most appropriate? 1. Obtain a stethoscope with longer tubing. 2. Ask another nurse to listen to the lung sounds. 3. Hold the stethoscope tubing while listening to the lung sounds. 4. Close the eyes and focus on one sound at a time.

4

While conducting a review of systems assessment during a health history, which question is appropriate? 1. "Have you ever had a surgical procedure?" 2. "What is your level of education?" 3. "Are you currently taking any medication?" 4. "Do you have a history of respiratory issues?"

4