Head-to-Toe Assessment (Chapter 28)

The client is experiencing severe sepsis. What assessment finding would the nurse expect?

+1 pulses

Which ribs are considered "floating ribs"?

11th and 12th

pulmonic area

2nd left ICS close to the sternum

Mitral (Apical) area

5th left ICS medial to the MCL

When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?

68-year-old African American male with hypertension

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?

A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min

crepitus

A grating or grinding sensation caused by fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.

A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client?

A grey-white line

An increased risk of falls is dangerous for any patient. What patient would be at an increased risk of falls?

A patient with vertigo.

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to

Approach client posteriorly

A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?

Arthritic changes of the cervical spine

A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?

Blood pressure

What lines the cheeks?

Buccal mucosa

COLDSPA

Character, Onset, Location, Duration, Severity, Pattern, Associated factors (how it affects them)

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

Conjunctiva

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?

Coordination

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin

D

A client diagnosed with a peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse's priority concern for this client?

Ensure pt airway

Ongoing health history

Follow-up; every hour, 4 hours, etc.

The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem?

Heart failure

Phase IV of nursing process

Implementation- Carrying out the plan

During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina?

Inspection. The nurse should use the technique of inspection for assessment of the vagina. The nurse should insert the speculum and inspect the vagina for color, consistency, and discharge

LOC

Level of Conciousness- Oriented to time, place, and person

CN VIII

Nerve impulses are sent to the brain through this

A modifiable risk factor for breast cancer includes what?

Obesity

CN III

Oculomotor nerve- pupillary constriction lid elevation

A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems?

Orthopnea

While interviewing a client who complains of earache, the nurse asks, "Is there anything that makes it better or worse?" The client replies, "It hurts much worse when I wiggle my ear." Which of the following conditions should the nurse most suspect?

Otitis externa

A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client?

Romberg

A 41-year-old woman is considering the use of hormonal contraceptives. What is contraindicated in this client?

Smoking

A patient has an open draining wound located on the underside of the chin. Which lymph nodes should the nurse assess in this patient?

Submental

During the eye assessment, a nurse performs part of the neurological examination for which cranial nerve?

The nurse checks the function of cranial nerve VII when assessing the corneal reflexes during an eye assessment.

Objective data

Visible, assess-able factors

The submandibular glands open under the tongue through openings called

Wharton ducts

The apex of each lung is located at the

area slightly above the clavicle.

A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend?

avoid excessive alcohol intake

The nurse is planning to inspect the anal area of an adult female client. To assess for any bulges or lesions, the nurse should ask the client to

bear down

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are

caused by aging of the skin in older adults.

circumduction

circular motion

dub

closing of aortic and pulmonic valves

atrophy

decrease in muscle size; wasting away

Subjective data

how the patient feels

When documenting that a patient has freckles, the appropriate term to use is

macules

McBurney's test

used to evaluate for appendicitis

The client has a Foley catheter. What should be assessed related to catheter that may alert the nurse to an infection? Select all that apply.

• Color • Odor • Pain • Temperature

A client asks the nurse when a colonoscopy is recommended. Which advise by the nurse provides the most appropriate advice?

"A flexible sigmoidoscopy should be done every five years starting at age 50"

Which question asked by the nurse is assessing problems with vertigo?

"Do you ever have problems with balance?"

Which question asked by the nurse is assessing problems with tinnitus?

"Do you experience buzzing in your ears?"

An nursing instructor is discussing the functions of the breasts. A student asks about the function of Montgomery glands. What would be the instructor's best answer?

"During lactation, they secrete a protective lubricant."

A middle-aged female tells the nurse that she is concerned because her breasts are not as firm as they used to be. What is an appropriate response by the nurse?

"Firmness of the breasts decrease with lower estrogen levels"

The nurse is performing a genitourinary assessment on a 42-year-old client and has explained to her that the assessment will require rectovaginal palpation. The client winces and asks, "Is that really necessary?" Which of the nurse's responses would provide the best rationale for rectovaginal palpation?

"I know this is probably unpleasant, but it's important for me to determine if your uterus is where it's expected."

The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate?

"Quitting smoking and keeping good control of your blood sugar levels are important."

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse charts "Swooshing sound heard over right carotid artery." How should this documentation be corrected?

"Right carotid bruit auscultated"

aortic area

2nd right ICS close to the sternum

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?

3

A patient is able to activley move the right arm against gravity. How should the nurse document this finding?

3

tricuspid area

5th left ICS close to the sternum

A nurse is palpating a Caucasian client's chest as part of a routine assessment. Which of the following findings would the nurse expect in this client because of his race?

A larger thorax and greater lung capacity

The nurse suspects an abdominal aortic aneurysm when what is assessed?

Abdominal bruit

CN VI

Abducens nerve- lateral movement of eyeballs

What should the nurse assess to test the function of the occipital lobe?

Ability to read

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

While inspecting the labia minora, a nurse notices that they are asymmetric. Which of the following does this finding most likely point to?

Abscess

Francis is a middle-aged man who noted right sided lower abdominal pain after straining with yardwork. Which of the following findings would make a hernia a more likely diagnosis?

Absence of symmetry of the inguinal areas with straining

A female client presents to the clinic with chills and fever for 3 days. She also complains of sores in her genital region. The nurse should prepare to give which instructions to this client?

Abstinence should be practiced while sores are weeping.

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2?

Accentuated

A 26-year-old sports store manager comes to the clinic with severe right-sided abdominal pain for 12 hours. He began having a stomach ache yesterday with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 38.8° and his heart rate is 170. His bowel sounds are decreased, and he has rebound and involuntary guarding at one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain?

Acute appendicitis

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

Acute infection

A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?

Acute pain

The nurse is caring for a client exhibiting jugular vein distention and dyspnea. The nurse auscultates an new S3 heart sound. What is the nurse's best action?

Administer prescribed diuretic.

When a patient is obese or has a thick chest wall, what is difficult to palpate?

Apical impulse

Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely?

Appendicitis

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears

Ashen

The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should

Ask pt to empty his bladder

An older adult client states that she has to get up during the night to urinate. How would the nurse further assess this patient's nocturia?

Ask the client "Have you made any changes because of this?"

A mother of a small child calls the clinica and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action?

Ask the mother how long the tubes have been in place.

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?

Assess for hypothyroidism

When you enter the room of a hospitalized patient, the intravenous pump is alarming. The patient is restless, moaning, crying, and exhibiting guarding behavior. An uneaten meal is sitting on the over-bed table; several family members are arguing loudly. What would be your priority?

Assessing for pain

Phase I of nursing process

Assessment- Collecting subjective and objective data

To properly evaluate the jugular venous pressure in a client, the nurse should perform which intervention?

Assist client to supine position with head elevated

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

Assist the client to walk as soon and as often as possible.

A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client?

Asthma

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?

Asymmetrical shape

he nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage?

Asymmetrical smile. Facial asymmetry may indicate damage to facial nerve (cranial nerve [CN] VII) or a serious condition such as a stroke.

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

Atelectasis

As the nurse is auscultating a client's heart sounds, she hears the first heart sound, which indicates the beginning of systole. The nurse knows that which structure slightly delays the incoming electrical impulses from the atria before relaying the impulse on to the ventricles, causing them to contract during this phase?

Atrioventricular (AV) node

uring which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

Ausculation of a patient's heart murmur.

The nurse is preparing to examine a patient's posterior thorax. What will be included in this examination?

Auscultation of lung sounds

A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?

B12

A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?

Balance

When documenting findings...

Be concise, descriptive, document pertinent negatives and positive findings, avoid terms such as "good/fair/poor" and "normal"

The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment?

Begin above the right clavicle and percuss each section comparing the right chest with the left chest.

While performing an examination of the head and neck, a nurse notices left sided facial drooping. The nurse recognizes this as what condition?

Bell's palsy

While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The nurse recognizes this as what condition?

Bell's palsy

A 60-year-old coach comes to the clinic complaining of difficulty starting to urinate for the last several months. He believes the problem is steadily getting worse. When asked he says he has a very weak stream, and it feels like it takes 10 minutes to empty his bladder. He also has the urge to go to the bathroom more often than he used to. He denies any blood or sediment in his urine and any pain with urination. He has had no fever, weight gain, weight loss, or night sweats. His medical history includes type 2 diabetes and high blood pressure treated with medications. He does not smoke but drinks a six pack of beer weekly. He has been married for 35 years. His mother died of a myocardial infarction in her 70s, and the client's father is currently in his 80s with high blood pressure and arthritis. Examination reveals a mildly obese alert and cooperative man. His blood pressure is 130/70 with a heart rate of 80. He is afebrile, and his cardiac, lung, and abdominal examinations are normal. Visualization of the anus shows no inflammation, masses, or fissures. Digital rectal examination reveals a smooth, enlarged prostate. No discrete masses are felt. There is no blood on the glove. An analysis of the urine shows no red blood cells, white blood cells, or bacteria. What disorder of the anus, rectum, or prostate is most likely?

Benign prostatic hyperplasia (BPH)

The nurse is assessing the upper extremities of the client. What pulses should be assessed? Select all that apply.

Brachial and radial

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's

Brachial pulse

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden scale

A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse?

Bradycardia

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?

Bradypnea

Which of the following statements relating to assessment of the lungs and thorax is most accurate?

Bronchitis is characterized by excess mucus production and chronic cough.

How will the nurse, who is conducting the physical assessment, encourage the client to be honest and open in identifying the health problem?

By explaining that all information will be kept confidential.

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

C7

A nurse has just finished assessing a client's spine and neck muscles. How would the nurse document normal findings?

C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?

COPD

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?

Call for help and use the draw sheet to move the client.

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems?

Can be caused by an underlying systemic illness

The client is experiencing septic shock. What assessment finding would the nurse expect to find?

Capillary refill greater than 2 seconds

A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following?

Cardiac cycle

The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment?

Carotid artery

A client presents to the health care clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition?

Cervical strain

Testing CN V

Check for symmetry of jaw clenching and movement; touch pt's face with sharp and dull points in area of the 3 branches, assess for pain only where sharp point has touched;

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?

Check insertion site for redness

Health interview

Clarify questions, establish relationship, teach patient

A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding?

Client has an increased chest diameter

When assessing a client's strength, it is necessary to

Compare one side to the other

The nurse is to perform an assessment on a newly admitted client. Which assessment would be most appropriate?

Comprehensive. A comprehensive assessment of a newly admitted client. This assessment is more detailed and complete than shift and focused assessments, which evaluate progress toward a goal later in the stay

What type of assessment would a nurse perform on a patient being admitted to the hospital?

Comprehensive. The nurse in the hospital performs a comprehensive assessment of the client on admission. This assessment is more detailed and complete than screening and focused assessments that evaluate progress toward a goal later in the stay.

A college student presents to the health care clinic with reports no bowel movement for four (4) days, bloating, and generalized abdominal discomfort. She states she has not been eating and drinking correctly and is stressed because she has a final exam in two (2) days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants, tenderness in the left lower quadrant with a few small round, firm masses. Rovsing's sign and the Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client?

Constipation related to decrease in fluid intake

A 35-year-old client has a Pap test with a normal test result. The client has had two previous tests with normal results. Which information is correct for the nurse to tell this client with regard to future screening for cervical cancer?

Continue exams every 3 years

Which of the following assessment findings is most congruent with chronic arterial insufficiency?

Cool foot temperature and ulceration on the client's great toe

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?

Cool skin

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

Corrective lenses

The nurse assess for kidney tenderness at what location?

Costovertebral angle

A Nurse Practitioner is examining a patient who presented at the free clinic with vulvar pruritus. Which assessment factor would the practitioner look for that may indicate that the patient has an infection caused by Candida albicans?

Cottage cheese-like discharge

A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause?

Crohn's disease

A nurse examines the external genitalia of a client and observes that the scrotum is underdeveloped and the testis can not be palpated. How should the nurse document this condition?

Cryptorchidism

A nurse observes the presence of hirsuitism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?

Cushing's disease

A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client?

Cyanotic

The nurse should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client?

Decrease to 44 beats/minute. Acute and urgent situations such as the following warrant immediate attention and interventions: Acute change in heart rate to fewer than 50 or greater than 120 beats per minute.

During an interview with the nurse, a client complains of a fatigue that seems to get worse in the evening. Which of the following causes of fatigue would explain this pattern?

Decreased cardiac output

The nurse performing an admission assessment on an older adult. What would be an expected finding?

Decreased vision

The nurse is performing an assessment on a client that is on postop day 2. The abdominal wound has pulled apart and the contents are spilling out. The nurse recognizes this as a what?

Dehiscence

A nurse is working with a 13-year-old boy who complains that he has begun to sweat a lot more than he used to. He asks the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of skin?

Dermis

A patient recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. The nurse realizes that this patient's burn extended into which skin layer?

Dermis

The school nurse is presenting a class on female reproductive health. While discussing prevention the nurse teaches what about a Pap smear?

Detect cervical cancer

The nurse is caring for an older adult client with a nasogastric feeding tube ordered by the physician. The nurse notes that the client is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?

Deviated septum

Phase II of nursing process

Diagnosis- analyzing subjective and objective data to make a potential nursing judgment

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?

Distribution

A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?

Document the findings in the client's record as normal

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding

A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what?

Dorsiflexion and plantar flexion

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?

Dysphagia

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

Dyspnea

A nurse is evaluating a client's jugular venous pressure. Which of the following findings would tend to indicate obstructive pulmonary disease?

Elevated venous pressure only during expiration

The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action?

Ensure patient airway

The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?

Eustachian tube

The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?

Evaluate changes in respiratory pattern and rate.

A nurse is conducting the general survey at the beginning of the head-to-toe assessment. Which of the following does the nurse need to address as part of the general survey?

Evaluate personal hygiene

Phase V of nursing process

Evaluation- Assessing whether outcome criteria have been met and revising the plan as necessary

When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?

Exotropia

A nurse examines the anal area of a client and observes the presence of a varicose vein. How should the nurse document this finding?

External hemorrhoid

A new nurse is learning how to perform a head-to-toe assessment. Her preceptor correctly tells the new nurse that it's best to do the musculoskeletal examination with range of motion before assessing the cardiac and respiratory status

False

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of

Fissures

Which technique is appropriate for the nurse to use to palpate a client's breast?

Flat pads of three fingers

What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor?

Flexion

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash?

Fluid-filled lesions less than 1 cm in diameter

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the

Glossopharyngeal

What is the most common type of hyperthyroidism?

Grave's disease

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following?

Have the client stand and face the nurse with gown raised

A nurse assesses a 22-year-old client who has never had a Pap test. Which factor should the nurse explain to the client as being a risk for cervical cancer?

Having multiple sexual partners

A client presents to the health care clinic with reports of a 12-pound unintentional weight loss despite being hungry all the time, profuse sweating, and swelling around the anterior neck area. The client states she does not have insurance and cannot afford to see a regular health care provider. What nursing diagnosis can the nurse confirm from this data?

Health Seeking Behaviors

The finding of a fourth heart sound (S4) is considered benign under which of the following conditions?

Healthy older adulthood

During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following?

Heart attacks in his father and siblings

What documentation in a client's history should a nurse recognize as an indication that the client has a normal prostate?

Heart shaped, smooth with two distinct lobes

While interviewing a client, the nurse asks her what her typical daily diet consists of. Which of the following is associated with an increased risk for breast cancer?

High-fat diet

Which finding should a nurse recognize as normal when assessing the ears of an elderly client?

High-tone frequency loss

An adult client states she has been drinking a very large amount of water since she has begun walking everyday. She has been transported to the emergency room due to acute confusion. Which electrolyte imbalance is most likely the cause of this client's symptoms?

Hyponatremia

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?

Hypothyroidism

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past two months. The client denies the use of any new shampoos, or other hair care products; no new medications. The nurse should ask the client questions related to the onset of which disease process?

Hypothyroidism

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?

Hypovolemia

The nurse is planning care for a patient recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development?

Immobility

A client presents to the health care clinic with reports of pain in the hands and right wrist. Additional history reveals that the client is a factory worker who spends all day performing the same repetitive task. The nurse performs Phalen's test and Tinel's test with positive results. The hand grips are unequal, with the right weaker than the left. What nursing diagnosis can the nurse confirm from this data?

Impaired Physical Mobility

An older adult client is admitted to the hospital after a fall during which the client's head was injured. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The client reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this client?

Impaired comfort related to possible neck injury

A nurse caring for a client admitted 2 days ago following a cerebral vascular accident. The nurse notes that the client is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this client?

Impaired swallowing

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?

Impending stroke

What nursing diagnosis would be most appropriate for a client admitted with heart failure?

Ineffective tissue perfusion

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

Instruct the client to cough forcefully

When conducting a focused health assessment, the nurse asks questions specifically targeting what?

Issues and symptoms specific to the client

A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on gloves?

Just before the mouth and throat assessment

A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?

Kiesselbach's plexus

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?

Legs should be elevated for 15 seconds

A nurse has introduced herself to a new client and asked the client to accompany her to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's:

Level of consciousness. The client's response to the nurse's introduction and direction gives useful information about his or her level of consciousness.

During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do?

Look for a source such as infection in the area that it drains

A 43-year-old store clerk comes to the office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago); until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The client does not smoke, drink, or use illegal drugs. Her father is in good health. Examination shows a tense woman appearing her stated age. Visual inspection of her left axilla reveals a tense red area with no surrounding scarring. On palpation, the examiner feels a 2-cm tender movable lymph node underlying hot skin. Other shoddy nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examination of the left arm reveals a scabbed-over superficial laceration over her left hand. Upon questioning, the client remembers that she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms?

Lymphadenopathy of infectious origin

The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication?

Lymphedema

Your patient describes her stool as soft, light yellow to gray, mushy, greasy, foul-smelling, and usually floats in the toilet. What would you suspect is wrong with your patient?

Malabsorption syndrome

A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

Meningeal inflammation

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine headache

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

Migraine headache

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?

Modes of transportation are the leading cause

After examining a patient's nose and sinuses, the nurse should examine which structure?

Mouth and pharynx

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

Narrowing or partial obstruction of an airway passage

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?

Nasolabial folds

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter

The nurse aide reports to the nurse that an older adult client has abnormal vital signs. What is important to remember in this type of situation?

Normal readings vary according to age

The nurse is assessing a patient with Raynaud disease. When assessing the wrist pulses, what would the nurse expect to find?

Normal wrist pulses

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action?

Notify healthcare provider

A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?

Observe for a decrease in jugular venous pressure

CN I

Olfactory nerve- sense of smell

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

Open mouth

It is important to apprise the patient of what you are doing and what you find as it does what?

Opens up teaching/learning moments

A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?

Opiates, which may cause hypoventilation

CN II

Optic nerve- vision

What is the common channel for the respiratory and digestive systems?

Oropharynx

A nurse has been ordered to include an ear assessment as part of a head-to-toe examination of a client. Which of the following pieces of equipment will the nurse need for this assessment?

Otoscope

During palpation of the male genitalia, which of the following is an expected finding?

Palpable spermatic cord

The nurse manager on a cardiac unit should immediately intervenen when observing which staff nurse's assessment technique?

Palpating carotid pulses simultaneously.

Assessment of the pulse amplitude is accomplished by which of the following?

Palpating the flow of blood through an artery

When assessing the abdomen, which assessment technique is used last?

Palpation

A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority?

Patient C

Which statement reflects accurate documentation by the nurse of a normal, left tympanic membrane?

Pearly gray, translucent, with cone of light at 7 o'clock position

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?

Perform a focused assessment

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for?

Peripheral vascular problems

An uncircumcised, 78 year-old male has presented at the clinic complaining that he cannot retract his foreskin over his glans. On examination it is noted that the foreskin is very constricted. What is this condition called?

Phimosis

When performing the physical assessment of a client, the nurse notes the presence of a small cyst that contains hair, which is located midline in the sacrococcygeal area and has a palpable sinus tract. How should the nurse document this finding?

Pilonidal cyst

Phase III of nursing process

Planning- Determining outcome criteria and developing a plan

A nurse asks a supine client to raise his knee partially. The nurse then places the thumbs on the knee while positioning the fingers deep in the bend of the knee. The nurse is palpating the pulse of which artery?

Popliteal

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

Posterior tibial

Lymph nodes

Preauricilar, Postauricular, Occipital, Tonsillar, Submandibular, Submental, Supraclavicular, Intraclavicular, Lateral (Brachial), Central (Midaxillary) Posterior (Subscapular), Anterior (Pectoral)

Which terms refers to the progressive hearing loss associated with aging?

Presbycusis

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?

Presbyopia

When assessing a client's respirations, what is most important to include in the documentation?

Presence of dsypnea

Testing CN I

Present odors, test nostrils seperately

The nurse is documenting current health concerns during the health history of an older adult male client. Identification of what may help most at this time?

Previous problems

Focused health history

Problem oriented; focus on specific problem

Some clients with acoustic neuromas have vertigo. What is a priority nursing action with clients with vertigo?

Protect the client from injury

During the abdominal examination, a nurse hyperextends a client's right leg. At this point, the client reports pain in the right lower quadrant. This test is positive for which sign?

Psoas

The nurse is admitting a 79-year-old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

Pt may have been abused

What action should the nurse implement when assessing the ear of an adult client using an otoscope?

Pull the auricle out, up, and back.

Testing CN III, IV, VI

Pupillary reaction, extraocular movements

The nurse has reviewed the previous physical assessment notes on a client and sees the following documentation: PERRLA, L 6-4, R 6-4. What is the nurse's best action for follow-up care on this client?

Re-assess as needed. PERRLA stands for pupils equal, round, reactive to light, and accomodate. L 6-4, R 6-4 indicates the pupil sizes of both eyes changed from 6 mm to 4 mm when testing pupil reaction. These results are normal for an adult. There is no indication or need for an opthamologist consult, Weber test (hearing), or Romberg test (balance) based on these results

A nurse prepares a male client for a physical assessment of the external genitalia. Which instruction is appropriate for the nurse to give the client before the examination?

Reassure him that it is not unusual to have an erection during the examination

What is important to tell the male patient before beginning examination of genitalia?

Reassure him that it is not unusual to have an erection during the examination

A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this occurs at the child's hands and feet. She does not remember the child's lips turning blue. The mother says that the child is eating and growing well. What should the nurse do?

Reassure the mother that this is normal.

Which nursing diagnosis is most appropriate for an elderly client with poor dentition?

Risk for Imbalanced Nutrition: Less Than Body Requirements

At the beginning of the exam you would perform a general survey. What would you assess at this time?

Safety

The nurse is documenting the description and amount of wound drainage present in a Stage III pressure ulcer. Which term should the nurse use to describe bloody drainage observed when the dressing was removed?

Sanguineous

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

She can see at 20 feet what a normal person could see at 100 feet.

While completing the cardiovascular system health history, a patient tells the nurse about using four pillows at night to sleep. The nurse will use this information to further assess which area?

Shortness of breath

When palpating the female breast for masses, the nurse distinguishes which of the following characteristics as a potentially cancerous mass?

Single, firm, fixed nodule

A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses?

Sitting with the head erect and at the eye level of the nurse

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess?

Skin. Sequential compression devices are placed on extremities. It is important that skin under these devices be at least every shift

A nurse should perform an ongoing assessment of which system throughout the entire examination?

Skin. The nurse should assess the skin with each part of the head-to-toe assessment looking for color changes or any suspicious lesion

The nurse is reviewing the functions of the ovaries, uterus, clitoris and vagina with a group of high school students. Based on this information, what would be the best response by the high school student about the function of the clitoris?

Small erectile structure that responds to sexual stimulation.

A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client?

Smoking increases the heart's workload and contributes to atherosclerosis.

The nurse is providing teaching about cardiovascular disease in a community setting. What risk factors would the nurse identify to the group as those they can modify through lifestyle choices? Select all that apply.

Smoking, Blood Pressure, Cholesterol

Which equipment will the nurse gather to conduct a physical examination of a patient's eyes? (Select all that apply.)

Snellen chart, Rosenbaum card, Ophthalmoscope

Which of the following is a symptom related to vertigo?

Spinning sensation

A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ?

Spleen

Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes?

Spleen

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement according to the JNC VII guidelines?

Stage 2 Hypertension

During the admission assessment of a new patient, the nurse is now preparing to assess the patient's thyroid gland. How should the nurse perform this assessment?

Stand behind the patient and palpate the sides of the trachea

When assessing for an inguinal hernia, the nurse asks the client to assume what position?

Standing facing the examiner

A nurse is preparing to perform the nurse's first complete assessment of a client at a hospital. Which of the following should the nurse consult to find out what can legally be assessed and diagnosed?

State's nurse practice act

A client reports the new onset of mucus in the stool. How should the nurse document this in the client's history?

Steatorrhea

A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a heavier-than-usual set of boxes. He also states that he has numbness and tingling in the left leg. What test should the nurse perform to assess for a herniated disc?

Straight leg raise test

During the health history of the urinary system, a patient tells the nurse about "leaking" urine when coughing or laughing. The nurse should focus additional questions to address which health problem?

Stress incontinence

Weber test

Strike tuning fork, place tuning fork in the midline on the crown or forehead, have pt indicate when the sound is no longer heard;

Which of the following is an important function of the skin?

Synthesis of vitamin D

During the integument health history, the nurse asks the patient about prescription medications, immunizations, and diagnosed illnesses. What will this information provide to the nurse?

Systemic diseases that have skin manifestations

A nurse is performing a general survey of a patient admitted to the hospital. Which of the following actions is an element of this procedure?

Taking vital signs

When collecting subjective data, the nurse gives the client time and encouragement to do what?

Tell about the client's concerns

Impaired Physical Mobility

Tendons

A patient presents at the clinic with severe scrotal pain. What is the presumptive diagnosis?

Testicular torsion

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

The client has chronic hypoxia

The nurse is providing a sex education informational session for a group of male clients. Which information should the nurse include?

The hepatitis A vaccine is recommended for men who have sex with men.

The nurse is caring for a patient who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?

The node is fixed and rubbery.

A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork?

The nurse should place the stem of the vibrating tuning fork on the mastoid area behind the ear to test for bone conduction of sound waves in the tested ear.

A client comes to the cardiovascular intensive care unit (CVICU) directly after a three-vessel coronary artery bypass graft (CABG). The client's orders state "maintain systolic blood pressure >90 but <120." How does this order affect the monitoring of the client's blood pressure?

The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

There is an infection in the area that these nodes drain.

A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort?

There is loss of involuntary respiratory control

Which is true of women who have had a unilateral mastectomy?

They should be examined carefully along the surgical scar for masses.

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation?

This could be a sign of cancer

During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensorineural hearing loss

A nurse is performing a part of a physical assessment for a client using palpation. What is the purpose of using this technique?

To check the skin temperature and moisture.

The nurse is assessing the head and neck areas of an adult client and discovers several abnormal findings. Which assessment finding requires priority nursing care?

Tracheal deviation

CN V

Trigeminal nerve- innervates at the temporal and masseter muscles

CN IV

Trochlear nerve- downward/inward movement of eyeballs

A nurse is testing the range of motion of a client's wrist for supination. Which movement will this involve?

Turning the palm of the hand upward

What is the most important focus area for the integumentary system?

UV radiation exposure

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

Use of safety equipment

What pattern of palpation is currently the best validated technique for detecting breast masses?

Vertical strip pattern

A client complains, "I feel like the whole room is spinning around me, and it makes me nauseous sometimes." What term should the nurse use to document the client's symptom?

Vertigo

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the patient's lungs?

Vesicular

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:

Vestibule, nasal passages, and nasopharynx

Testing CN II

Visual activity, Snellen chart, determine visual fields

How should a nurse assess graphesthesia as a part of the physical assessment of arms, hands, and fingers?

Write a number in the palm of the client's hand

The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs?

a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter > 6 mm; e = evolution

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is

a foreign body obstruction

The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of

a great degree of cyanosis.

Before beginning a physical assessment it is important for the nurse to

acquire your client's verbal permission to perform the physical examination

An adult client visits the clinic complaining of recurrent ulcers in the mouth. The nurse assesses the client's mouth and observes a painful ulcer. The nurse should document the presence of

aphthous stomatitis

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breasts

While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for

arthritis

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should

ask the client to breathe deeply through her mouth.

When integrating the total physical examination the nurse should

assess peripheral vascular status when examining the lower extremities. When you assess the legs you will be assessing the parts of the skin (color and condition of skin on legs), peripheral vascular system (pulses, color, edema, lesions of legs), musculoskeletal system (movement, strength, and tone of legs), and neurologic system (ankle and patellar reflexes, clonus)

While assessing an older adult client, the nurse detects a bruit over the carotid artery. The nurse should explain to the client that a bruit is

associated with occlusive arterial disease.

The semilunar valves are located

at the exit of each ventricle at the beginning of the great vessels.

Flexion

bending at the joint

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

blue

apical impulse (PMI-Point of Maximal Impulse)

brief systolic beat usually found in the 5th left ICS, 7-9 cm from the midsternal line

The nurse documents a 2+ radial pulse. What assessment data indicated this result?

brisk, expected (normal) pulse

A client is admitted to the health care facility for the onset of a stroke. To test the function of cranial nerve I, the nurse should ask the client to:

close eyes and assess for smell.

lub

closing of mitral and tricuspid valve

The nurse has assessed a male client and determines that one of the testes is absent. The nurse should explain to the client that this condition is termed

cryptorchidism

During examination of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?

either side of the frenulum on the floor of the mouth

The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents

entropion

Two body systems that may be logically integrated and assessed at the same time are the

eye exam and cranial nerves II, III, IV, and VI.

Walking contracts the calf muscles and forces blood away from the heart.

false

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate

fluid intake

What would the nurse expect to hear when auscultating the lungs of a client with pleuritis?

friction rub

Complete health history

full history; comprehensive

Whisper test

have pt occlude one ear, whisper 1-2 feet away, have pt repeat what was said

The nurse has discussed the risks for breast cancer with a group of high school seniors. The nurse determines that one of the students needs further instructions when the student says that one risk factor is

having a baby before the age of 20 years.

The nurse is preparing to conduct a physical examination of an adolescent patient for a school physical. Which examination approach would be the most appropriate for this patient?

head-to-toe assessment

When listening to heart sounds, the nurse notes a swishing sound. The nurse recognizes that this as what?

heart murmur

An older adult client visits the clinic and tells the nurse that she has had shooting pain in both of her legs. The nurse should assess the client for signs and symptoms of

herniated intervertebral disc.

While assessing an adult male client, the nurse detects pimple-like lesions on the client's glans. The nurse explains the need for a referral to the client. The nurse determines that the client has understood the instructions when the client says he may have

herpes infection.

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the patient's lips and surrounding skin. The nurse would document this finding as being:

herpes simplex

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of

hypothyroidism

A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data?

impaired skin intergrity

hypertrophy

increase in muscle size

The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are .

increased central venous pressure.

During assessment of the vaginal area of an adult client, the client tells the nurse that she has had pain in her vaginal area. The nurse should further assess the client for

infection

The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible

internal bleeding

A 21-year-old receptionist comes to the clinic reporting frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a university student majoring in accounting. She smokes when she drinks alcohol but denies any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What cause of diarrhea is the most likely etiology?

irritable bowel syndrome

Across the lifespan, a nurse knows that the female heart

is smaller than the male heart

An African American female client visits the clinic. She tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear lobe. The nurse should document a

keloid

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?

left midclavicular line at the fifth intercostal space

When examining a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to:

look up

While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with

malignancy

A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

migraine

Abduction

moving away from midline

Adduction

moving toward midline

sinoatrial node (SA)

pacemaker of the heart; electrical impulses are generated here

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

position the client 609.6 cm (20 ft) away from the chart.

The anterior chest area that overlies the heart and great vessels is called the

precordium

A client comes to the Emergency Department complaining of sudden sharp testicular pain. Further examination reveals torsion of the spermatic cord. Which of the following would the nurse expect to do next?

prepare client for surgery

A male client tells the nurse that he has received a diagnosis of hernia. He visits the clinic because he is nauseated and has extreme tenderness on the left side. The nurse should

refer client to ER

A client complains of a sudden onset of pain in the back. On questioning the client further, the nurse learns that the cause of the pain is acute pancreatitis. The nurse recognizes that this type of pain is which of the following?

referred pain

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?

resonance

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located?

right upper quadrant

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is

risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect?

severe brain damage

The subacromial bursae are contained in the

shoulder joint

pitting edema

sign of fluid retention; Press the edematous area with the tips of your fingers, hold for a few seconds, then release. If the depression does not rapidly refill and the skin remains indented on release, pitting edema is present.

The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates

some impairment

Conductive hearing

sound waves from the external ear and middle ear

Sensorineural hearing

sound waves from the inner ear

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

stage II

A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of

stomach ulcers.

Extension

straightening at the joint

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to

strike a tuning fork and place it on the center of the client's head or forehead.

Rinne test

strike tuning fork and place it on the mastoid process, have pt indicate when the sound is no longer heard, then move the tuning fork in front of the ear w/ the "u" facing forward, have pt indicate when sound is no longer heard; AC should be twice as long as BC

Connecting the skin to underlying structures is/are the

subcutaneous tissue.

Romberg test

test for equilibrium; pt stands w/ feet together, arms at side, eyes open then closed; note for swaying

The diencephalon of the brain consists of the

thalamus and hypothalamus.

The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the

third to fifth intercostal space at the left sternal border.

A 23 year old male comes to the clinic complaining of sudden and severe pain in his scrotum. The nurse would suspect what?

torsion of spermatic cord

external rotation

turning away from center

internal rotation

turning toward the center

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is

ultraviolet light exposure.

Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?

under breast

The nurse has assessed the nose of an adult client and has explained to the client about her thick yellowish nasal discharge. The nurse determines that the client understands the instructions when the client says that the yellowish discharge is most likely due to

upper respiratory infection

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should

use the diaphragm stethoscope

McMurray's test

used to evaluate for tears in the meniscus of the knee

Short, pale, and fine hair that is present over much of the body is termed

vellus

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

vesicles

When collecting a client's medical history, the nurse should ask if the client is taking which medications that most likely contribute to complaints of recurrent epistaxis? (Select all that apply.)

• Anticoagulants • Herbal supplements • Antihistamines

Which factors should the nurse include in a discussion with a young female to assist the client to reduce her risk for breast cancer? Select all that apply.

• Breast-feed if possible • Engage in regular, strenuous physical activity • Pregnancy is beneficial before 30 years of age

The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.)

• Call bell within reach • Wearing client identification bracelet • Correct intravenous lines and fluids • Correct tubes and drains intact

You are taking a sexual history on a new patient. What action is considered appropriate at this time? (Mark all that apply.)

• Explain why you are taking the sexual history • Affirm that your conversation is confidential • Note that you realize this information is highly personal

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention?

• Helps make vitamin D in the body • Largest organ of the body • Protects against damage to the body from sunlight • Aids in maintaining body temperature

A patient has sustained burns over 50% of the body. When planning care for this patient, the nurse will include interventions to address an alteration in the skin's barrier function, specifically: (Select all that apply.)

• Injury caused by mechanical or chemical sources • Penetration by microorganisms • Loss of water and electrolytes

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply.

• Lack of exercise • Smoking • Overweight

The nurse is conducting a head-to-toe assessment on a client. The nurse would be concerned if the following characteristics were noted? (Select all that apply.)

• Lesions • Rashes • pressure ulcers

At the completion of a reproductive health history, a female patient tells the nurse about having pain with penetration during intercourse. What should the nurse assess at this time? (Select all that apply.)

• Onset of the problem • Severity of the problem • What makes it better or worse

When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply.

• Quit or do not start smoking • Exercise regularly • Undergo regular cholesterol screening • Undergo regular screening for diabetes

A nurse is instructing a client on how to perform testicular self-examination (TSE). Which of the following should the nurse mention? Select all that apply.

• Roll the testis gently in a horizontal plane between thumb and fingers • Perform the TSE once a month • Stand in front of a mirror and check for scrotal swelling

What symptom found during assessment would cause the nurse to suspect the client may be experiencing sepsis?

• Temperature greater than 102 F (38.9 C) • Respiratory rate 36