health assessment midterm

During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches? A) Pain radiating from eye to temporal region B) Throbbing and severe pain C) Report of ringing in the ears prior to headache D) Complaint of sensitivity to light

A) Pain radiating from eye to temporal region

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated? A) Asking the client to flex his or her neck B) Compressing the arteries bilaterally C) Performing the examination while the client is seated D) Asking the client to swallow water

B) Compressing the arteries bilaterally

A client's electronic health record reveals that he had surgery as an infant to correct the fact that his urethra was located on the ventral side of his penis. The nurse should recognize that this client had which of the following? A) Epispadias B) Hypospadias C) Paraphimosis D) Phimosis

B) Hypospadias

A nurse is assessing a client who is exhibiting decorticate posturing. Which of the following would the nurse observe? A) Extended upper extremities B) Internally rotated lower extremities C) Pronated forearms D) Flexed hands at the side of the body

B) Internally rotated lower extremities

6. During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition? A) Diabetes mellitus B) Iron deficiency anemia C) Vitamin A deficiency D) Peripheral vascular disease

B) Iron deficiency anemia

. A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following should the nurse do next? A) Document the benign findings. B) Perform a random blood sugar test. C) Ask the client about a family history of cancer. D) Refer the client for medical follow-up.

B) Perform a random blood sugar test.

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? A) Purpura B) Petechiae C) Ecchymosis D) Cherry angioma

B) Petechiae

The nurse is inspecting the cervix of a client who has two children. The nurse would expect the cervical os to appear as which of the following? A) Round B) Slit-like C) Transverse D) Stellate

B) Slit-like

A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation? A) Sternocleidomastoid muscle B) Sternal notch C) Submental space D) Supraclavicular space

B) Sternal notch

The nurse is preparing to assess the remote memory of a client who has a diagnosis of early stage Alzheimer's disease. Which question would be most appropriate for the nurse to use? A) Can you tell me what you have eaten in the last 24 hours? B) When did you get your first job? C) What did you do last evening? D) How are an apple and orange the same?

B) When did you get your first job?

The nurse is preparing to perform a rectovaginal examination on a client. Which statement by the nurse would be most appropriate? A) I have to do this exam to make sure everything is okay, so just bear with me. B) You might feel uncomfortable, almost like you have to move your bowels. C) Just relax, it will only take a minute and then I'll be all finished .D) I want you to hold your breath as I insert my fingers into the openings.

B) You might feel uncomfortable, almost like you have to move your bowels.

When assessing your patient's head and neck, what would you assess the face for? (Select all that apply) A - Hair color B - Asymmetry C - AffectD - Edema/swelling E - Involuntary movements

B, D, E

A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment? A. Comprehensive B. Body systems C. Functional D. Head to toe

B. Body systems

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's A. Lungs. B. Bone. C. Abdomen .D. Liver.

B. Bone.

You are assessing the lymph nodes of the head and neck. Where are the posterior cervical nodes located? A - On the sternomastoid muscle B - In the anterior angle C - In the posterior triangle D - Above the clavicle

C - In the posterior triangle

To facilitate palpation of the thyroid gland, you instruct your patient to: A - Rotate the neck B - Hyperextend the neck C - Swallow D - Hold breath

C - Swallow

The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform? A) Obtain a full set of vital signs. B) Percuss the client's thyroid. C) Auscultate the client's thyroid. D) Perform a swallowing assessment

C) Auscultate the client's thyroid.

To examine the Bartholin's glands of a female client, the nurse would palpate at which anatomic location? A) On both sides of the clitoris B) Just inside the urethral orifice C) Between the vaginal opening and labia minora D) Inside the vaginal orifice

C) Between the vaginal opening and labia minora

The nurse is preparing to perform a nutritional assessment of a newly admitted client. Which of the following questions would be most appropriate to use when initiating the assessment? A) Did you eat breakfast today? B) How many meals do you eat each day? C) Can you tell me what you've eaten in the last 24 hours? D) How often do you eat out?

C) Can you tell me what you've eaten in the last 24 hours?

While inspecting the penis of a client, the nurse suspects herpes progenitalis based on which assessment finding? A) Red, oval ulcerations B) Hardened nodules on the glans C) Clear vesicles that erupt D) Painless, fleshy papules

C) Clear vesicles that erupt

The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following? A) Deep coma B) Coma C) Obtunded D) Alert and oriented

D) Alert and oriented

An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize? A) Do you use any over-the-counter dietary supplements? B) Are you familiar with the USDA's MyPlate recommendations? C) Have you ever been diagnosed with heart disease? D) Are you currently taking any diuretic medications?

D) Are you currently taking any diuretic medications?

The emergency department (ED) nurse is assessing for kidney tenderness in a client who has presented with complaints of dysuria and back pain. What assessment technique should the nurse utilize? A) Deep palpation B) Indirect percussion C) Moderate palpation D) Blunt percussion

D) Blunt percussion

A client describes her frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines? A) Do they occur after you have been tense or anxious? B) When you consume alcohol, do you get a headache? C) Do you have any eye symptoms, such as tearing? D) Do you have any visual changes before the headache?

D) Do you have any visual changes before the headache?

The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. During health promotion, the nurse should focus education on which of the following topics? A) Management of dry skin B) Susceptibility to bruising C) Risks of fungal infections D) Risks of sun exposure

D) Risks of sun exposure

The nurse is collecting data from a client about his nutrition. Which of the following would the nurse document as objective data? A) Client states he is not eating well. B) Client complains of nausea and vomiting. C) Clients experiences urinary frequency. D) Tenting of client's skin observed upon skin pinch.

D) Tenting of client's skin observed upon skin pinch.

Skin inspection and palpation includes assessment for: A. Color, uniformity, and symmetry B. Skin lesions C. Skin temperature D. All of the above

D. All of the above

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about? A. Body system B. Functional C. Focused D. Head-to-toe

D. Head-to-toe

A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data? A. Subjective B. Realistic C. Concrete D. Objective

D. Objective

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area? a) Broken with the presence of a blister b) Exposure of subcutaneous tissue and muscle c) Ulceration resembling a crater d) Unbroken but red in color

a) Broken with the presence of a blister

A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal? A) Acromegaly B) Brain tumor C) Paget disease D) Parkinson disease

A) Acromegaly

A female client has presented for a Pap smear test, and the nurse is discussing risk factors for cervical cancer. What risk factor should the nurse describe? A) Having multiple sexual partners B) Previous treatment for chlamydial infection C) Pregnancy before age 21 D) African-American ethnicity

A) Having multiple sexual partners

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a a. ongoing or partial assessment b. focused or problem-oriented assessment c. emergency assessment d. initial comprehensive assessment

b. focused or problem-oriented assessment

The nurse should use which assessment tool to assess the client's risk for skin breakdown? a) Hendrich II b) VTE prophylaxis algorithm c) Braden Scale d) Morse Scale

c) Braden Scale

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse? a) Vesicle b) Papule c) Nodule d) Macule

d) Macule

The nurse documents which information in the patient's history? a. The patient's skin feels warm to the touch. b. The patient is scratching his arm. c. The patient's temperature is 100° F. d. The patient complains of itching.

d. The patient complains of itching.

A patient admitted with dehydration would typically have a decrease in skin turgor. a) False b) True

false

While interviewing a teen, he asks, "What does the epididymis do?" What would the nurse say "it allows sperm to mature "it produces sperm and male sex hormones "it transports sperm away from testes "it separates the testes from the scrotal wall"

"it allows sperm to mature

A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction? A) I'm going to press on several different places below and in front of your ear .B) I'm going to put my fingers in front of your ears and ask you to open your mouth wide. C) Turn so I can see the side of your face and then open your mouth wide like you're yawning. D) When I place my hands on your cheeks, clench your teeth and then relax them.

.B) I'm going to put my fingers in front of your ears and ask you to open your mouth wide.

Which findings alert the nurse to possible abuse in a patient? Select all that apply. 1Explanations that don't match the injury 2Inability to keep the story straight 3Frequently seeking care for suspicious injuries 4One bruise on the lower leg 5A hip fracture from a fall

1Explanations that don't match the injury 2Inability to keep the story straight 3Frequently seeking care for suspicious injuries

An emergency department nurse has utilized the Confusion Assessment Method (CAM) in the assessment of a 79-year-old client with a new onset of urinary incontinence. This assessment tool will allow the nurse to confirm the presence of what health problem? A) Delirium B) Vascular dementia C) Schizophrenia D) Psychosis

A) Delirium

The nurse should prioritize assessments related to overhydration for a client experiencing which of the following health problems? A) Early congestive heart failure B) Chronic emphysema C) Newly diagnosed hepatitis C virus infection D) Adult respiratory distress syndrome

A) Early congestive heart failure

A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted client, the nurse should recognize the possibility of which of the following? A) Hazardous and harmful alcohol use B) Imminent liver disease C) Acute pancreatitis D) Alcoholism

A) Hazardous and harmful alcohol use

A woman brings her 69-year-old husband to the clinic for an evaluation because he has become increasingly forgetful. Which of the following would lead the nurse to suspect that the client has Alzheimer's disease? Select all that apply. A) He repeats the same story, word for word, over and over again. B) He took a fall when he was replacing a light bulb last month C) I have to balance the checkbook now because he just won't do it. D) If I don't tell him when to shower, he won't and will fight me on it. E) He got lost walking to the pharmacy around the corner the other day.

A) He repeats the same story, word for word, over and over again. C) I have to balance the checkbook now because he just won't do it. D) If I don't tell him when to shower, he won't and will fight me on it. E) He got lost walking to the pharmacy around the corner the other day.

A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first? A) Inspection B) Palpation C) Percussion D) Auscultation

A) Inspection

While interviewing a teenage male client, the nurse reviews the various structures of the male genitalia. The client asks, So what does this epididymis do? Which of the following would the nurse include in the response? A) It allows sperm to mature. B) It transports sperm away from the testes. C) It separates the testes from the scrotal wall. D) It produces sperm and male sex hormones.

A) It allows sperm to mature.

A teenage boy has been diagnosed with orchitis. When reviewing the child's health history, the nurse should expect that the client may have recently been treated for what health problem? A) Measles B) Varicella C) Phimosis D) Influenza A

A) Measles

The nurse is assessing a client who has been admitted with signs and symptoms that are consistent with malnutrition. Which of the following physiological phenomena would the nurse recognize as an early indicator of malnutrition? A) Protein stores are lower than normal B) Bone is metabolized to compensate for missing nutrients C) Calcium levels decrease D) Hemoglobin levels decrease

A) Protein stores are lower than normal

The nurse utilizes the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. Which of the following would be most appropriate for the nurse to do next? A) Refer for further evaluation .B) Evaluate benefits versus risks of a mental health label. C) Assess further for dementia .D) Document this as a normal score.

A) Refer for further evaluation

A nurse in the emergency department is utilizing the SAD PERSONAS assessment guide during the mental status assessment of a client. What is the most likely rationale for the nurse's choice of this assessment tool? A) The client may have a high risk for suicide. B) The client may have major depression. C) The client may have schizophrenia or psychosis. D) The client may be using alcohol excessively.

A) The client may have a high risk for suicide.

The nurse is assessing a client who is suspected of having an incarcerated scrotal hernia. Which finding would help confirm this suspicion? A) The mass cannot be pushed up into the abdomen .B) The area around the hernia is ecchymotic. C) The client complains of tenderness and nausea. D) A scrotal bulge disappears when the client lies down.

A) The mass cannot be pushed up into the abdomen

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which of the following assessment findings would be indicative of a stage I pressure ulcer? A) There is a nonblanching reddened area on the client's coccyx region B) There is scant, frank blood present on the skin surfaces surrounding the client's coccyx. C) There is noticeable bruising on and around the client's coccyx region. D) There is a generalized rash on the client's lower back and buttocks.

A) There is a nonblanching reddened area on the client's coccyx region

An adult client has sought care at the clinic, stating that she believes she has a raging yeast infection. The nurse would expect to assess what type of vaginal discharge? A) Thick, white vaginal discharge B) Copious clear, foul-smelling discharge C) Yellowish discharge with a metallic odor D) Blood-tinged vaginal discharge

A) Thick, white vaginal discharge

You are assessing the lymph nodes of the head and neck. Where are the tonsillar lymph nodes located? A - Under the jaw B - At the angle of the jaw C - Under the chin D - In front of the ears

B

An 18-year-old college student presents to the clinic with complaints that her heart is "racing". A diagnosis of Hyperthyroidism is made. On physical examination of her eyes, what would you expect to find? A - Recession B - Protrusion C - Clouding of the cornea D - Ciliary injection

B - Protrusion

Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies? A) Fungal infection B) Bacterial infection C) Yeast infection D) Circulatory disorder

B) Bacterial infection

A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status? A) Flat, firm abdomen B) Brittle hair C) Pink mucous membranes D) Elastic skin

B) Brittle hair

A client's recent episode of becoming lost near his home has prompted the nurse to use the Saint Louis University Mental Status (SLUMS) Assessment Tool. The nurse should begin this assessment by asking what question? A) How would you respond if someone said that you might have dementia? B) Can I ask you some questions about your memory? C) Do you generally consider yourself to be an intelligent person? D) I want to ask you some questions to see if you have Alzheimer's.

B) Can I ask you some questions about your memory?

A nurse is assessing a client for possible fluid overload. Which of the following assessment findings is most consistent with this diagnosis? A) Venous filling of 3 seconds B) Distended neck veins with head elevated at 45 degrees C) Moist, plump tongue D) Boggy eyeball

B) Distended neck veins with head elevated at 45 degrees

A nurse is planning to assess a male client for urethral discharge. Which technique would be best for the nurse to use? A) Have the client hold the penis while the examiner looks for discharge. B) Gently squeeze the glans between the thumb and index finger. C) Inspect the scrotal skin while holding the penis aside. D) Observe the glans of the penis for signs of abnormal discharge.

B) Gently squeeze the glans between the thumb and index finger.

While assessing the scrotum of an adult client, the nurse notes thin and rugated scrotal skin with little hair dispersion. The nurse interprets this finding as which of the following? A) Reiter's syndrome B) Normal findings C) Effects of chemotherapy D) Gonorrhea

B) Normal findings

15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the presence of which of the following? A) Macule B) Papule C) Nodule D) Pustule

B) Papule

The nurse is percussing the area over the client's lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following? A) Flatness B) Resonance C) Tympany D) Dullness

B) Resonance

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer? A) Stage I B) Stage II C) Stage III D) Stage IV

B) Stage II

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? A) The client has a full-time caregiver. B) The client is consistently incontinent of urine. C) The client has a surgical diagnosis. D) The client adheres to a vegetarian diet.

B) The client is consistently incontinent of urine.

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? A) The client's current medication regimen B) The client's ability to change position C) The pigmentation of the client's skin D) The client's history of integumentary disorders

B) The client's ability to change position

The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment? A) The client will be less anxious early, providing the nurse with more accurate and reliable data. B) The exam can provide clues about the validity of the client's responses now and throughout. C) The exam provides data about mental health problems that the client may be afraid to report. D) The client's fears about having a serious illness may be alleviated by the results of the exam.

B) The exam can provide clues about the validity of the client's responses now and throughout.

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis? A) Audible referred breath sounds at the site of the thyroid B) An audible S3 sound at the site of the thyroid C) A sound of turbulent blood flow in the thyroid D) Irregular S1 and S2 rhythms in the thyroid

C) A sound of turbulent blood flow in the thyroid

While inspecting the vagina, the nurse observes a thin, grayish-white vaginal discharge with a fishy odor. Which of the following would the nurse suspect? A) Moniliasis B) Trichomoniasis C) Bacterial vaginosis D) Atrophic vaginitis

C) Bacterial vaginosis

When examining a newborn male infant, the nurse notes that neither testicle is descended. The nurse documents this finding as which of the following? A) Epididymitis B) Orchitis C) Cryptorchidism D) Varicocele

C) Cryptorchidism

A young man has presented to the clinic with a 2-week history of head congestion, fever, and malaise. What assessment technique should the nurse utilize to assess for sinus tenderness? A) Light palpation B) Deep palpation C) Direct percussion D) Blunt percussion

C) Direct percussion

An older adult client has a body mass index of 15.5 and is consequently considered to be underweight. The client lives alone and states that she has never been a heavy eater. How can the nurse most accurately assess the client's nutritional habits? A) Assess the client's waist circumference and waist-to-hip ratio. B) Measure the client's mid-arm circumference. C) Elicit the client's 24-hour food recall. D) Have the client describe an ideal meal.

C) Elicit the client's 24-hour food recall.

A client complains of scrotal pain, and the nurse elicits a positive Prehn sign, in which passive elevation of the testes relieves the scrotal pain. The nurse should refer the client for treatment of which of the following? A) Strangulated hernia B) Tortuous varicocele C) Epididymitis D) Scrotal mass

C) Epididymitis

The nurse is preparing to examine a client's skin. Which of the following actions would be most important for the nurse to do? A) Ensure that the room is hot to prevent chilling. B) Wear gloves when preparing to inspect the skin and nails. C) Expose only the body part that is being examined. D) Have the client remove clothing from the upper body.

C) Expose only the body part that is being examined.

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause? A) Safe use of firearms B) Safe use of machinery C) Falls prevention D) Domestic violence prevention

C) Falls prevention

A nurse is reviewing a depression questionnaire completed by a client. Which of the following would the nurse interpret as being suggestive of depression? A) Occasionally I feel like my attention wanders. B) I haven't noticed any change in my appetite. C) It usually takes me over an hour to fall asleep. D) I might wake up once during the night but not often.

C) It usually takes me over an hour to fall asleep.

When palpating the Bartholin's glands, the nurse expresses a purulent discharge. Which of the following would be most appropriate for the nurse to do next? A) Recommend sitz baths. B) Palpate the uterus. C) Obtain a culture. D) Perform a rectal exam.

C) Obtain a culture.

When assessing the cervix of an older postmenopausal woman, which of the following would the nurse document as a normal finding? A) Bluish color B) Bright red C) Pale pink D) White patches

C) Pale pink

An adult male client reports hesitancy when urinating. The nurse would further assess this client for which of the following? A) Scrotal hernia B) Sexually transmitted infection C) Prostate enlargement D) Testicular tumor

C) Prostate enlargement

Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data? A) RC: Thyroid crisis B) RC: Cerebrovascular accident C) RC: Cushing's syndrome D) RC: Acromegaly

C) RC: Cushing's syndrome

Assessment findings reveal that a client has herpes progenitalis. Which of the following would be most important to include in the teaching related to after the initial lesions disappear? A) The disease will spontaneously regress. B) The client is at increased risk for cancer of the glans. C) Recurrence can happen with varying frequency. D) The next outbreak will include moist, fleshy papules.

C) Recurrence can happen with varying frequency.

5A nurse is reviewing the laboratory test results of an adult client who has numerous chronic health challenges. Which assessment result would alert the nurse to potential malnutrition? A) Hemoglobin of 13.1 g/dL B) Hematocrit of 40% C) Serum albumin of 2.6 g/dL D) Total protein of 7 g/dL

C) Serum albumin of 2.6 g/dL

An ABNORMAL angle between the nail base and the nail is called clubbing and may indicate which of the following conditions? A. Poor hygiene B. Dehydration C. Cardiopulmonary disorder D. Skin cancer

Cardiopulmonary disorder

You are assessing the lymph nodes of the head and neck. Where are the occipital nodes located? A - In front of the ears B - Behind the sternomastoid muscle C - Behind the ears D - At the base of the skull

D - At the base of the skull

A 43-year-old Asian female presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 87 F. The nurse also notes that the patient has gained 10 pounds since her last visit 3 months ago. What might the nurse suspect? A - Effect of age-related changes B - Brain tumor C - Hyperthyroidism D - Hypothyroidism

D - Hypothyroidism

A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands? A) At the angle of the client's mandible B) At the base of the client's skull C) On the area behind the client's ears D) Behind the tip of the client's mandible

D) Behind the tip of the client's mandible

A client has presented to the emergency department (ED) with a lower leg laceration that she suffered while I was on a bender last night. The nurse recognizes the need to screen for alcohol use and will implement the CAGE questionnaire. What question will the nurse ask during this assessment? A) Have you ever experienced a memory blackout after drinking? B) Have you ever vomited blood after drinking alcohol? C) Have you ever been treated for alcohol abuse? D) Have you ever felt guilty about your alcohol use?

D) Have you ever felt guilty about your alcohol use?

the nurse is presenting a class to a group of high school students about sexually transmitted infections. Which of the following should the nurse include as a major risk factor for cervical cancer? A) Gonorrhea B) Chlamydia C) Syphilis D) Human papilloma virus

D) Human papilloma virus

During a client's genitourinary exam, the nurse notes that the client's scrotum is enlarged and easily transilluminates. Which of the following should the nurse suspect? A) Tumor B) Hernia C) Varicocele D) Hydrocele

D) Hydrocele

A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion? A) Test whether gentle abrasion with an emery board is painful. B) Apply hydrogen peroxide to see whether the client's pruritus is relieved. C) Perform a trial with a topical antibiotic. D) Illuminate the area using a Wood's light.

D) Illuminate the area using a Wood's light.

male client has presented for follow-up to a diagnosis of genital warts. The nurse should expect to assess for what type of lesions? A) Reddened ulcers that occasionally bleed B) Pimple-like vesicles C) Firm, shiny nodules D) Moist, fleshy papules

D) Moist, fleshy papules

The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis? A) Nail beds B) Sclerae C) Palms D) Oral mucosa

D) Oral mucosa

A young female client refuses treatment for a sexually transmitted infection. The nurse explains that lack of treatment may put her at risk for which condition? A) Endometriosis B) Urinary tract infection C) Cervical cancer D) Pelvic inflammatory disease

D) Pelvic inflammatory disease

A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique? A) Inspection B) Auscultation C) Palpation D) Percussion

D) Percussion

The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment? A. A focused assessment involves all body systems, unlike a comprehensive assessment B. A focused assessment covers the body head to toe, unlike a comprehensive assessment C. A focused assessment occurs only in the clinic area, unlike a comprehensive assessment D. A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment

D. A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment

The ABCD rule of melanoma includes: A. Asymmetry of shape B. Border irregularity and color variation C. Diameter larger than the eraser of a pencil D. All of the above

D. All of the above

Which are the best places to check the skin for tenting, which is a sign of dehydration? A. Top of the hand and foot B. Neck and top of the head C. Shoulder and thigh D. Forearm and sternum

D. Forearm and sternum

Which of the following is considered an ABNORMAL finding in an older adult? A. Malignant melanoma B. Cherry angioma C. Seborrheic keratoses D. Lentigines

Malignant melanoma

using a scale with 0 being no pain and 10, the worst pain imaginable, a person notes their pain on the point scale

Numeric Rating Scale

Which technique should the nurse use to properly assess a client's skin turgor? a) Pinch the skin on the sternum and observe its return to the original shape. b) Pinch the skin on the abdomen and observe for color changes c) Palpate the skin around the umbilicus to assess for intactness d) Palpate the skin on the sternum to determine its flexibility

a) Pinch the skin on the sternum and observe its return to the original shape.

Mrs. Helms is admitted to your unit with an exacerbation of COPD. When you enter her room to do your initial assessment, you note that she is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you? a) respiratory distress b) peripheral edema c) depression d) a relaxed attitude

a) respiratory distress

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply. a) Aids in maintaining body temperature b) Involved in digestion of food c) Circulates blood throughout the body d) Protects against damage to the body from sunlight e) Helps make vitamin D in the body f) Largest organ of the body

a, d, e, f

After collecting the data, the nurse begins data analysis with which action? a. Clustering data b. Documenting subjective data c. Reporting information to other health team members d. Documenting objective information

a. Clustering data

Which is an example of data a nurse collects during a physical examination? a. The patient's lack of hair and shiny skin over both shins b. The patient's stated concern about lack of money for prescriptions c. The patient's complaints of tingling sensations in the feet d. The patient's mother's statements that the patient is very nervous lately

a. The patient's lack of hair and shiny skin over both shins

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to a. arrive at conclusions about the client's health b. document any physical symptoms the client may have c. contribute to the medical diagnosis d. validate the data collected

a. arrive at conclusions about the client's health

Which of the following is an important function of the skin? a) Maintenance of acid-base balance b) Synthesis of vitamin D c) Protection against melanin deposits d) Production of carotene

b) Synthesis of vitamin D

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? a) The client has melanoma b) The client has chronic hypoxia c) The client has asthma d) The client has COPD

b) The client has chronic hypoxia

Which situation illustrates a screening assessment? a. A patient visits an obstetric clinic for the first time and the nurse conducts a detailed history and physical examination b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood pressure checks to mall patrons c. The nurse in an urgent care center checks the vital signs of a patient who is complaining of leg pain d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood glucose level.

b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood pressure checks to mall patrons

What is the best action by a nurse when a client has difficulty describing the chief complaint? a. Restate the question using simple terms b. Wait in silence until the client can find the correct words c. Ignore the complaint & return to it at a later time in the interview d. Provide the client with a laundry list of words to choose from

d. Provide the client with a laundry list of words to choose from

During an interview, the client begins to talk about the frequency of being abused by a spouse. What can the nurse do at this time to acknowledge the sensitivity of the information the client is providing? a. Write down the information as the client is speaking. b. Key the information into the electronic medical record as the client is speaking. c. Avoid maintaining eye contact while the client is discussing spouse abuse. d. Stop documenting in order to maintain eye contact with the client.

d. Stop documenting in order to maintain eye contact with the client.

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should a. allow the client time to calm down .b. avoid discussing sensitive issues. c. set time limits with the client. d. explain the role and purpose of the nurse.

d. explain the role and purpose of the nurse.When interacting with an anxious client provide the client with simple, organized information in a structured format and explain who you are, along with your role and purpose.

The result of a nursing assessment is a. prescription of treatment. b. documentation of the need for a referral c. client's physiologic status d. formulation of nursing diagnoses.

d. formulation of nursing diagnoses.