HESI Practice: Health Assessment/Physical Assessment

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the primary health care provider (PHCP)? Absence of a bruit Concave, midline umbilicus Pulsation between the umbilicus and the pubis Bowel sound frequency of 15 sounds per minute

Pulsation between the umbilicus and the pubis

A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique? "I will ask the client to raise the legs up to the waist and then to lower the legs slowly." "I will ask the client to raise the legs and to try to lower them against pressure from my hand." "I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." "I will ask the client to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward."

"I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward."

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test? "I will tell you when I see the colored dots." "I will tell you when I see the flash of bright light." "I will tell you when the small object is in my visual field." "I will tell you when the blocks and shapes are in my visual field."

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

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? The major bronchi The trachea and larynx The peripheral lung fields The lower posterior thorax

The major bronchi

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. Auscultating lung sounds Obtaining the client's temperature Assessing the strength of peripheral pulses Obtaining information about the client's respirations Performing a musculoskeletal and neurological examination Asking the client about a family history of any illness or disease

Auscultating lung sounds Obtaining the client's temperature Obtaining information about the client's respirations

The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if 1 of the students states that which action should be performed? Perform the exam after a cold shower. Expect the exam to be slightly painful. Perform the self-examination every other month. Roll the testicle between the thumb and forefinger.

Roll the testicle between the thumb and forefinger.

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? Turn the flashlight on directly in front of the eye and watch for a response. Ask the client to follow the flashlight through the 6 cardinal positions of gaze. Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.

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

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? Complaints of ringing in the ear An excessive amount of cerumen in the ear canal Intolerance for sound levels that do not bother other people Complaints of dizziness and sensations of being "off balance"

Intolerance for sound levels that do not bother other people

The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment of the client's smoking history? Number of pack-years Desire to quit smoking Brand of cigarettes used Number of past attempts to quit smoking

Number of pack-years

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area? Sclerae Oral mucosa Sole of the foot Palm of the hand

Oral mucosa

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? Over the second intercostal space at the left sternal border Over the fourth intercostal space at the right sternal border Over the second intercostal space at the right sternal border Over the fifth intercostal space in the left midclavicular line

Over the fifth intercostal space in the left midclavicular line

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? Assess for drainage from the wound. Assess for redness around the wound edges. Palpate for swelling around the wound edges. Palpate for increased skin temperature around the wound edges

Palpate for increased skin temperature around the wound edges

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client? A wider than normal ear canal A pearly gray tympanic membrane Redness and swelling in the ear canal An excessive amount of cerumen lodged in the ear canal

Redness and swelling in the ear canal

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? To examine the testicles while lying down That the best time for the examination is after a shower To gently feel the testicle with one finger to feel for a growth That TSEs should be done at least every 6 months

That the best time for the examination is after a shower

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? Lub-dub sounds Scratchy, leathery heart noise A blowing or swooshing noise Abrupt, high-pitched snapping noise

A blowing or swooshing noise

The nurse is making an initial home visit to a client who was recently discharged from the hospital after treatment for a myocardial infarction. The nurse should use which type of database initially to obtain information from the client? An episodic database A follow-up database An emergency database A complete health database

A complete health database

A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate. The client returns to the primary health care provider's (PHCP's) office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment? A problem-centered database A follow-up database An emergency database A complete health database

A follow-up database

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? At the onset of menstruation Every month during ovulation Weekly at the same time of day One week after menstruation begins

One week after menstruation begins

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? Rhythmic respirations with periods of apnea Regular rapid and deep, sustained respirations Totally irregular respiration in rhythm and depth Irregular respirations with pauses at the end of inspiration and expiration

Rhythmic respirations with periods of apnea

The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction? "TSE is performed once a month." "TSE should be performed on the same day each month." "It is best to do TSE first thing in the morning before a bath or shower." "The scrotum is held in 1 hand and the testicle is rolled between the thumb and forefinger of the other hand."

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

The nurse is conducting a health screening clinic and is preparing to test the visual acuity of a client using a Snellen chart. The nurse educates the client about the procedure. Which statement by the client indicates that the teaching has been effective? "Stand 10 ft (3 meters) from the chart and cover 1 eye." "Stand 20 ft (6 meters) from the chart and cover 1 eye." "Stand 30 ft (9 meters) from the chart and read the largest line on the chart." "Stand 40 ft (12 meters) from the chart and read the largest line on the chart."

"Stand 20 ft (6 meters) from the chart and cover 1 eye."

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective? "This is mostly used in a walk-in clinic or emergency department." "This is focused on disease detection and conducted in a health care provider's office." "This is conducted on admission in a primary care or long-term care setting." "This is conducted as a follow-up examination by a health care provider."

"This is mostly used in a walk-in clinic or emergency department."

A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6º F (37º C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first? "Do you exercise regularly?" "Are you considering trying to lose weight?" "Is there a history of diabetes mellitus in your family?" "When was the last time you had your blood pressure checked?"

"When was the last time you had your blood pressure checked?"

The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client? "You have normal vision." "You have some degree of blindness." "You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)." "You can read at a distance of 30 ft (9 meters) what a person with normal vision can read at 20 ft (6 meters)."

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

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? A defect in the cochlea A defect in cranial nerve VIII A physical obstruction to the transmission of sound waves A defect in the sensory fibers that lead to the cerebral cortex

A physical obstruction to the transmission of sound waves

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? An involuntary rhythmic, rapid, twitching of the eyeballs A dorsiflexion of the great toe with fanning of the other toes A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

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

The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? A tuning fork A stethoscope A tongue blade A reflex hammer

A tuning fork

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? After a shower or bath While standing to void After having a bowel movement While lying in bed before arising

After a shower or bath

A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child? Assess the child's physical status Ask the child how the injury occurred. Report the case as suspected child abuse. Observe the interactions between the child and his friends.

Assess the child's physical status

The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time? At ovulation time 7 to 10 days after menses Just before menses begins At a specific day of the month and on that same day every month thereafter

At a specific day of the month and on that same day every month thereafter

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/min. On the basis of this finding, which action is most appropriate? Administer oxygen Document the findings Notify the primary health care provider Reassess the respiratory rate in 15 minutes

Document the findings

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? Focus on a close object Focus on a distant object Close 1 eye and read letters on a chart Raise 1 finger when the sound is heard

Focus on a distant object

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. Allergy to pollen History of headaches Previous back injury History of hypertension History of diabetes mellitus

History of headaches Previous back injury History of hypertension History of diabetes mellitus

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? Tapping the Achilles tendon using the reflex hammer Gently pricking the client's skin on the dorsum of the foot in 2 places Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument Holding the sides of the client's great toe and, while moving it, asking what position it is in

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

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for? A yellow tinge to the skin Bluish discoloration of the skin Loss of normal red tones in the skin An ashen-gray appearance to the skin

Loss of normal red tones in the skin

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? Have 1 of the client's family members interpret. Have the Spanish-speaking triage receptionist interpret. Page an interpreter from the hospital's interpreter services. Obtain a Spanish-English dictionary and attempt to triage the client.

Page an interpreter from the hospital's interpreter services.

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive? Absent bowel sounds Client complaints of wound pain Pain with dorsiflexion of the foot Crackles on auscultation of the lungs

Pain with dorsiflexion of the foot

The nurse is caring for a pediatric client who just arrived at the emergency department with an extremity fracture. The nurse uses the 5 "Ps" to assess the extent of the client's injury. What are some of the 5 "Ps"? Select all that apply. Pallor Pain and point of tenderness Paralysis distal to the fracture site Pulses proximal to the fracture site Sensation distal to the fracture site

Pallor Pain and point of tenderness Paralysis distal to the fracture site Sensation distal to the fracture site

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? Focus only on the physical examination. Obtain all information from family members. Plan short sessions with the client to obtain data. Use the primary health care provider's medical history.

Plan short sessions with the client to obtain data.

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? Wheezes Rhonchi Crackles Pleural friction rub

Pleural friction rub

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? Ataxia Nystagmus Pronator drift Hyperreflexia

Pronator drift

A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the nurse include in the client's focused assessment? Ability to drive a car The normal everyday routine in the home Ability to do light or heavy housework and to pay bills Self-care needs such as toileting, feeding, and ambulating

Self-care needs such as toileting, feeding, and ambulating

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? Ask the client to puff out the cheeks. Separate the client's jaw by pushing down on the chin. Place a small amount of sugar on the client's tongue and ask him or her to identify the taste. Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

Separate the client's jaw by pushing down on the chin.

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. Set the room temperature at a comfortable level. Remove distracting objects from the interviewing area. Place a chair for the client across from the nurse's desk. Ensure comfortable seating at eye level for the client and nurse. Provide seating for the client so that the client faces a strong light. Ensure that the distance between the client and nurse is at least 7 feet (2.1 meters).

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

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? Flashlight Snellen chart Reflex hammer Ophthalmoscope

Snellen chart

The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action? Whisper a statement while the client blocks both ears. Quietly whisper a statement and test both ears at the same time. Whisper a statement with the examiner's back to the client. Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal.

Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal.

The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex? Stroking the foot from the heel to the toe Gently inserting a gloved finger in the rectum Directing a flashlight onto the pupils of the eyes Using a tongue depressor and stimulating the back of the throat

Stroking the foot from the heel to the toe

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination? Modified left lateral recumbent position Supine with the head and feet flat Supine with the head raised slightly and the knees slightly flexed Semi-Fowler's position with the head raised 45 degrees and the knees flat

Supine with the head raised slightly and the knees slightly flexed

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

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

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? The right eye is tested, followed by the left eye, and then both eyes are tested. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

The right eye is tested, followed by the left eye, and then both eyes are tested.

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply. Sclera Tongue Nail beds Elbows and knees Mucous membranes

Tongue Nail beds Mucous membranes

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? Waves of loud gurgles auscultated in all 4 quadrants Low-pitched swishing auscultated in 1 or 2 quadrants Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants

Waves of loud gurgles auscultated in all 4 quadrants

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

Wheezes

The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen chart. After the client's vision is tested with a Snellen chart, the results of testing are documented as 20/40. Which statement by the new RN indicates that the teaching has been effective? "The client's vision is normal, but the client may require reading glasses." "The client is legally blind, and glasses or contact lenses will not be helpful." "The client can read at a distance of 40 ft (12 meters) what a person with normal vision can read at 20 ft (6 meters)." "The client can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters)."

"The client can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters)."

The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions on breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which information should the nurse give to the client? "You need to perform BSE on the same day every month." "It is not necessary to do BSE because you are postmenopausal." "You are not at risk for breast cancer because you are in the postmenopausal phase." "Mammograms performed every 20 years are sufficient in the postmenopausal phase."

"You need to perform BSE on the same day every month."

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

10 pack years

A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used. 1. Asks the client to cover 1 eye 2. Examiner covers eye opposite to the eye covered by the client 3. Asks the client to report when object is first noted 4. Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client 5. The examiner brings in an object gradually from periphery

4, 1, 2, 5, 3

The nurse would perform which action to assess for a pulse deficit? Count the carotid pulsations for 1 full minute. Measure the blood pressure in both the arm and leg. Auscultate the apical heartbeat while palpating the radial artery. Place the diaphragm of the stethoscope directly over the skin at the mitral area.

Auscultate the apical heartbeat while palpating the radial artery.

The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action? Ask a second nurse to be present during the interview. Defer both the health history and the neurological examination. Defer the health history and proceed with the neurological examination. Ask the client to give permission for a family member to stay during the interview.

Ask the client to give permission for a family member to stay during the interview.

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? Poor hygiene Difficulty walking Fear of the parents Bald spots on the scalp

Difficulty walking

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action? Identify an object placed in the client's hand. Identify 3 numbers or letters traced in the client's palm. State whether 1 or 2 pinpricks are felt when the skin is pricked bilaterally in the same place. Identify the smallest distance between 2 detectable pinpricks, made with 2 pins held at various distances.

Identify an object placed in the client's hand.

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? Near the lateral 12th rib Just under the left clavicle In the fifth intercostal space Posteriorly under the left scapula

Just under the left clavicle

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply. Presence of fasciculations Muscle strength graded 5/5 Symmetrical movements bilaterally Increased muscle size on the dominant arm A 1-cm hypertrophy of the right upper arm

Muscle strength graded 5/5 Symmetrical movements bilaterally Increased muscle size on the dominant arm A 1-cm hypertrophy of the right upper arm

A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? Palpating over the lung apices in the supraclavicular area Asking the client to repeat the word ninety-nine during palpation Palpating over the breast tissue to assess and compare vibrations from 1 side to the other Comparing vibrations from 1 side to the other as the client repeats the word ninety-nine

Palpating over the breast tissue to assess and compare vibrations from 1 side to the other

After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds? Waves of loud gurgles auscultated in all 4 quadrants Low-pitched swishing auscultated in 1 or 2 quadrants Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants Very high-pitched loud rushes auscultated especially in 1 or 2 quadrants

Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? Test the corneal reflexes. Test the 6 cardinal positions of gaze. Test visual acuity, using a Snellen eye chart. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

Test the 6 cardinal positions of gaze.

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status? The client's ability to ambulate The intactness of the tympanic membrane The intactness of the retinal structure of the eye The functional status of the vestibular apparatus in the inner ear

The functional status of the vestibular apparatus in the inner ear

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff? One half of the distance between the antecubital fossa and the shoulder One third of the distance between the antecubital fossa and the shoulder Two thirds of the distance between the antecubital fossa and the shoulder One quarter of the distance between the antecubital fossa and the shoulder

Two thirds of the distance between the antecubital fossa and the shoulder

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve? Coffee beans A tuning fork A wisp of cotton An ophthalmoscope

A wisp of cotton

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? Provide the client with materials on legal blindness. Instruct the client that he or she may need glasses when driving. Inform the client of where he or she can purchase a white cane with a red tip. Inform the client that it is best to sit near the back of the room when attending lectures.

Instruct the client that he or she may need glasses when driving.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the primary health care provider (PHCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry? It is painless and safe. It causes only mild discomfort at the site. It requires insertion of only a very small catheter. It has an alarm to signal dangerous drops in oxygen saturation levels.

It is painless and safe.

The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area? Left shoulder Right scapula Right shoulder Small of the back

Left shoulder