NURS251 Exam 2 review questions

What characteristic nail color should the nurse recognize as an indication of hypoxia? A. Pink B. Cyanotic C. Yellow D. Red

B. Cyanotic

A nurse asks a client the following question: "What do you do if you have pain?" The nurse is assessing which of the following? A. Orientation B. Judgment C. Abstract thought D. Memory

B. Judgment

The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's: A. Pectus thorax B. Pectus excavatum C. Pectus carinatum D. Pectus diaphragm

B. Pectus excavatum

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. Nodule B. Papule C. Macule D. Vesicle

C. Macule

In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds? A. Infection B. Multiple sclerosis C. Malignant melanoma D. Peripheral vascular disease

D. Peripheral vascular disease

During a health history interview, a nurse asks a client about childhood illnesses, past surgeries, and allergies. The nurse knows that this information will be charted in what section of the initial comprehensive assessment database? A. Biographic B. Family health history C. Review of systems D. Personal health history

D. Personal health history

A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's: A. Abdomen B. Arms C. Legs D. Sclera

D. Sclera

The nurse assesses the frontal sinus where? A. Above the eyes B. Below the eyes C. Above the jaw D. Below the jaw

A. Above the eyes

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? A. Bradypnea B. Tachypnea C. Dyspnea D. Bradycardia

A. Bradypnea

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? A. Bradypnea B. Tachypnea C. Hypoventilation D. Hyperventilation

A. Bradypnea

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative? A. Fluid in the alveoli B. Fluid in the bronchioles C. Fluid in the bronchus D. No fluid present

A. Fluid in the alveoli

In order to effectively assess the oral mucosa, the nurse should have which assessment tools available? (Select all that apply) A. Gloves B. Penlight C. Tongue depressor D. Speculum E. Centimeter ruler

A. Gloves B. Penlight C. Tongue depressor

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields? A. Listen at each site for at least one complete respiratory cycle B. Move from anterior to posterior on the same side C. Instruct the client to breathe in and out rapidly through the mouth D. Use the diaphragm then the bell in each location

A. Listen at each site for at least one complete respiratory cycle

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? A. Open the mouth B. Sit upright C. Sit without moving D. Perform chewing action

A. Open the mouth

When recording the client's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer: A. Quote the client's words B. Summarize the client's words C. Paraphrase the client's words D. Describe the client's concerns and health goals

A. Quote the client's words

The nurse performs the action shown in this image during the assessment of a client. What is the nurse assessing? A. Skin turgor B. Carotid pulse C. Capillary refill D. Lymph nodes

A. Skin Turgor

A nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, "Do you spend long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question? A. To determine the clients risk for pressure ulcers B. To determine the clients risk for skin cancer C. To determine the clients risk for dehydration D. To determine the clients risk for infection

A. To determine the clients risk for pressure ulcers

A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. Which finding would the nurse identify as being most suggestive of melanoma? A. Solid, dark brown color B. Asymmetric, irregular borders C. Diameter of 3mm D. Flat with silvery scales

B. Asymmetric, irregular borders

When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding? A. Fine crackles B. Coarse crackles C. Wheezes D. Rhonchi

B. Coarse crackles

A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response? A. Nail problems may affect a persons body image negatively B. Nail problems can be caused by an underlying systemic illness C. Local irritation can cause damage to the nail bed D. Abnormalities may be a sign of poor hygiene

B. Nail problems can be caused by an underlying systemic illness

The nurse is assessing the characteristics and positioning of the client's uvula, which deviates asymmetrically when the nurse has the client say "aaah." This finding should prompt the nurse to focus on which of the following during subsequent assessment? A. The client's nutritional status B. The client's neurological status C. The client's immune function D. The client's respiratory function

B. The client's neurological status

A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time? A. "Are both of your parents still living?" B. "What do you usually eat in a typical day?" C. "What diseases did you have as a child?" D. "How do you feel about having to seek health care?"

C. "What diseases did you have as a child?"

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following? A. One quiet full inspiration through pursed lips B. Two full breaths every 10 seconds through the nose C. One deep inspiration and expiration through the open mouth D. Two full breaths in through the mouth and out through the nose

C. One deep inspiration and expiration through the open mouth

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should: A. place the bell of the stethoscope firmly on the posterior chest wall. B. auscultate from the base of the lungs to the apices. C. ask the client to breathe deeply through her mouth. D. ask the client to breathe normally through her nose.

C. ask the client to breathe deeply through her mouth.

How should a nurse position a client to accurately auscultate the right middle lobe of the lung? A. Lateral with the right lung facing up B. Lean forward at the waist C. Rest the arms on the knees D. Move the right arm away from the body

D. Move the right arm away from the body

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing? A. Fluid in the alveoli B. Blockage of a respiratory passage C. Decreased compliance of lungs D. Narrowing or partial obstruction of an airway passage

D. Narrowing or partial obstruction of an airway passage

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation? A. Auscultate for the presence of crackles B. Palpate the anterior chest wall C. Apply oxygen D. Observe for the use of accessory muscles

D. Observe for the use of accessory muscles

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information? A. Health patterns B. Review of systems C. Family health history D. Past medical history

D. Past medical history