Physical Assessment preassessment
A 40-year-old client goes to the medical clinic and says to a nurse, "I have extreme tenderness in my toes." The nurse notes that the client's toes are swollen, reddened, and warm to the touch. Which should the nurse document as the likely cause? A Acute gout B Osteoporosis C Ankylosing spondylitis D Degenerative joint disease
A
A 55-year-old client is being evaluated for a hearing impairment. Which question would be most appropriate to provide the most useful information? A Are you having difficulty hearing high-frequency sounds? B Do you notice any drainage from your ears? C Are you experiencing any pain in your ears? D Have you felt any popping sensations?
A
A 60-year-old client has difficulty hearing high-pitched sounds. How should a nurse document this finding? A Presbycusis B Vertigo C Tinnitus D Otalgia
A
A client has a history of telangiectasias. Which assessment finding supports this diagnosis? A Bright red, visible, fine dilated blood vessels B Pink to slightly red lesions with indistinct borders C Warty lesions with scaly surfaces D Flat tan to brown-colored macules
A
A client is noted to have patches of hypo-pigmented skin on forearms. Which is the best documentation of this finding? A Vitiligo B Birthmark C Lichenification D Impetigo
A
A client's visual acuity is measured by which of these tests? A Snellen test B Corneal reflex test C Cover test D Eye positions test
A
A male client comes to the clinic because of "gradual worsening of pain muscle weakness, limited shoulder range-of-motion." Physical examination reveals tenderness over the shoulder and pain when the shoulder is raised overhead. Based on the assessment, which evaluation would be correct? A The client has chronic rotator cuff tear B The client has crepitation C The client has dislocated shoulder D The client rheumatoid arthritis
A
A nurse assesses a client's pupillary reaction and observes pinpoint pupils. The nurse should interpret this finding as suggesting which condition? A Opiate ingestion B Recent eye trauma C Encephalitis D Conjunctivitis
A
A nurse assesses an irregular area of localized skin edema on a client that reports having "hives". Which is the best documentation term? A Wheal B Vesicle C Bulla D Nodule
A
A nurse has completed the physical assessment of a 5-month-old infant. The results of the assessment include: closed posterior fontanel, absent femoral pulses, tonic neck reflex absent, and doubling of the birth weight. Which finding should be reported? A Absent femoral pulses B Closed posterior fontanel C Absent tonic neck reflex D Birth weight has doubled
A
A nurse is assessing a brown-skinned client and notes a yellow-brown coloration on the buccal mucosa. Which is the best evaluation of the finding? A Pallor B Cyanosis C Erythema D Vitiligo
A
A nurse is assessing the skin of an African-American client. The nurse focuses on the assessment of which skin condition? A Keloids B Atrophy C Vitiligo D Senile lentigines
A
A nurse is auscultating the carotid arteries. Which sound indicates a bruit? A Swishing sound B Purring sound C Silent interval D Rumbling sound
A
A nurse is auscultating the heart of a 30-year-old client. Which is an expected finding? A S3 B S4 C Friction rub D Summation gallop
A
A nurse is caring for a client who is on oxygen therapy via face mask. Which of these measures most accurately determine the client's response to the oxygen therapy? A Examining the client's arterial blood gases B Checking the color of the client's skin and nail beds C Monitoring for changes in the client's vital signs D Observing for a decrease in the client's respiratory effort
A
A nurse is explaining the pathophysiology of gout to a medically informed client. Which of these processes should the nurse include in the explanation? A The uric acid crystallizes, and the crystals deposit in joints, tendons, and tissues B The formation of tophi in the kidneys with increased excretion of uric acid C A reduction of uric acid, which allows calcium to precipitate D A thinning of articular cartilage, leading to splitting and fragmentation
A
A nurse is observing an abdominal assessment conducted by a novice nurse graduate. Which action would indicate additional instruction is needed by the nurse? A Percusses the abdomen before inspection B Assesses for bruits using the bell of the stethoscope C Auscultates the abdomen before palpation D Evaluates the presence of bowel sounds
A
A nurse is preparing to assess the pulse of an 18-month old. Which location is best for the nurse to obtain an accurate pulse rate? A Apical pulse B Radial pulse C Brachial pulse D Pedal pulse
A
A nurse notes that an older adult has cutaneous tags in the neck region. Which is the best documentation of this finding? A Acrochordons B Lichenification C Scales D Keloids
A
A nurse places a stethoscope on a client' chest wall at left midclavicular line near the fifth intercostal space. Which is the best description of the placement? A Point of maximal impulse B Angle of Louis C Erb's point D Manubrium
A
A nurse will be evaluating a pediatric client for an inguinal hernia. What is the best technique for this evaluation? A Position the little finger into the external inguinal ring and have the child cough B Palpate the sac for abdominal contents C Place the index finger on the child's femoral pulse and palpate the skin toward the midline D Insert the ring finger into the femoral canal while the child is sneezing
A
A nurse will be performing the cover test to assess ocular alignment in a 5-year-old child. Which of these findings would be considered normal? A Uncovered eye does not move when one eye is covered B Covered eye moves indicating misalignment C Uncovered eye shows a pseudostrabismus D Covered eye has developed an epicanthal fold
A
A school nurse is conducting scoliosis screenings in an elementary school. Which is a good method for assessment of potential scoliosis? A The Adams forward bend test B Results of the anteroposterior and frog-leg X-rays C The Ortolani test D Positive Trendelenburg sign with lordosis
A
The skin surface of an older client is dry, translucent, and paper-like. Which is the correct term for documentation of the finding? A Atrophy B Lichenification C Scales D Keloids
A
What is the priority assessment of a client who sustained a head injury one hour ago? A Level of consciousness B Measure upper arm strength C Test reflexes D Measure head circumference
A
What is the rationale for a nurse assessing Tinel's sign? A To assess for nerve irritation B To determine joint injury C To measure muscle strength D To determine if underlying tissue is absent
A
When examining a young client who reports a sore throat, a nurse notes swelling on either side of the oropharynx. How should the nurse document this finding? A Enlarged pharyngeal tonsils B Enlarged palatine tonsils C Enlarged adenoids D Enlarged lingual tonsils
A
When performing the cover test, a nurse should first cover one of the client's eyes and then ask the client to do which movement? A Focus on a distant object, and the nurse observes for movement in the other eye B Close the other eye, then open that eye quickly and blink C Follow the examiner's finger with the other eye D Look directly at a light with the other eye and the nurse observes for constriction
A
When teaching a client to collect sputum specimens, a nurse should give which of these instructions to the client? A Take a deep breath then cough and spit into this container. B Gargle with antiseptic mouthwash before you spit into this container. C Spit whatever sputum you have in your mouth into this container. D Keep your head down for five minutes then spit into this container.
A
Which abdominal assessment finding is typical for older adults? A Thin abdominal wall B Few subcutaneous fat deposits C Distant, quiet bowel sounds D Liver inaccessible for palpation
A
Which activity should a nurse perform first when completing a focused gastrointestinal (GI) assessment? A Obtains a complete health history B Identifies primary client concerns C Determines family health patterns D Inquires about medication use
A
Which assessment finding should a nurse report and document as abnormal? A Bowel sound absence for one minute B Dull percussion over urinary bladder C Borborygmi on auscultation D Tympany on percussion
A
Which functional change should be considered an expected finding when a nurse assesses an older adult? A Decreased cardiac output B Increased sinoatrial node rate C Increased cardiac output D Increased heart rate during exercise
A
Which is an expected finding when assessing an adult's external jugular veins? A They disappear when the head of the client's bed is elevated greater than 30 degrees B They disappear when the head of the client's bed is elevated greater than 10 degrees C They appear when the head of the client's bed is elevated greater than 40 degrees D They are not visible with client in supine position
A
Which is an expected finding when assessing the fingernails of a client with chronic decreased blood oxygenation? A Clubbing B Spoon-shaped C Onychomycosis D Beau's lines
A
Which is the best position to place a client when auscultating for a friction rub? A High Fowlers' B Low Fowlers' C Supine D Left lateral
A
Which is the best site to assess an older adult's skin turgor? A Sternum B Extremity C Hand D Face
A
Which is the most accurate diagnostic test to measure blood oxygenation? A Arterial blood gas B Pulse oximetry C Pulmonary angiography D Pulmonary function test
A
Which laboratory value would indicate to a nurse that a client may have ventricular dysfunction? A B-type natriuretic peptide (BNP) level of 200 pg/mL B B-type natriuretic peptide (BNP) level of 80 pg/mL C Creatine phosphokinase (CPK) level of 100 mcg/L D Creatine phosphokinase (CPK) level of 60 mcg/L
A
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII? A Test the client's hearing for lateralization and bone and air conduction. B Test the client's vision for near and distance. C Test the client's sense of smell with sweet and noxious agents. D Test the client's sense of balance by standing on one foot.
A
Which of these client descriptions should a nurse document as tinnitus? A Ear ringing B Ear pain C Ear wax D Ear swelling
A
Which of these findings requires immediate intervention? A Stridor B Crackles C Wheezes D Pleural friction rub
A
Which site should be inspected when assessing for cyanosis? A Buccal mucosa B Sclera of eyes C Posterior hard palate D Lobes of ears
A
Which are unexpected findings when assessing the skin of an adult? Choose 2 answers A Port-wine hemangiomas B Edema C Multi-colored nevi D Cavernous hemangiomas
A, B
What are functions of the middle ear? Choose 3 answers A To transmit sound vibrations B To protect the auditory apparatus from intense vibrations C To equalize air pressure on both sides of the tympanic membrane D To prevent cerumen buildup
A, B, C
A client has a nursing diagnosis of risk of impaired skin integrity. Which interventions are appropriate for this diagnosis? Choose 3 answers A Encourage ambulation B Limit hydration C Change position every 2 hours D Use a lift sheet
A, C, D
A 75-year-old woman who has had rheumatoid arthritis for years reports to a nurse that she is starting to notice that her fingers are drifting to the side. The nurse should suspect that the woman has which of these conditions? A Radial drift B Ulnar deviation C Swan neck deformity D Dupuytren's contracture
B
A charge nurse is assisting a novice nurse in how to check for residual urine. Which instruction is correct? A Have the client void before the procedure. B Begin percussing above the umbilicus. C Press down gently over the suprapubic area. D Proceed with firm upward pressure.
B
A client can neither turn the head against resistance nor shrug the shoulders. The nurse documents a deficit in the functioning of which cranial nerve? A Abducens (VI) B Accessory (XI) C Hypoglossal (XII) D Trochlear (IV)
B
A client who has been diagnosed with chronic obstructive pulmonary disease (COPD) is scheduled for an annual physical examination. A nurse has completed a focused respiratory assessment with the client. Which finding by the nurse should be considered normal? A Compensated respiratory alkalosis B Clubbing of the nailbeds C Pectus excavatum D Aphonia
B
A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? A Trigeminal neuralgia B Hypoglossal C Facial D Vagal
B
A nurse is evaluating head control in a five-month-old infant. Which of the following findings is expected? A Spontaneously lifts head off a surface when supine B Demonstrates no head lag C Lifts head when about to be pulled to a standing position D Sits erect momentarily
B
A nurse is examining the deep tendon reflexes of an adult client. Which is an unexpected finding? A Toe flexion when the sole of the foot is stroked from heel to toe B The toes fan out and draw back when the lateral aspect of the sole of the client's foot is stroked C Dorsiflexion of the foot and striking the Achilles tendon elicits a plantar flexion response D Contraction of the quadriceps and knee extension with patellar tendon stimulation
B
A nurse is performing an abdominal assessment on a newly admitted client. Which action should the nurse take first? A Assess painful areas reported by the client. B Auscultate for 5 minutes over each quadrant C Percuss the liver and measure the liver border D Palpate the spleen firmly for enlargement
B
A nurse is performing an admission nursing assessment on an older adult client with a history of emphysema. Which assessment finding should be reported to the healthcare provider? A Use of accessory muscles to exhale B Absent breath sounds on one side C Increased anteroposterior chest diameter D Decreased thoracic expansion
B
A nurse is presenting a class to a local community about vision and eye health. As part of the presentation the nurse explains the how visual perception occurs neurologically. Which should included in the explanation? A Refers to what a person sees with one eye B Involves light rays striking the retina C Acts as a protective reflex to limit light D Allows the eyes to focus on near objects
B
A nurse is teaching a group of students about the bones and their functions and wants to know if they have understood what she taught. She asks them to tell her which sites blood cells are produced in. What will the students answer, if they understood her lecture correctly? A Compact bone B Red marrow C Spongy bone D Yellow marrow
B
A nurse mentor is observing a novice nurse instruct a client on how to perform a home stool guaiac test for occult blood. Which instruction needs correction? A You should collect stool from three different samples, preferably on three consecutive days. B It's okay to take your daily aspirin, but avoid drinking orange juice or products with vitamin C. C You can collect all three samples using this same test kits. All supplies are included. D Avoid having dental procedures at least three days before you collect stool samples.
B
A nurse notes pulsation of the aorta when assessing a client's epigastric area. Which additional finding suggests the need for additional evaluation? A 100 °F oral temperature B Widened pulse pressure C Visible peristalsis D Abdominal distention
B
A nurse notices that a client has decreased range of motion with lateral bending of the cervical spine to the left side. What should the nurse do next in relation to this finding? A Report this finding to the physician immediately B Compare this finding to the range of motion to the right side C Place the client in Trendelenburg position D Assess the client's Babinski reflex
B
A nurse will be measuring the blood pressure in a 4-year-old child. Which blood pressure cuff will provide the most accurate measurement of radial arterial pressure? A Equal to the limb length circumference B Equal to 40% of the upper arm circumference C Oversized to account for the widening pulse pressure D Designated for preschool use
B
At a 6-month checkup for an infant, a parent states, "I used to touch my baby's cheek and her head would turn towards my touch and she would open her mouth. I have noticed that does not happen anymore." Which response is most appropriate for a nurse to make? A I will document your concern so the care provider can evaluate further. B The rooting reflex normally disappears by 3-4 months. C The baby should return to doing this in the next 2-3 months. D The startle reflex disappears by 3 months, so I wouldn't worry.
B
During a physical exam, a nurse notes a very tender and painful, inflammation at the bottom of the foot. The client states the pain is experienced in the first steps in the morning. Which is the best evaluation of the finding? A Gouty arthritis B Possible plantar fasciitis C Rheumatoid arthritis D Degenerative joint disease
B
The husband of a 65 year old female tells the nurse, "My wife is having trouble navigating the steps in our home and she needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem? A Brain stem B Cerebellum C Occiput D Temporal region
B
When clients have osteoarthritis and rheumatoid arthritis, which of these medication classifications should a nurse expect the clients to receive? A Narcotics B NSAIDS C Steroids D Uricosurics
B
When performing an ophthalmoscope exam, a nurse observes a round shape with distinct margins. How should the nurse document this finding? A Physiologic cup B Optic disc C Retinal vessels D Fovea
B
Which is a characteristic of bronchovesicular breath sounds? A High pitched, harsh sounds heard over the trachea B Moderate "blowing" sounds heard over the mainstem bronchus C Soft, low-pitched sounds heard over the base of the lungs D Sonorous, low-pitched sounds heard over the apex of the lungs
B
Which is a normal finding in the cardiovascular assessment of an adult? A Neck vein distention B Palpable apical impulse C Lower extremity edema D Capillary refill time of five seconds
B
Which is the best assessment question if a male client complains of nocturia? A Does it burn when you urinate? B Are you taking a diuretic medication? C Do you urinate just before retiring? D Is straining needed to start your stream?
B
Which of these tests should a nurse plan to assess motor function of the trigeminal nerve? A Ask client to differentiate sharp and dull sensations on client's face B Palpate temporal and masseter muscles while client clenches teeth C Assess dilatation of pupils with direct light D Ask the client to smile, frown and wrinkle the forehead
B
Which of these assessments of the tympanic membrane should a nurse document as a normal finding? Choose 2 answers A Dull B Shiny C Pearl grey color D Soft pink color
B, C
A 28-week-gestation client calls the obstetrical clinic and speaks with a nurse. The client reports of shooting pain referred to the upper leg from the hip, sacroiliac and intervertebral facet joints with feeling burning and tingling sensation down the leg. Which is the best evaluation? A Ankylosing spondylitis B Peroneal palsy C Sciatica D Osteoarthritis
C
A 6o-year-old client with a history of heart failure states "I am awakened from my sleep at night with shortness of breath and have to sit up to breathe." Which is the best nursing action? A Obtain a personal history of the client's allergies and family history of asthma B Instruct the client to increase the number of pillows to achieve comfort when sleeping C Assess for other signs and symptoms of paroxysmal nocturnal dyspnea D Assure the client that this is normal for older adults over the age of 60
C
A 9-month-old infant is in the clinic for a well-child physical examination. The results of the oral examination include pink gums, uvula in midline, six central incisors, and intact soft palate. Which finding is inconsistent with the infant's stage of development? A Pink gums B Uvula in midline C Six central incisors D Papillae on the tongue
C
A client has a sensorineural hearing loss. Which condition should a nurse most likely identify as a cause? A Perforated eardrum B Otosclerosis C Cranial nerve damage D Otitis media
C
A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing? A Minimizing the amount of noise exposure tothree hours a day B Taking a 10-minute break everytwo hours C Wearing ear guards whenever inside the plant D Cleaning ears regularly to prevent ear infections
C
A nurse identifies an older adult client with orthostatic hypotension to be at high risk for falls. Which is the priority nursing intervention? A Place a "fall risk" bracelet on the client's wrist B Raise all four bed side rails C Put the call light within the client's reach D Educate the client about fall safety at home
C
A nurse is evaluating the admission lab values on an adult client who takes digoxin (Lanoxin) 0.25 mg PO daily. Which assessment finding is critical for documentation of a risk factor for digoxin toxicity? A Serum calcium of 8.7 mg/dL B Serum glucose of 172 mg/dL C Serum potassium of 3.5 mg/dL D Serum sodium of 155 mg/dL
C
A nurse is performing a cranial nerve assessment on a client. The client is unable to differentiate between sharp and dull sensations. Which cranial nerve should the nurse suspect is affected? A Abducens B Facial C Trigeminal D Oculometer
C
A nurse is preparing for an assessment of the carotid artery. The nurse manager knows the nurse is competent with this assessment when the new graduate nurse demonstrates which activity? A Massages the arteries briskly B Uses the diaphragm of the stethoscope C Palpates each carotid artery separately D Places the client in a lateral position
C
A nurse is teaching a class of 10-year-old girls about the development of secondary sex characteristics. Which information should be included in the teaching plan? A Axillary hair will appear before the onset of menses B Pubic hair development will appear after your period begins C Menstruation will begin about two years after breast bud development D Ovulation begins with the first menses
C
A nurse is teaching appropriate diet choices to an older adult client with a diagnosis of hypertension. Which dietary selection by the client indicates a need for additional dietary teaching? A Orange juice B Grilled chicken C Canned soup D Dairy products
C
A nurse shines a light into one eye during ocular exam, and the pupil of the other eye constricts. How should the nurse interpret this observation? A Direct reflex B Optic chiasm C Consensual response D Accommodation
C
A nurse suspects a client is experiencing constipation. Which abdominal assessment finding supports the presence of feces in the intestine from constipation? A Curve in lower half of abdomen on inspection B Hyperactive bowel sounds on auscultation C Scattered dullness heard on percussion D Taut skin felt on palpation
C
After assessing a client's musculoskeletal system, a nurse prepares to document the data gathered. Which of these findings should the nurse document as objective data? A Has a family history of gout and osteoporosis B Complains of burning in lower back C Has limited neck rotation to 50 degrees D Denies pain in hip joints or legs
C
An admitting nurse documented phimosis as an assessment finding for a client admitted to the acute care facility. A nurse caring for the client should understand this to mean which condition? A Glans foreskin retracted and fixed B Prolonged painful erection of penis C Non-retractable foreskin over glans D Peyronie disease of glans penis
C
During a health history a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of these problems should a nurse suspect? A Myopia B Tropia C Presbyopia D Cataracts
C
During the health history, a client reports complaints of intermittent facial pain, radiating to eye lasting several minutes. The nurse would suspect which pathology? A Migraine headache B Meningitis C Trigeminal neuralgia D Temporo-mandibular joint dysfunction
C
During the history taking, a young adult client tells a nurse, "My parents have osteoporosis. What can I do to help reduce my risk?" Which is the best response? A Keep your calcium intake around 800 milligrams each day. B Avoid being out in the sun for long periods of time. C Try to avoid drinking too much coffee or other caffeinated fluids. D Increase the amount of non-weight-bearing physical activity that you do.
C
How should a nurse assess the vestibulocochlear cranial nerve? A Observe for asymmetry B Tell the client to puff out both cheeks C Whisper numbers and ask the client to repeat them D Have the client show all the teeth and smile
C
The nurse will be performing a focused cardiac assessment. Which is the best location to evaluate the pulse? A Pulmonic area B Aortic area C Point of maximum intensity D Tricuspid area
C
When assessing a client's elbow, a nurse asks a client to hold the arm out and turn the palm down to test which of these motions? A Rotation B Supination C Pronation D Flexion
C
When performing the Phalen's test, which of these assessment findings, if present, would indicate to a nurse that the test is positive for carpal tunnel syndrome? A No tingling B Hard, painless Bouchard nodes C Numbness D Atrophy of the thenar prominence
C
Which comfort measure enhances abdominal wall relaxation and facilitates abdominal assessment? A Keeping the room moderately cool B Placing client in semi-Fowler's position C Examining painful areas last D Maintaining a quiet environment
C
Which data is necessary for assessment of a client's urinary pattern? A Sexual history B Urological surgeries C Voiding frequency D Color of urine
C
Which of these factors may negatively impact the olfactory nerve? A High fat diet B Ill-fitting dentures C Smoking D Oral infections
C
Which of these findings should a nurse expect to assess in a client who has esotropia? A Eye turning outward B Eye misalignment C Eye turning inward D Eye oscillating
C
While auscultating the heart sounds of an older adult client, a nurse detects an S3 sound. How is an S3 sound best heard? A The stethoscope diaphragm in the tricuspid area B With the stethoscope diaphragm in the pulmonic area C With the stethoscope bell in the mitral area D With the stethoscope bell in the aortic area
C
While examining a client, a nurse notes fasciculation of the tongue. Which of these steps should the nurse take next? A Have the client do a 24-hour diet recall B Review the client's medication regimen C Assess the client's cranial nerves D Prepare the client for a thyroid screening
C
A client asks why cerumen is important because it "just clogs up the ear anyway." Which response would be most appropriate? A It helps create the smoothness of the external auditory canal. B It helps conduct sound waves through the inner ear. C It helps maintain the reddish color of the eardrum. D It helps keep the tympanic membrane soft.
D
A client describes blackish colored stools. Which question should the nurse ask about food or medication within the past day or two to appropriately assess the client? A Meat B Cocoa C Senna D Bismuth
D
A client is admitted to the acute care facility with the medical diagnosis of renal insufficiency. Which would be a priority assessment? A Recent pelvic surgery B Hyperparathyroidism C Diabetes mellitus D Hypertension
D
A nurse is assessing a client's gait. Which finding would require a need for further evaluation? A Stands on heels and toes B Arms swinging in opposition C Weight evenly distributed D Shuffling of feet
D
A nurse is assessing a client's scrotum and testicles. Which finding would need careful documentation? A Asymmetrical appearance B Rubbery feeling testicles C Multiple yellowish nodules D Thickened spermatic cord
D
A nurse is preparing a program on osteoporosis for a local women's group. Which of these factors should the nurse include as a modifiable risk? A Personal history of fractures B Cultural background C Small-boned, thin frame D Low estrogen levels
D
A nurse is teaching a class on the risk factors for developing osteoarthritis (OA). Which of these modifiable risk factors should the nurse include in the teaching plan? A Having increasing age B Previous joint damage C Genetic susceptibility D Being overweight
D
A nurse will be conducting an assessment of a client with a three (3) day history of vomiting and diarrhea. Which would be an expected finding of a focused assessment for dehydration? A Respiratory rate: 30 breaths per minute B Pulse rate: 120 beats per minute C Capillary refill less than 2 seconds D Poor skin turgor
D
An African-American parent returns to the pediatric clinic with a 3-day-old newborn. The infant is being monitored for hyperbilirubinemia. Which is the best method for assessing the skin for jaundice? A Tent the skin and quickly release it B Assess the infant's palpebral conjunctiva C Inspect the infant's scalp D Assess the infant's palmar surfaces
D
During a health history, a 42-year-old client reports seeing spots. How should a nurse interpret this report? A Increased ocular pressure B Vascular spasm C Vitamin A deficiency D Normal findings for client's age
D
During a pulmonary assessment of a pediatric client, a nurse notes the use of abdominal muscles during respiration. Which nursing action is the priority? A Notify the client's healthcare provider immediately B Order a chest X-ray C Place the client in the tripod position D Continue assessing the client
D
During physical examination of the female client the nurse notes warty growths on the labia majora. Documentation of the finding would include which potential condition? A Contact dermatitis B Syphilitic chancre C Herpes simplex type 2 D Human papillomavirus
D
How should a nurse position a client who has increased intracranial pressure? A Prone B Trendelenberg C Supine D Semi-Fowlers
D
Upon collecting a client's urine sample, a nurse notices the client's urine is tea-colored. Which constituent is likely present in the urine on the basis of this observation? A Bacteria B Protein C Glucose D Blood cells
D
When a nurse finds that an adolescent has a 45-degree flexion of the cervical spine, which of these actions should a nurse take? A Assess the thoracic and lumbar spine B Palpate the spinous processes C Perform the Lasegue test D Continue the exam because this curve is normal
D
When assessing a client for possible oral cancer, the nurse would closely inspect which area? A The top of the tongue B The gum line C The back teeth D Under the tongue
D
When testing the range of motion of the cervical spine, a nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. Based on the findings, the nurse should suspect which of these conditions? A Compression fracture B Cervical disc degeneration C Cervical strain D Meningitis
D
Which abdominal assessment is accomplished by the technique of palpation? A Abdominal symmetry B Vascular sounds C Aortic pulsation D Quadrant tenderness
D
Which finding in an older client indicates a deviation from normal age related neurological changes, indicating additional assessment is needed? A Decreased need for sleep B Decreased hearing acuity C Decreased appetite D Decreased ability to maintain balance
D
Which finding on inspection verifies the presence of uncomplicated hemorrhoids? A Shiny blue skin bag B Inflamed lesion C Red doughnut of tissue D Flabby skin sac
D
Which finding should a nurse expect to assess in a client who has Parkinson's disease? A Sunken face B Drooping of the extremities on one side C Asymmetry of earlobes D Masklike facial expression
D
Which of these directions should a nurse give the client to assess the client for facial asymmetry? A Hold your tongue out B Shrug your shoulders C Turn your head side to side D Raise both eyebrows
D
A nurse obtains a blood pressure reading of 108/68 for a 10-year old client. Which of the following nursing actions is most appropriate? A Document findings as assessed B Re-take the blood pressure in 15 minutes C Notify the nurse practitioner on call D Inquire about previous activities before visit
a
When assessing a client with intermittent claudication, which assessment finding should a nurse document? A Pain at rest in lower extremities B Chest pain during exercise C Finger pain in cold weather D Pain in lower extremities during ambulation
a