Questions- HA final

42. Which assessment notation describes a client's level of consciousness?

- "Client was alert and cooperative during the assessment"

44. The nurse should respond to a client's request to "keep what I'm about to tell you a secret" with which statement?

- "I have to share the information if it reveals something that could hurt you"

1. The nurse is examining a client who has an exacerbation of hip pain when in a sitting position. Which body system can the nurse examine with the client lying down?

- Anterior Thorax

40. When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves?

- Aortic and pulmonic

13. The nurse is documenting the findings from a mental status examination. After stating the patient's appearance and behavior, what should the nurse document next?

- Articulates needs verbally

38. Which characteristics would support the determination that a client is at high risk for breast cancer?

- First degree relative with a history of either BRCA1 or BRCA 2 mutation

22. The nurse is preparing to conduct a physical examination of an adolescent client as part of general physical assessment. Which examination approach would be the most appropriate for this client?

- Head-to-toe assessment

8. During a comprehensive health history, a client reports smoking cigarettes for 20 years. The nurse will document this information in which of the following section?

- Past history

32. When assessing for apocrine gland function, the nurse would asses for moisture where's on the client's body?

- Underarms

18. An older adult male client reports a 2 wk history of sleep disruption due to frequently waking up to void in the middle of the night. Where in the review of system should the nurse document this symptoms?

- Urinary

47.When preparing the examine a patient's sclera and conjunctive during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction?

Up

18. A nurse conducts a physical examination of the musculoskeletal system of a client who reports upper arm pain. Which instruction should the nurse provide the client when assessing flexion of the elbow?

- "Bend you elbow"

48. When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask?

- "Can you tell me where you are right now?"

40. A patient is concerned that the spouse is planning to commit suicide. What can the nurse respond to this patient?

- "Firearms in the home and substance abuse are risk factors"

47. Which terms are used to identify the lobes of the right lung?

- A upper lobe - A middle lobe - A lower lobe

4. The nurse is preparing to examine a client's posterior thorax. Which of the following should be included in this examination?

- Auscultating of lung sounds

34. What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?

- Collecting data regarding the nature of the pain

39. Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility?

- Collecting information regarding the client's health status

21. To assess a client's abdominal reflexes, which assessment should be included in the physical examination?

- Light stoke inward from all quadrants

5. During as assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

- VIII (acoustic nerve)

41. The nurse is instructing a patient on conducting breast self-examination. What should the nurse include in these instructions?

-Lie down and place one arm behind the hand, use the finger pads of the three middle fingers of the hand

14. A patient asks what can be done to reduce the risk of developing breast cancer. What instruction should the nurse provide the patient?

-Maintain a normal body weight, Exercise, Breastfeeding, Limit alcohol use.

1.As the nurse palpate the lymph nodes of the neck, hard and fixed nodes are notes in the supra-clavicular region. The finding is consistent with which condition?

-Malignancy

2. The diagnosis of superficial phlebitis increase the client's risk for which vascular disorder?

Deep vein thrombosis

7.While auscultating heart sounds, asking the client to turn onto a left lying position would help the nurse assess the presence of which of the following?

Mitral stenosis

44. The nurse assesses the apical pulse while conducting a cardiovascular exam. The nurse notes the client has an irregular pulse. Which of the following chambers of the heart sound be further assessment?

Right atrium

50. In order for the nurse to asses jugular venous pressure (JVP), the client should be in which of the following positions?

The head of the bed raised 60 degrees

45. A nurse is assessing a client with a history of alcohol abuse. The client reports right upper quadrant pain. Which type of pain is the client experiencing?

Visceral

3. While the nurse is obtaining a client's health history regarding the head and neck, the client reports having a lump in the neck. In order to assess for associated manifestation of this problem, which of the following questions should the nurse ask next?

- "Do you have difficulty swallowing?"

2. A student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding?

- Consult with a clinical instructor

39. Which nursing intervention does a client who is in the obtunded level of consciousness require most?

- Frequent orientation

43. A nurse assesses a client with knee pain and observes swelling over the patella. This finding suggests which condition of the knee?

- Prepatellar bursitis

22. Which is at GREATEST risk for the development of a cancerous breast lesion?

-A 16-year old athletic woman

36. When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

-Vertigo

15.A client reports having chronic discomfort in the upper abdomen. The nurse can be certain that this client is experiencing dyspepsia when which symptoms are present?

-felling fullness after eating, satiation early in meal, epigastric burning

16.While conducting the physical examination, which of the following assessment would require the nurse to auscultate the abdomen?

To identify bowel sounds

50. the nurse is conducting cultural assessment with a client who recently immigrated to the US. Which interview question is of most importance when addressing family history as it impacts the client's care?

who is primarily responsible for making family decisions since arriving in the US"

49. During a health history, which of the following can the nurse ask to determine an older adult client's abilities to conduct instrumental activities of daily living? (Select all that apply).

- "Do you shop for groceries?" - "Who prepares your meals?" - "Do you do your own laundry?" - "Do you manage your own money?"

36. The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point?

- "Effective blood glucose regulation can prevent this problem"

27. When the nurse is obtaining the health history of the nose and sinuses, a client reports symptom of rhinorrhea. Which questions should the nurse ask to determine associated manifestation of this symptom?

- "Have you had a sore throat?"

32. A client presents with otalgia and yellow-green discharge from the external ear canal. Which question should the nurse ask to determine the cause of this problem?

- "Have you had any recent trauma to the inside of your ear?"

7. How should the nurse document a patient's chief complaint of right hip pain for the comprehensive health history?

- "I have pain in my right hip when I walk"

5. Which statement by the nurse demonstrates an understanding of the importance a client's culture plays in the client's health and wellness?

- "I need to understand the client's cultural background to best interrupt the clients needs."

48. A patient is concerned about a right breast lump. What questions can the nurse ask to effectively assess the associated manifestation of the mass?

- "Is there pain with the lump" - "Are you menstruating when the lump is present?" -" Is there any discharge from the lump?"

28. When considering high-yield screening data, which question would likely gather the most relevant information concerning a client's mental status?

- "Over the last 2 weeks, have you become less interested in your hobbies?"

27. During the health history of the musculoskeletal system, the client reports having low back pain that radiates into the leg with numbness and tingling. The nurse should further assess for spinal stenosis when the client makes which of the following statements?

- "The pain is relieved when I am leaning over a shopping cart"

33. A nurse is assessing a client for abnormalities of gait due to a concern that the client is at increased risk for fall. Which instruction should the nurse give the client first?

- "Walk across the room and back"

29. An older patient is demonstrating mental status changes. Which question would the nurse ask when conducting a mini-mental state examination of this patient?

- "What is todays date"

42. The nurse notes that a patient is grimacing. What can the nurse ask the patient to determine that cause of this facial expression?

- "are you currently experience any pain"

6. Which general survey question focuses on the common "5th vital sign"?

- "are you experiencing any pain right now"

37. Which statements demonstrate the nurse's attempt to empower the client during an assessment interview

- "falling as you did must be a very frightening experience." - "I'm not sure when the test will be scheduled, but I will find that out before you leave" - "please tell about what brought you here today."

14. it would be a priority for the nurse to provide counseling about nutrition and exercise for weight loss for which client?

- A client with a body mass index of 27 - BP of 145/80 mmHG

9. While the client is sitting quietly, the thumb and index finger of the left hand are moving in circular motion. The nurse identifies this finding as which of the following problems?

- A resting tremor

3. What data collected during an integumentary assessment should cause the nurse to be concerned that a patient is at risk for the development of skin care?

- Actinic keratosis on face - Light-colored hair - Age 55 years

28. A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely?

- Acute bacterial sinusitis

16. After completing the musculoskeletal health history, the nurse determines that a client is at risk for osteoporosis. Which of the following risk factors were most likely identified in the client? (Select all that apply)

- Age over 50, current smoker, sedentary lifestyle, and alcohol intake four drinks per day

24. a patient has arrived in the clinic for a routine physical examination. Prior to assessing the patient BP, what should the nurse do?

- Ask the patient to sit quietly in a chair for 5min

45. The nurse is preparing to conduct an interview with a hospitalized patient. What nursing intervention can best ensure a confidential and comfortable environment for the patient?

- Asking permission to draw the client's privacy curtain

41. After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? (Select all that apply).

- Asking the client to open and close the mouth - jutting the jaw forwards - rocking the jaw laterally

11. Which nursing intervention best demonstrates the nurse's attempt to provide effective spiritual care to a client in spiritual distress?

- Assessing the spiritual needs of a client who is critical ill

16. the nurse begins a client assessment by conducting a general survey that focuses on objective observation. What is the primary purpose for collecting this short of information first?

- Assist the nurse in formulating appropriate subjective questioning

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

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

12. After conducting a screening neurologic examination, the nurse identifies the client is at risk for a stroke. Which of the following client education should the nurse provide at this time? (Select all that apply)

- Begin smoking cessation, Take prescribed antihypertensive medication, Use continuous positive airway pressure (CPAP) device as prescribed, Warning signs of stroke

17. Which sign can the nurse include in the general survey of the older adult client during the physical exam?

- Body hygiene

25. A nurse wants to assess the prevertebral muscles of a client who reports neck stiffness. In order to effectively conduct the physical examination of this area, the nurse should give which instruction to the client?

- Bring your chin to your chest

41. What is the nurse's focus while conducting a health assessment with a client?

- Conducting a physical examination - Completing the health history

25. The nurse is focusing an interview on a patient's respiratory status. Which question should the nurse ask first to begin this interview?

- Describes how you breath for me?

35. The nurse is preparing to conduct an examination of a clients breasts an axilla. Which of the following will the nurse need for this examination?

- Drape

7. A nurse is conducting a health history with a client who has recently had a stroke. The nurse notes the client has slurred speech, although language is intact. Which disorder of speech is the nurse observing?

- Dysarthria

24.During the physical examination of a patient's eye, the nurse asks the patient to follow the tracing of a giant H with the eyes. What function is the nurse assessing in this patient?

- Extraocular movement

29. A patient, with a family history of melanoma, wants to have specific body moles assessed. When performing this assessment, the nurse will use what equipment?

- Gloves, Chair, Examination table, and Natural lighting

1. Which of the following findings from a nutritional history most likely indicate the client is showing signs of an eating disorder?

- Has body mass index of 16 - Discusses feeling fat in clothes

32. Which strategy can the nurse use to effectively approach the older adult client during the health history?

- Have the room well-lit with minimal background noise

19. During the health history of an 8-month-old patient, the nurse asks the mother to list the immunizations that the patient has received. The information is important for which party of the history?

- Health maintenance

30. A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?

- Health maintenance

8. A client with a diagnosis of type 1 diabetes is admitted to the hospital with acute symptomatic seizures. Given the clients underlying condition, what would be the most likely cause of this type of seizure?

- Hyperglycemia

26. The nurse is reviewing the lab report for a client with poor controlled diabetes. The action fall within step of clinical reasoning?

- Identifying abnormal or positive findings

45. When preparing an education session for a group of women who have been identified as postmenopausal, the nurse includes which teaching point?

- Increase intake of vitamin D and calcium

36. The client reports several pain when breathing in deeply. The description suggest to the nurse that the client is experiencing which respiratory condition?

- Inflammation of the parietal pleura

11. Which characteristic observed is a recently widowed patient should prompt the nurse to assess for possible early depression? (Select all that apply)

- Insomnia, Impaired decision making, Anhedonia

50. The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client?

- Instruct the client to flex and extend the right elbow

9. During the review of systems within the comprehensive health history, the nurse notes that a client has multiple previous injuries and accidents. Which of the following issues is a priority in the nurse's assessment?

- Investigate the possibility of physical abuse

17. Before completing the physical examination, the nurse determines that the patient is awake, alert, and oriented. This information would be important for which part of the general survey?

- LOC

33. While conducting a physical examination of the cardiovascular system, the nurse fine crackles on auscultation of the lungs. The finding is mostly likely manifestation of which problem?

- Left side heart failure

12. Which of the following is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?

- Limit position changes as much as possible

33. The nurse recognizes the value of the healthy people 2020 guidelines when creating a plan of care that addresses which client-centered goals?

- Living a healthy lifestyle - Improving one's quality of life - Increasing the longevity of one's life - Disease prevention

3. When providing teaching to clients in the community, a nurse is accurate in stating that the musculoskeletal system is most likely aligned with which other body system?

- Neurological system

10. During a patient interview, the nurse is focusing on culture influences particularly when assessing which area?

- Nutrition - High-risk behaviors - Health care beliefs and practices

31. During the assessment of a 2-month-old infant's reflexes, the nurse placed a finger in the baby's hand and pressed against the palm. The baby flexed all fingers to grasp the nurse's finger. How would the nurse document this finding?

- Palmar grasp reflex intact

6. An auditory hallucination is considered an alteration in which component of the mental health assessment?

- Perception

21. During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should techniques should the nurse use for this assessment?

- Percussion - Palpitation

24. A 6-month-old infant is awake but resting quietly in the mothers arms while waiting for a wellness physical examination. What can the nurse do to make the examination process comfortable for the child? (Select all that apply)

- Perform much of the examination in the mother's lap - make sure the baby is fed before the examination - approach the infant with a toy

43. The nurse is following a structured head-to-toe approached to identify changes in a patient's body system. Which component of the health assessment is the nurse completing with the patient?

- Physical examination

20. While assessing a client's musculoskeletal status, the nurse asks the client to perform lateral bends. Which of the following will this movement provide information about?

- Range of motion

48. During a spiritual assessment, the nurse asks the patient what religious symbols are helpful to them. The nurse is assessing the patient

- Religious practice

46. A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document the finding?

- Right knee +2; Left knee +1

30. A new client is admitted to a long-term care facility. The nurse assesses the client with an unsteady gait and incontinence. Which problem should the nurse address when planning care for this client?

- Risk for falls

20. The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as begin a priority?

- Significantly impaired hearing

35. A client has areas of petechiae and ecchymosis over the arms and legs. In which section of the review of system's (ROS) of the nutritional health assessment would the nurse document this finding?

- Skin, hair, and nails

47. When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?

- Smile

15. While conducting a mental status history, the nurse notes that the patient is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the history is this information important?

- Speech and language

46. A 60-year-old female client report a 5-day history of constipation. She describes a sensation of "burning" in her perianal area. This information is considered which part of the assessment data?

- Subjective date

10. The nurse assesses a client who reports chronic pain with chewing. The nurse should assess which body are to investigate the client's problem further?

- Temporomandibular joint

44. Which assessment finding supports a diagnosis of scoliosis?

- The right hemithorax is generally prominent

19. Which observation confirms to the nurse that the client is experiencing a normal inspiration?

- The thoracic cavity enlarges

31. Which statement is true concerning the location and structure of the trachea and major bronchi?

- The trachea divides or bifurcates anteriorly at the sternal angle

34. A client is clenching the jaw closed to avoid taking the oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

- Trigeminal

38. A nurse in the community id competing a manual blood pressure assessment in the dayroom of a senior center. Which action should the nurse take to ensure the assessment is accurate?

- Turn down the TV volume

37. The nurse is preparing to conduct a physical examination of a client who experiences pain when moving positions. Which of the following can the nurse examine while the client is still standing? (Select all that apply)

- Vision, spinal motion, and balance

23. The nurse is preparing to assess a client's cranial nerve using a screening neurologic examination. Which of the following should the nurse include in the assessment? (Select all that apply)

- Visual acuity - Eye movements - Hearing - facial strength

4. The nurse preparing to conduct an integumentary assessment will include which intervention when preparing the patient for this examination?

- Wearing gloves when palpating lesion - Assisting the patient to put on a gown - Providing adequate drapes

38. The nurse determines the heart rate of 100 beats per minute for a 5-year-old patient. What conclusion about the child's heart rate should the nurse draw from this assessment finding?

- Within normal limits (68-138 bpm)

13. A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status?

- accessibility

26. When the nurse is assessing a client who is comatose, which actions should be included in the assessment? (Select all that apply)

- assessing airway' circulation; and breathing - obtaining medical history - repositioning of the neck - checking pupillary light reflexes

2. A nurse is preparing an educational session on exercise for older adults. Which points should be included to promote the benefit of exercise for this age group? (Select all that apply)

- being able to walk faster, improve blood glucose regulation, decrease risk for fractures

27. While conducting a comprehensive health history, the nurse asks a client to describe strategies for managing stress. This information is important for the nurse because it assesses the patient's

- coping stress tolerance patters

23. a client has a BP of 178/92. What lifestyles changes can the nurse recommend helping decrease the client BP.

- increase the intake of sweet potatoes - walks briskly for 30min each day - avoid snacks such as pretzels and potatoes chips

49. During an assessment, the nurse ask a patient with low back pain if the pain is radiating. The nurse is asking this question to obtain assessment information for which category of the mnemonic OLD CART?

- location

14. The nurse wants to ensure that a thorough medication history has been completed with the older adult client. Which checks need to be included? (Select all that apply)

- medication name, medication dose, medication frequency, clients understanding of the need for the medication

22. a patient's risk for pressure sore development according to the Braden Scale is as follows: sensory perception: 4, moisture: 4, activity:2, mobility: 2, nutrition:1, friction and shear: 3 from this assessment, the nurse determines that the patient's risk for pressure sore development is:

- mild risk

15. In partnership with the client, the nurse identifies a priority health goal for this client as smoking cessation. The nurse and client discuss possible interventions to assist the client in achieve this goal. In which phase of the nursing process are the nurse and patient participating?

- planning

28. the nurse is preparing to assess a patient's visual acuity. The equipment that the nurse will need to conduct this portion of the PE is

- rosenbaum chart - Snellen chart

25.The nurse planning to instruct a group of adolescents on ways to prevent traumatic brain injury. What should be included in these instructions?

-Always use seat belts

23.Which client should the nurse assess for possible primary amenorrhea?

-An 18-year old who has never started menses.

10.During the physical assessment of the peripheral vascular system, a patient's foot is pale when elevated and dark red when in the dependent position. The nurse is concerned that this patient is at risk for developing:

-Arterial insufficiency ulcers

31. During deep palpation of the abdomen, a client experience right lower quadrant rebound tenderness. The nurse should conduct which additional assessment?

-Assess for the Obturator sign and Psoas sign, Palpate for Rovsing's sign

18.A 57- year old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?

-Assess the client's blood pressure

8. During the health history, a client who has abdominal pain reports having occasional nausea and diarrhea. In which section of the health history should the nurse document the finding?

-Associated manifestations

4. A nurse palpates a mass in the client's right lower quadrant. The nurse suspects that this mass could be associated with which of the following organs?

-Bladder, Ascending colon, Appendix

35. When conducting the physical examination of a client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following statements would accurately describes these findings?

-Bowel sounds normal

39. A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1-10. This subjective data should be documented in which section of the assessment?

-Characteristic syndrome

20. What eye function is the nurse is the nurse preparing to assess when the patient is asked to stand 20 feet from a specific chart the is mounted on the examination room wall?

-Distal vision

12. The nurse is going to assess a patient's ankle-brachial index. Which equipment will the nurse for the assessment?

-Doppler device, Blood pressure cuff

5. A patient has developed an infection on the right forearm. The nurse will focus the assessment of the patient's lymphatic system on which area?

-Epitrochlear

6.While conducting an abdominal physical examination, the client reports pain with deep palpation of the right kidney. Which of the following should be the nurse's next step in the physical examination?

-First percussion of the costovertebral angles

21.Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)?

-III oculomotor

49. A patient is diagnosed with glaucoma affecting the left eye. What assessment data concerning the left eye noted in the patient's medical record supports this diagnosis?

-Increase intraocular pressure.

17. Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report?

-Inspect for dependent edema

46. Which characteristics are present in a cancerous lesion?

-Irregular in shape, firm of even hard to the touch, not clearly delineated, usually nontender, may cause noticeable retraction of the nipple.

42. During the reproductive system health history, a patient tells the nurse about having excessive menstrual flow. The nurse would document this information as:

-Menorrhagia

13. In order to effectively examine a patient's eyes with an ophthalmoscope, the nurse should follow which procedure related to this piece of equipment?

-Place the ophthalmoscope in the right hand and look through the right eye.

29. A patient is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess the patient's symptom?

-Press up on the frontal sinuses from under the bony brows, Press up on the maxillary sinuses

9. A client reports occasionally experiencing hoarseness. In response to this statement, the nurse asks, "What makes the hoarseness go away?" Which characteristics of the client's symptoms is the nurse assessing?

-Relieving factors

19. To best secure accurate assessment information, the nurse should complete which part of the reproductive history last?

-Sexual

26. During the inspection of a patient's reproductive system, the nurse identifies small lacerations and bruises of the labia majora and minora. What does the finding suggest to the nurse?

-Sexual abuse

34. The nurse asks the patient to sit with the arms at both sides when beginning the clinical breast examination. With this position, the nurse will assess which breast characteristics?

-Size and symmetry of breasts, contour of the breasts, appearance of skin, characteristics of the nipples.

43. A client is being assessed for indications of a possible obstructed nasolacrimal duct in the right eye. Under what circumstances should the nurse avoid compressing the lacrimal sac?

-The area around the sac is inflamed

37. When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

-To observer the movement of the thyroid gland

30. Which nursing assessment finding supports the diagnosis of chronic arterial insufficiency?

-Ulceration is noted on the great toe of the affected foot.

11. A family member of a client recovering from a traumatic brain injury, asks the nurse what safeguards can be put in place at home to prevent future head injuries. What should the nurse instruct the family member?

-Use rails on stairs, Avoid the use of throw rugs, Remove extension cords from high traffic areas.