Quiz Questions

A client tells a nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? a. move to the next body system b. inspect the area c. palpate the area d. document the statement

b: inspect the area

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse noted considerable skin tenting. Why does this finding require further assessment? a. tenting indicates extreme weight loss b. tenting indicates vitamin B12 deficiency c. Tenting indicates dehydration d. Tenting indicates malnutrition

c - tenting indicates dehydration

One extremity cooler than the other indicates venous insufficiency. True False

False

The nurse assesses the response of the eye to light and documents normal findings as PERLLA True False

False

The Right Middle Lobe can best be assessed posteriorly. True False

False - Posteriorly

If S4 is present, it will be heard following S1 and sounds like "lub-lub dub." True False

Flase

Decreasing the angle between bones is called... a. Extension b. Eversion c. Flexion d. Inversion

Flexion

A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive? A. Murphy sign B. Rovsing sign C. Psoas sign D. Obturator sign

A

When documenting a finding over the stomach, the nurse most accurately identifies the region as which of the following? A. LUQ B. RUQ C. hypogastric D. epigastric

D

A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern? A. Cheyne-Stokes B. Kussmaul's C. Eupnea D. Tachypnea

A

Nursing students are learning about different methods of charting in clinical. What method is the model for improving communication between and among clinicians? A. SBAR B. CBE C. SOAP D. PIE

A

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known at what? A. Angina B. Crushing C. Musculoskeletal D. Gastrointestinal

A

The RN working on a surgical unit should question which of these orders before completing it? A. Reapply a staple in an incision B. Administer a narcotic infusion C. Change a central line dressing D. Check intracranial pressure

A

The nurse palpates a fine, round, mobile, non tender nodule and suspects that it is A. a fibroadenoma B. a cyst C. breast cancer D. a fibrocystic breast change

A

During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+ Selected Answer:

2+

The point of maximum impulse is most often found where? A. 5th intercostal space (ICS), left midclavicular line (MCL) B. 5th intercostal space (ICS), right midclavicular line (MCL) C. 2nd intercostal space (ICS), left midclavicular line (MCL) D. 2nd intercostal space (ICS), right midclavicular line (MCL)

A

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. A. Frontal B. Parietal C. Occipital D. Temporal

A

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding? A. Systolic pressure 201 mm Hg B. Apical pulse 70 beats/minute C. Respirations 12 breaths/minute D. Oxygen saturation 95% on room air

A

A hospitalized client complains of pain 10/10 one hour after receiving a dose of intravenous Morphine sulfate intravenously. The next dose is not due for over an hour. What is the nurse's best action? A. Document the pain assessment findings and reassess in 30 minutes. B. Administer another dose of Morphine early. C. Tell the client he/she can not have anymore pain medication. D> Notify the healthcare provider.

A

A nurse performs a comprehensive assessment on a client. Which is included only in a comprehensive assessment? A. Complete health history B. Circulatory assessment C. Assessment of the airway D. Disability assessment

A

What percussion sound is heard over most of the abdomen? A. Tympany B. Resonance C. Dullness D> Hyperresonance

A

A nursing diagnosis appropriate for a patient with ear problems is... A. disturbed sensory perception. B. kinesthetic disturbed perception. C. sensory perception, gustatory. D. olfactory sensory perception.

A

A patient is reporting pain after palpation of the right lower quadrant. What condition does the nurse expect? A. Appendicitis B. Irritable bowel syndrome C. Nephrolithiasis D. Gastroenteritis

A

A client comes to the clinic reporting pain in her legs while walking. the client states the pain is goes away when resting. The nurse suspects the client is experiencing what? A. Intermittent claudication B. Varicose veins C. Pulmonary embolism D. Deep vein thrombosis

A

A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about the lump? A. Size B. Symmetry of the chest C. Nipple size D. Pallor

A

A client in the ED tells a nurse that she feels short of breath. What term would the nurse use in documenting this finding? A. Dyspnea B. Orthopnea C. Tachypnea D. Anxiety

A

When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following? A. Right iliac artery B. Abdominal aorta C. Right femoral artery D. Right renal artery

A

Which formula will the nurse use to calculate cardiac output? A. heart rate x stroke volume B. systolic x diastolic C. preload x afterload D. heart rate x preload

A

Which of the following would the nurse consider objective data? A. Evaluating the jugular pulse B. Smoking history C. Reported palpitations D. Chest pain

A

Which principle should guide the nurse's approach when conducting a general survey on an older adult client? A. Allow the client time to answer questions B. Speak louder than normal to the client C. Read all written instructions for the client D. Direct questions to family whenever possible

A

The nursing instructor is discussing the normal functioning of the nose and sinuses with the nursing class. What would be the best description of the major factors related to the normal functioning of these structures? Select all that apply. A. Normal quality and quantity of the mucous B. Normal cilia function C. Deep cervical and retropharyngeal nodes D. Patency of the sinus ostia E. An abundant lymph supply

A, B, D

When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply A. Undergo regular cholesterol screening B. Undergo regular screening for diabetes C. Eat a low-fiber diet D. Quit or do not start smoking E. Exercise regularly

A, B, D, E

What techniques can be performed when palpating the breasts? Select all that apply. A. Circular pattern B. Rectangular pattern C. Side to side pattern D. Vertical pattern E. Wedge pattern

A, D, E

A client diagnosed with peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse's priority concern for this client? A. Ensure a patent airway B. Begin antibiotics immediately C. Obtain a throat culture D. Correct clients dehydration

A: Ensure a patient airway

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels? A. Lymphatic B. Veins C. Aortic D. Arteries

A: Lymphatic

The results of a client's Rinne test are as follows: bone conduction > air conduction. How should the nurse explain these findings to the client? A."You have conductive hearing loss." B. "You have nerve damage in your ears." C. "You have a high frequency hearing loss." D. "You have a unilateral hearing loss."

A: You have conducting hearing loss

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? A. Dermis B. Subcutaneous layer C. Connective layer D. Epidermis

A: dermis

The nurse assessing a clients skin identifies an ulcer. What would indicate to the nurse it is an arterial ulcer? A. The ulcer is necrotic B. The borders are irregular C. The ulcer is superficial and pale D. The extremity has a pulse

A: the ulcer is Necrotic

How does the nurse use critical thinking when accurately assessing vital signs? A. Evaluating assessment techniques B. Developing nursing diagnoses C. Monitoring evaluations D. Planning assessment techniques

B

How many quadrants is the abdomen divided in to during an assessment? A. 6 B. 4 C. 2 D. 8

B

The RN may delegate which care component to a nursing assistant? A. Evaluating vital signs B. Ambulation assistance C. Check client's pain level D. Wound care and assessment

B

The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action? A. Scan the barcode on the client's chart, then administer the medications. B. Leave the room to obtain another armband for the client. C. Confirm the client's identity with visitors who are present. D. Ask the client for name and birth date, then administer the medications.

B

The nurse is caring for a client with a sudden onset of chest pain. Which assessment is highest priority? A. Auscultate heart sounds B. Obtain pulse and blood pressure C. Inspect the precordium D. Percuss the left border

B

The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment? A. Comprehensive B. Functional C. Head to toe D. Body systems

B

When conducting a focused health assessment, the nurse asks questions specifically targeting what? A. The client's sexual orientation B. Issues and symptoms specific to the client C. The client's gender D. The client's culture

B

Which client-satisfaction related intervention of staff nurses may lead to improved client outcomes? A. Daily client rounds B. Bedside hand-off reports C. Request that visitors remain in waiting room D. Leaving client room doors open

B

Which of the following assessment findings would lead the nurse to suspect that a client has Bell's palsy? A. Closure of the affected eye from swelling B. Inability to wrinkle the forehead C. Inability to detect sharp and dull stimuli D. Muscle spasm of the lower face on the affected side

B

A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for signs of hyperthyroidism. What are some signs of hyperthyroidism? Select all that apply. A. Cold Intolerance B. Heat Intolerance C. Anxiety D. Headache E. Palpitations

B, C, E

According to the guidelines from the Centers for Disease Control and Prevention (CDC), why are nurses supposed to wear gloves? (Select all that apply.) A. help maintain a sterile environment B. prevent the transmission of bacteria from nurses to clients C. reduce the risk of infecting health care personnel D. Reduce the number of bacteria in the health care environment E. Reduce transient contamination of the hands

B, C, E

The six Ps of arterial occlusion include which of the following? Select all that apply. A. Pilonidal B. Paresthesia C. Pilocarpine D. Pulselessness E. Pallor F. Pain

B, D, E, F

What pulse is located in the groove between the medial malleolus and the Achilles tendon? A. Popliteal B. Posterior tibial C. Dorsalis pedis D.Femoral

B. Posterior tibial

A client reports to the ER complaining of pain in their left calf. Upon assessment a nurse notes the reported area is edematous, red, and warm to the touch. The nurse suspects the client may have what? A. Varicose veins B. Deep vein thrombosis (DVT) C. Lymphedema D. Pulmonary embolism (PE)

B: DVT

When assessing the lower extremities, it is critical that the examiner A. starts at the femoral area. B. compares side to side. C. starts at the feet. D. evaluates the venous system and then the arterial system.

B: compare side to side

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: A. Lack of coordination. B. A normal finding. C. Positive Romberg sign. D. Ataxia.

C

A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test? A. Sensation B. Remote memory C. Balance D. Mental status exam

C

A nurse notes a bruit when auscultating over the right carotid artery. The nurse determines the abnormal sound is a bruit because a _________ sound is heard. A. S1 & S2 B. S3 & S4 C. Swishing D. Humming

C

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? A. To establish rapport with the client and family. B. To gather information for specialists to whom the client might be referred. C. To establish a database against which subsequent assessments can be measured. D. To quantify the degree of pain a client may be experiencing.

C

A patient reports changes in bowel pattern. Which is the best question to determine normal bowel habits? A. Is there a family history of irritable bowel syndrome? B. How often do you have a bowel movement? C. What was your bowel pattern before you noticed the change? D. Have any of your parents or siblings had cancer of the colon?

C

A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg (20 lb) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain? A. Listen for a fluid wave B. Auscultate for lymph nodes C. Percuss the abdomen for shifting dullness D. Stroke the abdomen to elicit the abdominal reflex

C

A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will elicit kidney pain? A. Inspection with indirect lighting B. Iliopsoas muscle sign C. Indirect percussion of CVA tenderness D. Blumberg sign

C

At the beginning of the shift, an older adult hospitalized for pneumonia complains of shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time? A. Focused B. Comprehensive C. Immediate D. Shift

C

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as: A. Tinnitus B. Dizziness C. Vertigo D. Syncope

C

HIPAA gives clients greater control over their medical records. What else does HIPAA provide? A. Copying of medical records B. Education of lay people about medical records C. Client recourse if privacy protections are violated D. Legal use of medical records

C

Students are learning about the many uses of the medical record. One of these uses is to perform an internal audit. What is the goal of an internal audit? A. The evaluation of financial reimbursement B. The evaluation of client nutrition C. The evaluation of care for continual improvement D. The evaluation of timely documentation of pain

C

The nurse is assessing a 15 year old male and finds soft, fatty enlargement of the breast tissue. The nurse would document this at what? A. Fibroadenoma B. Cysts C. Gynecomastia D. Breast abscess

C

The nurse should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client? A. Decrease to 54 beats/minute B. Increase to 90 beats/minute C. Decrease to 44 beats/minute D. Increase to 112 beats/minute

C

The nursing instructor is explaining SBAR documentation to students before taking them into the clinical area. The instructor explains that SBAR charting is based on? A. The client's background B. Information that the nurse obtains from the family C. Complete and accurate assessment findings D. Data in old medical records

C

To make a legal entry into the medical record, the nurse must document what? A. Laboratory tests ordered B. Attending physician C. Time of the assessment D. Nature of the assessment

C

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder? A. Diabetes mellitus B. System lupus erythematosus C. Chronic obstructive pulmonary disease D. Heart failure

C

What tool does the nurse use to auscultate the client's abdomen? A. None B. Fetoscope C. Stethoscope D. Sonoscope

C

When caring for clients in any health care environment, what is the most important technique for preventing infection? A. Sterile technique B. Standard precautions C. Hand hygiene D. Use of gloves

C

While performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 6-mm depression. How would the nurse document this? A. 4+ pitting edema B. 1+ pitting edema C. 3+ pitting edema D. 2+ pitting edema

C, +3 pitting edema

Peripheral vision is evaluated by the nurse using the... A. cover test B. cardinal fields of gaze test C. confrontation test D. corneal light test

C: confrontation test

A high-pitched crowing sound from the upper airway results fro tracheal or laryngeal spasm and is called what? A. Wheezes B. Rales C. Crackles D. Stridor

D

The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action? A. Check for pupil reaction. B. Count respirations. C. Assess blood pressure. D. Ensure a patent airway.

D

The nurse is assessing balance. Which test would the nurse plan on omitting from the exam? A. Hop on one foot B. Walking heel-to-toe C. Romberg D. Achilles reflexes

D

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: A. Sticks out the tongue midline without tremors or deviation. B. Demonstrates the ability to hear normal conversation. C. Follows an object with his or her eyes without nystagmus or strabismus. D. Moves the head and shoulders against resistance with equal strength.

D

The sternal angle at the right 2nd rib space is also known as what? A. The pulmonic area B. The tricuspid area C. The mitral area D. The aortic area

D

What is the second step of physical assessment when assessing the abdominal? A. Inspection B. Percussion C. Palpation D. Auscultation

D

When assessing cranial nerves IX and X, which of the following would the nurse consider as an abnormal finding? A. Contraction of the pharyngeal muscle. B. Asymmetrical tongue movement. C. Upward movement of the palate. D. Impaired swallowing.

D

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve? A. Assess dilatation of pupils with direct light B. Have the client smile, frown, and wrinkle the forehead C. Ask the client to differentiate sharp and dull sensations on the face D. Palpate the temporal and masseter muscles while the client clenches teeth

D

During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes an ulcer at the ankle that The client describes pain at the ulcer site as achy. The nurse suspects the client may have what? A. Hypertrophic changes B. Venous insufficiency C. Intermittent claudication D. Arterial insufficiency

D: Arterial insufficency

Moving a part of the body away from the mid line is called? A. Adduction B. Extension C. Flexion D. Abduction

D: abduction

The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of A: asthenia B. the loss of accommodation C. the unequal size of the pupils D. amblyopia

The loss of accommodation

Maintaining fluid balance is one function of the lymphatic system True False

True

S1 results from closure of the mitral and tricuspid valves. True False

True

When auscultating the thorax for adventitious breath sounds it is important to listen at each site for at least one complete respiratory cycle. True False

True

When using an otoscope to assess the inner ear the nurse should hold the patient's ear at the helix, lifting up and back for best visualization. True False

True