Basic Physical Assessment

A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson's disease. Which assessment finding should the nurse anticipate? a) Tremors in the fingers that increase with purposeful movement b) Pleasant and smiling demeanor c) Coughing when drinking liquids d) Muscle flaccidity of the lower extremities

Coughing when drinking liquids Explanation: In Parkinson's disease, dysarthria, or impaired speech, results from a disturbance in muscle control. Muscle rigidity, not flaccidity, causes resistance to passive muscle stretching. The client may exhibit a mask-like appearance rather than a pleasant and smiling demeanor. Tremors should decrease, not increase, with purposeful movement and sleep. When the disease is advanced, swallowing is impaired and coughing would indicated aspiration.

Tachycardia can result from: a) vomiting, anger, or suctioning. b) fear, pain, or anger. c) stress, pain, or vomiting. d) vagal stimulation.

fear, pain, or anger. Explanation: Fear, anger, stress, or pain can increase heart rate (tachycardia). Decreases in heart rate (bradycardia) can stem from vomiting, suctioning (causing vagal nerve stimulation), or certain medications.

A nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature? a) 40.1° C b) 38.9° C c) 39° C d) 47° C

38.9° C

The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD). During the assessment, the nurse should expect to find which of the following clinical manifestations of PVD? Select all that apply. a) Mottled skin. b) Moist skin c) Pink skin d) Hairy legs. e) Coolness

A. Mottled skin. E. Coolness Explanation: Reduction of blood flow to a specific area results in decreased oxygen and nutrients. As a result, the skin may appear mottled. The skin will also be cool to the touch. Loss of hair and dry skin are other skins that the nurse may observe in a client with PVD of the lower extremities

Which of the following findings would be expected in a client with chest trauma, rib fractures, and respiratory acidosis?" a) Hypoventilation due to inability to take deep breaths because of pain b) Hyperventilation due to inability to take deep breaths, so short fast breaths are more comfortable c) Kussmaul respirations due to inability to take deep breaths d) A massive diffusion disturbance due to the rib fractures

A. Hypoventilation due to inability to take deep breaths because of pain Explanation: Hypoventilation causes a buildup of CO2 in the blood. Kussmaul respirations are related to abnormal respiratory patterns and are characterized by rapid, deep breathing. They are often seen in clients with metabolic acidosis, and hyperventilation would not cause acidosis. The choice rib fractures do not represent any information in the scenario

Which of the following assessment questions is most likely to yield clinically meaningful data about a female client's sexual identity? a) "Are you satisfied with the quality of your relationships right now?" b) "Have you ever had any sexually transmitted diseases in the past?" c) "How do you feel about yourself as a woman?" d) "Do you find that your health allows you to enjoy a meaningful sex life?"

"How do you feel about yourself as a woman?" Explanation: Sexual identity is a broad concept that includes, but supersedes, sexual functioning. However, it is more specific than simply asking about the quality of relationships. Asking an open-ended question about how the client feels about herself as a woman is likely to elicit important insights. Assessing the client's history of STIs does not directly address her sexual identity.

The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which of the following children is in the greatest need of emergency medical treatment? a) A 6 year old with a fever of 104 degrees F (40 degrees C), muffled voice, no spontaneous cough, and drooling b) A 4 year old with a fever of 101 degrees F (38.3 degrees C), hoarse cough, inspiratory stridor, and restlessness c) A 3 year old with a fever of 100 degrees F (37.8 degrees C), barky cough, and mild intercostal retractions d) A 13 year old with a fever of 104 degrees F (40 degrees C), chills, and coughing with thick yellow secretions

A 6 year old with a fever of 104 degrees F (40 degrees C), muffled voice, no spontaneous cough, and drooling Explanation: This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency because of its risk of complete airway obstruction. The 3 and 4 year olds are exhibiting signs and symptoms of croup. Symptoms often diminish after a child with croup is taken out in the cool night air. If symptoms do not improve, the child may need a single dose of dexamethasone. Fever should also be treated with antipyretics. The 13 year old is exhibiting signs and symptoms of bronchitis. Treatment includes rest, antipyretics, and hydration.

The nurse assesses an older adult for signs of dehydration. Which of the following findings would be consistent with a diagnosis of dehydration? a) Shortness of breath. b) Moist crackles. c) Bounding pulse. d) Orthostatic hypotension.

Orthostatic hypotension. Explanation: Orthostatic hypotension or persistent hypotension is present in dehydration, as are poor skin turgor, dry oral mucous membranes, and tachycardia. If the dehydration is severe, the client may also be restless, confused, and thirsty. Most instances of crackles, shortness of breath, and bounding pulse are indicative of excess fluid volume.

Which of the following changes are associated with normal aging? a) The dermis becomes highly vascular and assists in the regulation of body temperature. b) The outer layer of skin is replaced with new cells every 3 days. c) Collagen becomes elastic and strong. d) Subcutaneous fat and extracellular water decrease.

Subcutaneous fat and extracellular water decrease. Explanation: With age, there is a decreased amount of subcutaneous fat, muscle laxity, degeneration of elastic fibers, and collagen stiffening. The outer layer of skin is almost completely replaced every 3 to 4 weeks. The vascular supply diminishes with age. Collagen thins and diminishes with age.

Which of the following is the most accurate method of determining the extent of a client's fluid loss? a) Weighing the client. b) Assessing skin turgor. c) Assessing vital signs. d) Measuring intake and output.

Weighing the client. Explanation: Accurate daily weight measurement provides the best measure of a client's fluid status: 1 kg (2.2 lb) is equal to 1,000 ml of fluid. To be accurate, weight should be obtained at the same time every day, with the same scale, and with minimal clothing on.

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are: a) progressively deeper breaths followed by shallower breaths with apneic periods. b) shallow breaths with an increased respiratory rate. c) rapid, deep breaths with abrupt pauses between each breath. d) rapid, deep breaths and irregular breathing without pauses.

progressively deeper breaths followed by shallower breaths with apneic periods. Explanation: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

When evaluating a client's preoperative cognitive-perceptual pattern, which of the following questions should the nurse ask the client? a) "Do you smoke?" b) "Do you wear glasses?" c) "Do you need special equipment to walk?" d) "Do you have difficulty swallowing?"

"Do you wear glasses?" Explanation: The nurse would ask the client whether he wears glasses to evaluate his preoperative cognitive-perceptual pattern. Asking about the client's swallowing pattern would evaluate his nutritional-metabolic pattern. Asking about his need for special equipment to walk would evaluate his activity-exercise pattern. Asking the client about his history of smoking would evaluate his health perception-health management pattern.

A nurse is assessing a client using light palpation. How does a nurse perform light palpation? a) By indenting the client's skin 1″ and then releasing the pressure quickly b) By indenting the client's skin 1″ to 2″ (2.5 to 5 cm) c) By indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm) d) By indenting the client's skin 1″, using both hands

By indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm) Explanation: To perform light palpation, the nurse indents the client's skin ½″ to ¾″, using the tips and pads of her fingers. She indents the skin approximately 1½″ (3.8 cm) when performing deep palpation. She indents the skin 1″ and then releases the pressure quickly when eliciting rebound tenderness.

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? a) Every 15 minutes. b) Every 20 minutes. c) Every 5 minutes. d) Every 10 minutes.

Every 15 minutes. Explanation: In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device

The nurse is assessing the client's bowel sounds. The nurse should: a) Use the bell of the stethoscope. b) Expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. c) Listen for 2 minutes in each area of the abdomen. d) Ask the client to drink a glass of warm water prior to auscultation.

Expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. Explanation: Normal bowel sounds occur at a rate of 5 to 35 sounds per minute. The nurse should use the diaphragm of the stethoscope and listen for 1 minute, moving the stethoscope in all four quadrants. The client should empty the bladder prior to auscultation, and not drink water, which might increase the frequency of the sounds

A client with a spinal cord injury says he has difficulty recognizing the symptoms of a urinary tract infection (UTI). Which assessment finding is an early symptom of UTI in a client with a spinal cord injury? a) Lower back pain b) Fever and change in urine clarity c) Frequency of urination d) Burning sensation on urination

Fever and change in urine clarity Explanation: Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

The nurse is obtaining a health history from a client of Puerto Rican descent. Which of the following is most likely to be a health problem with a cultural connection for this client? a) Sickle-cell anemia. b) Suicide. c) Tuberculosis. d) Lactose enzyme deficiency.

Lactose enzyme deficiency. Explanation: Common health problems that may affect the Puerto Rican population include lactose enzyme deficiency and parasitic diseases. Tuberculosis is a common health problem for the Native American population. Sickle-cell anemia predominantly affects the African-American population, and suicide is a common health problem for the Native American and white middle-class populations.

A nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test? a) Weber's test b) Watch tick test c) Whispered voice test d) Rinne test

Rinne test Explanation: The Rinne test compares air conduction to bone conduction in both ears. The whispered voice test evaluates low-pitched sounds, and the watch tick test assesses high-pitched sounds. Both tests assess gross hearing. Weber's test evaluates bone conduction.

A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis? a) Tripod position b) Mild fever c) Clear speech d) Gradual onset of symptoms

Tripod position Explanation: The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottitis because this position facilitates breathing. Epiglottitis presents with a sudden onset of signs and symptoms, such as high fever, muffled speech, inspiratory stridor, and drooling.

Which of the following nursing assessment findings in a client with septic shock would require immediate intervention? a) Urine output of 90 mL of dark, concentrated urine for the past 6 hours b) Fluctuation of temperature c) Confusion when listening to explanations of procedures d) Client experiencing polydipsia

Urine output of 90 mL of dark, concentrated urine for the past 6 hours Explanation: Early indicators of septic shock include decreased urine output. In the elderly, lack of fever is a poor indicator of presence or absence of sepsis due to decrease sensation from the hypothalamus. Polydipsia is reflective of diabetes.

When percussing a client's chest, the nurse should expect to hear: a) hyperresonance. b) tympany. c) resonance. d) dullness.

resonance. Explanation: Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in a client with emphysema. When percussing over the abdomen, the nurse may assess tympany, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.

Which plane divides the body longitudinally into anterior and posterior regions? a) Midsagittal plane b) Transverse plane c) Sagittal plane d) Frontal plane

Frontal plane Explanation: A frontal or coronal plane, which runs longitudinally at a right angle to a sagittal plane, divides the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions

The nurse is participating in a blood pressure screening event. After three separate readings taken at least 2 minutes apart, the nurse determines that a client has a blood pressure of 160/90 mm Hg. The nurse should advise the client to: a) Schedule a complete physical immediately. b) Have blood pressure evaluated within 1 month. c) Examine lifestyle to decrease stress. d) Begin an exercise program.

Have blood pressure evaluated within 1 month. Explanation: The client with a systolic blood pressure of 160 to 179 mm Hg should be evaluated by a health care professional within 1 month of the screening. The client with a diastolic blood pressure of 90 to 99 mm Hg should be rechecked within 2 months. Exercise and stress reduction may be desirable activities, but it is first necessary to evaluate the cause of elevated blood pressure. In the absence of other symptoms, it is not necessary to have the client evaluated immediately.

The nurse notices that a client's heart rate decreases from 63 to 50 beats per minute on the monitor. The nurse should first: a) Prepare for transcutaneous pacing. b) Take the client's blood pressure. c) Auscultate for abnormal heart sounds. d) Administer atropine 0.5 mg IV push.

Take the client's blood pressure. Explanation: The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if atropine is needed. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

Which of the following is an early indication that a client has developed hypocalcemia? a) Ventricular dysrhythmias. b) Depressed reflexes. c) Tingling in the fingers. d) Memory changes.

Tingling in the fingers. Explanation: Neuromuscular irritability is usually the first indication that a client has developed a low serum calcium level. Numbness and tingling around the mouth as well as in the extremities is an early sign of neuromuscular irritability. Depressed reflexes, decreased memory, and ventricular dysrhythmias are indications of hypercalcemia.

A client has a nursing diagnosis of fluid volume deficit. Which of the following nursing assessment findings would support this diagnosis? a) Pretibial pitting edema b) Leathery, pliable skin c) Pedal pulses of 4+ d) Orthostatic blood pressure changes

Orthostatic blood pressure changes Explanation: Fluid volume deficit is characterized by hypotension, tachycardia, increased body temperature, and weakness. Leathery, pliable skin may not demonstrate fluid deficit; it may reflect diabetes. Pitting edema and pedal pulses of 4+ demonstrate localized edema and potential fluid excess

Why should the nurse avoid palpating both carotid arteries at one time? a) Palpating both arteries at one time may cause severe bradycardia. b) Palpating both arteries at one time may cause severe tachycardia. c) The nurse can't assess the pulse accurately unless she palpates the arteries one at a time. d) Palpating both arteries at one time may cause transient hypertension.

Palpating both arteries at one time may cause severe bradycardia. Explanation: The nurse must palpate the carotid arteries one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia could lead to cardiac arrest.

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness? a) Pressing firmly with one hand, releasing pressure while maintaining fingertip contact with the skin, and noting increased tenderness on release b) Using light palpation, noting any tenderness over an area c) Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any increased tenderness on release d) Using deep ballottement, noting any tenderness over an area

Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any increased tenderness on release Explanation: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. She doesn't use light palpation or deep ballottment or maintain fingertip contact with skin to elicit rebound tenderness.

A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress? a) The client's head was down, gaze was cast down, and toes were pointed outward. b) The client's pulse and respiratory rates increased moderately during ambulation. c) The client's pulse and respiratory rate returned to baseline 1 hour after activity. d) The client reported feeling dizzy and weak and perspired profusely.

The client's pulse and respiratory rates increased moderately during ambulation. Explanation: Pulse and respiratory rates normally increase during, and for a short time after, ambulation, especially if it is the first ambulation after 3 days of bed rest. Vital signs should return to baseline within 5-10 minutes after activity. Dizziness, weakness, and profuse perspiration are definite signs of activity intolerance. A client who tolerates ambulation well holds his head erect, gazes straight ahead, and keeps his toes pointed forward. A client who ambulates with his head down, gaze cast down, and toes pointed outward is exhibiting activity intolerance.

The nurse is teaching a 17-year-old, sexually active female about the importance of regular Papanicolaou (Pap) smears. The nurse should instruct the client that: a) If four consecutive annual Pap smears are negative, the client should schedule repeat Pap smears every 3 years. b) The initial Pap smear should be done at age 21 or 3 years after becoming sexually active. c) Pap smears are recommended every other year. d) The client should request a colposcopy.

The initial Pap smear should be done at age 21 or 3 years after becoming sexually active. Explanation: The American Cancer Society, Canadian Cancer Society, American College of Obstetricians and Gynecologists, and Society of Obstetricians and Gynecologists of Canada recommend that a Pap smear and pelvic examination should be done 3 years after a woman first has vaginal intercourse, but no later than 21 years of age. Annual Pap smears are recommended only for clients at risk and not for the general female population. Women 21 to 30 years should have a Pap test every 2 years. Women older than 30 years, after three or more negative Pap smears, may have a Pap smear every 3 years. Colposcopy is indicated for clients who have an abnormal Pap smear and thus is not necessary for this young client.

An African-American (Black) client is brought to the emergency department after sustaining injury in a vehicle accident. The client is bleeding profusely from the wounded leg. In which of the following areas should the nurse check for pallor in the client? a) Tongue. b) Hands. c) Abdomen. d) Face.

Tongue. Explanation: In the African-American (Black) client, the nurse should check the tongue for pallor. Face, hands, and abdomen are not appropriate places to check for pallor because these areas have heavy pigmentation.

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding? a) Vesicle b) Papule c) Pustule d) Macule

Vesicle Explanation: A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.

An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply. a) Acute respiratory distress syndrome b) Pneumonia c) Cardiac tamponade d) Pulmonary edema e) Epiglottitis

• Pulmonary edema • Pneumonia • Acute respiratory distress syndrome Explanation: Crackles are typically heard on inspiration, can be low- or high-pitched, and occur when air is drawn through fluid in the lung's passageways. They can be classified as fine or course. They may be present on auscultation in a client with acute respiratory distress syndrome, pneumonia, and pulmonary edema. Crackles are not heard in clients with epiglottitis or cardiac tamponade.

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma? a) "The stoma should remain swollen distal to the abdomen." b) "At first, the stoma may bleed slightly when touched." c) "A burning sensation under the stoma faceplate is normal." d) "The stoma should appear dark and have a bluish hue."

B. "At first, the stoma may bleed slightly when touched." Explanation: The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

A nurse can auscultate for heart sounds more easily if the client is: a) leaning forward. b) supine. c) on his right side. d) holding his breath.

leaning forward. Explanation: The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This position enables the nurse to listen for heart sounds without the sound of expiration interfering. Using the supine position to visually inspect the precordium allows the nurse to observe the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole. Placing the client in a left lateral decubitus position may make it easier for the nurse to hear low-pitched sounds related to atrioventricular valve problems.

When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment? a) Checking the level of pain first upon the client's return from the operating room b) Assessing the vital signs and oxygen saturation levels c) Assessing for urinary retention and the need to void d) Checking the dressing, drain, and amount of drainage

B. Assessing the vital signs and oxygen saturation levels Explanation: This correct response is based on principles of ABCs. The return of urinary function after anesthesia usually takes 6 or more hours, so this assessment is not a priority upon return from the recovery room. Checking the dressing and level of pain are both important, but not the priority.

The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the: a) Changes from the normal expected findings. b) Appearance of age-related wrinkles. c) Similarities from one side to the other. d) Skin turgor.

Changes from the normal expected findings. Explanation: Noting changes from the normal expected findings is the most important component when assessing an older client's integumentary system. Comparing one extremity with the contralateral extremity (i.e., comparing one side with the other) is an important assessment step; however, the most important component is noting changes from an expected normal baseline. Noting wrinkles related to age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an assessment of the integumentary system.

The nurse in the postanesthesia care unit notes that one of the client's pupils is larger than the other. The nurse should: a) Check the client's baseline data. b) Administer oxygen. c) Rate the client on the Glasgow Coma Scale. d) Call the surgeon.

Check the client's baseline data. Explanation: The nurse should check the client's baseline data to ascertain whether the client's pupil has always been enlarged or this is a new finding. The preoperative assessment is valuable as the baseline for comparison of all subsequent assessments made throughout the perioperative period. The nurse may determine that a more involved neurologic examination is indicated or may choose to assess other signs using the Glasgow Coma Scale, administer oxygen, or call the surgeon, but the nurse still needs to know the baseline data before proceeding.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: a) pallor and coolness of the left foot with decreased sensation. b) a decrease in the left dorsalis pedis and posterior tibial pulses. c) loss of hair on the lower portion of the left leg and foot. d) left calf circumference 1" (2.5 cm) larger than the right.

left calf circumference 1" (2.5 cm) larger than the right. Explanation: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased sensation, decreased pulses, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

When auscultating a client's chest, a nurse assesses a second heart sound (S2). This sound results from: a) opening of the mitral and tricuspid valves. b) closing of the mitral and tricuspid valves. c) closing of the aortic and pulmonic valves. d) opening of the aortic and pulmonic valves.

C. closing of the aortic and pulmonic valves. Explanation: The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.

The nurse assesses a client and notes a weak, irregular pulse, as well as soft, flabby muscles. The nurse should assess the client further for: a) Hypernatremia. b) Hypokalemia. c) Hypomagnesemia. d) Hypercalcemia.

Hypokalemia. Explanation: Common clinical manifestations of hypokalemia include ventricular arrhythmias; weak and irregular pulse; soft and flabby muscles; and decreased deep tendon reflexes. Hypercalcemia causes confusion and decreased memory, bone pain, polyuria, and nausea, vomiting, and constipation. Hypernatremia causes signs of fluid volume deficit. Hypomagnesemia is manifested by tremors, confusion, hyperactive deep tendon reflexes, and seizures.

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method? a) Place a tongue blade lightly on the posterior aspect of the pharynx. b) Place a tongue blade on the middle of the tongue and ask the client to cough. c) Place a tongue blade on the uvula. d) Place a tongue blade on the front of the tongue and ask the client to say "ah."

Place a tongue blade lightly on the posterior aspect of the pharynx. Explanation: To assess a client's gag reflex, the nurse should gently touch the posterior aspect of the pharynx with a tongue blade, which should elicit gagging. Having the client say "ah" allows the nurse to evaluate cranial nerves IX and X. However, the nurse needn't use a tongue blade to hold down the tongue; the client need only stick out his tongue. Placing a tongue blade on the middle of the tongue and asking the client to cough has no value. Placing a tongue blade on the uvula may traumatize the area and harm the client.

A client asks the nurse why the prostate specific antigen (PSA) level is determined before the digital rectal examination. The nurse's best response is which of the following? a) "A prostate examination can possibly decrease the PSA." b) "It is easier for the client." c) "If the PSA is normal, the client will not have to undergo the rectal examination." d) "A prostate examination can possibly increase the PSA."

A. "A prostate examination can possibly increase the PSA." Explanation: Manipulation of the prostate during the digital rectal examination may falsely increase the PSA levels. The PSA determination and the digital rectal examination are both necessary as screening tools for prostate cancer, and both are recommended for all men older than age 50. Prostate cancer is the most common cancer in men and the second leading killer from cancer among men in the United States and Canada. Incidence increases sharply with age, and the disease is predominant in the 60- to 70-year-old age-group.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse? a) Check vital signs and level of consciousness; then place the client in a quiet area with a family member. b) Notify the emergency physician and request a telephone order for sedation. Administer the medication and place the client in a quiet place for monitoring. c) Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. d) Monitor the level of agitation, and when the client calms down, refer to the community addiction team.

C. Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. Explanation: This client has been ingesting an unknown amount of drugs and alcohol and is now exhibiting a change in neurologic status. It is a priority to carefully assess and closely monitor for any deterioration. The other choices are incorrect because a family member is not qualified to monitor the client. The client would eventually be referred to an addition team but is not medically stable. Sedation is not appropriate at this time.

A nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal? a) Dullness over the liver b) Vascular sound over the renal arteries c) Bowel sounds occurring every 10 seconds d) Shifting dullness over the abdomen

D. Shifting dullness over the abdomen Explanation: Shifting dullness over the abdomen indicates ascites, an abnormal finding. Dullness over the liver, bowel sounds occurring every 10 seconds, and vasular sounds over the renal arteries are normal abdominal findings.

If a mass casualty incident occurs near an acute care unit, which of the following is the nurse responsible for when implementing a disaster preparedness plan? a) A formal written plan of action for coordinating the response of the hospital staff and for designating how different areas will be used b) A designation of levels of casualty care and having nurses volunteer services at different levels c) A formal plan to ensure that medical supplies and medications are available for the great number of casualties d) An informal fan-out to contact and inform all registered nurses about the disaster and to elicit their help in assisting with the casualties

A. A formal written plan of action for coordinating the response of the hospital staff and for designating how different areas will be used Explanation: When a disaster occurs, a formal written plan of action is put into place. Nurses will be notified via telephone if not on duty and will be asked to come in. Those working in the hospital will be sent to the various designated areas within the hospital to care for clients who will be brought in. This plan needs to identify how areas will be used so there is not indecision at the time of the disaster. These are important components of a disaster preparedness plan. A formal fan-out contact list would be in place. Nurses need to commit to the disaster, not just have a volunteer plan. The disaster plan needs to focus on having health professionals and supplies available.

A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb all the way up to the hips. The nurse should do which of the following next? Select all that apply. a) Notify the health care provider of the change. b) Place respiratory resuscitation equipment in the client's room. c) Have the client perform ankle pumps. d) Check for advancing levels of paresthesia. e) Call the family to come in to visit.

A. Notify the health care provider of the change. B. Place respiratory resuscitation equipment in the client's room. D. Check for advancing levels of paresthesia. Explanation: A client who has been admitted for numbness and tingling in his lower extremities that advances upward, especially after having a viral infection, has clinical manifestations characteristic of Guillain-Barré syndrome. The health care provider must be notified of the change immediately because this disease is progressively paralytic and should be treated before paralysis of the respiratory muscles occurs. The nurse must assess the client continuously to determine how fast the paralysis is advancing. The family does not need to be called in to visit until the client is stabilized and emergency equipment is placed at the bedside. Performing ankle pumps will not relieve the numbness or change the course of the disease.

A client who fell through ice and was submerged for longer than 1 minute is admitted to the emergency department with hypothermia and near-drowning. At which point will the nurse best be able to determine the client's outcome status? a) After the parents' initial visit b) Three days after the incident c) As soon as cardiopulmonary resuscitation is successfully initiated d) As soon as the client is warmed

As soon as the client is warmed Explanation: The neural or hemodynamic status of the client cannot be determined until the client is warmed. The nurse would not have to wait 3 days to do so or wait for the parents' initial visit. The determining factor is the client's core body temperature.

What are important nursing responsibilities when a referral to other health team members has been made for a client? a) Ensuring that the physician reports the level of functioning of the client b) Recommending that each health team member independently completes his or her own assessment and then consults with each other c) Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living d) Recommending that each member read the history and nurse's notes to understand the client's progress

C. Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living Explanation: Sharing assessment findings and relevant information helps prepare other health team members and helps coordinate the team efforts, which is one of the nurse's primary roles in relation to the health team.

On the second day after surgery, the nurse assesses an elderly client and finds the following: • BP 148/92, HR 98, RR 32 • O2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula • Breath sounds coarse and wet bilaterally with a loose, productive cough • Client voided 100 ml very dark, concentrated urine during the last 4 hours • Bilateral pitting pedal edema Using the SBAR method to notify the health care provider of current assessment findings, which of the following is the most appropriate recommendation? a) Encourage additional fluid intake. b) Increase oxygen liter flow rate. c) Administer an antihypertensive medication. d) Administer a diuretic medication.

D. Administer a diuretic medication. Explanation: The client is experiencing fluid overload and has vital signs outside normal limits. The provider must be notified of the client's current status. It would be appropriate to recommend that the provider administer a diuretic to correct the fluid overload. It is not appropriate to administer an antihypertensive medication or more fluids. It may be appropriate to administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic administration is most important.

Which of the following sounds should the nurse expect to hear when percussing a distended bladder? a) Tympany. b) Hyperresonance. c) Flatness. d) Dullness.

Dullness. Explanation: A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drumlike sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.

A client had a total abdominal hysterectomy 10 hours ago. Knowing that sepsis is a potential complication of the surgery, the nurse will monitor for which early assessment change? a) Abrupt change in mental status b) Difficulty breathing c) Urine output of 20 ml/hour d) Temperature of 101.8° F (38.8° C)

Temperature of 101.8° F (38.8° C) Correct Explanation: Sepsis is a potentially life-threatening complication of an infection. Sepsis occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. To be diagnosed with sepsis, a person must exhibit at least two of the following symptoms: fever above 101.3° F (38.5° C) or below 95° F (35° C); heart rate higher than 90 beats/minute; respiratory rate higher than 20 breaths/minute; probable or confirmed infection. The diagnosis will be upgraded to severe sepsis if also exhibiting at least one of the following signs and symptoms, which indicate an organ may be failing: significantly decreased urine output, abrupt change in mental status, decrease in platelet count, difficulty breathing, abnormal heart pumping function, abdominal pain.

A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions? a) Papules b) Pustules c) Vesicles d) Plaque

Vesicles Explanation: Vesicles are raised, round, serous-filled lesions that are usually less than 1 cm in diameter. Examples of vesicles include chickenpox (varicella) and shingles (herpes zoster). A pustule is a raised, circumscribed lesion that's usually less than 3/8″ in diameter and contains purulent material that gives it a yellow-white color — for example, acne pustule and impetigo. A plaque is a circumscribed, solid, elevated lesion that's more than 3/8″, in diameter — for example, psoriasis. A papule is a firm, inflammatory, raised lesion that's as long as 1/4″ in diameter and that may be pigmented or the same color as the client's skin — for example, acne papule and lichen planus.