Health Assessment Final Exam
C) Wearing gloves to palpate the tongue and buccal membranes
11. A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which of the following actions? A) Performing hand hygiene between examinations of each body part B) Discarding in the trash can the safety pin that was used to assess sensory perception C) Wearing gloves to palpate the tongue and buccal membranes D) Wearing a gown, gloves, and mask during the physical exam
A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.
13. A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "Absolutely not! There's no way I'll let you do that to me!" Which response by the nurse would be most appropriate? A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam. B) Tell the client that this is the only way she can be checked for cancer. C) Ask the client if she would prefer another practitioner to perform the exam. D) Proceed with the pelvic exam and document the client's protests in the health record.
C) Dorsal hand surface
15. When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate assessment data? A) Finger pad surface B) Palmar hand surface C) Dorsal hand surface D) Ulnar hand surface
C) Pulses
16. The nurse is using her fingerpads to palpate a client's body part during the physical examination. Which of the following would the nurse best be able to detect? A) Temperature B) Vibrations C) Pulses D) Fremitus
A) Subjective data and objective data
18. A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following? A) Subjective data and objective data B) Interpretation and inference C) Observation and inspection D) Data and results
B) "I think this client would benefit from an antiemetic."
19. A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which of the following statements? A) "What would you like to do to address this client's nausea?" B) "I think this client would benefit from an antiemetic." C) "This client has no recent history of any nausea or vomiting." D) "This client rates his nausea as seven out of ten."
D) Perform further assessments addressing various aspects of the client's pain.
21. A client has illuminated his call light and tells the nurse that he is having "ten out of ten" pain. The nurse's initial inspection reveals that the client is watching videos on his tablet computer and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain? A) Ask the client to repeat his rating of his pain. B) Observe the client for several seconds to see if his demeanor or his behavior changes. C) Consult the client's medication administration record (MAR) to check for recent analgesic use. D) Perform further assessments addressing various aspects of the client's pain.
D) The client is separated from her usual social supports.
24. A nurse is planning a client's care following the completion of an initial assessment. When formulating a risk nursing diagnosis, which piece of data would be most useful? A) The client has an elevated white blood cell count. B) The client is 66 years of age. C) The client has pain in her joints, especially in the morning. D) The client is separated from her usual social supports.
D) The client's explanation of how her pain feels
38. The nurse is using the Verbal Descriptor Scale to assess a client's pain. The nurse will prioritize which of the following data? A) The client's facial expressions B) The client's report on a 0 to 10 numeric scale C) The client's rating on a 0 to 10 visual analog scale D) The client's explanation of how her pain feels
D) Presbycusis
====A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis? A) Vertigo B) Otalgia C) Tinnitus D) Presbycusis
A) A 55-year-old female client
====A nurse who works at an outpatient ophthalmic clinic has a large number of clients. Which client would be at the highest risk for developing cataracts? A) A 55-year-old female client B) A 40-year-old with arteriosclerosis C) A client who has severe environmental allergies D) A male client who is obese
C) Tender tragus
====When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment? A) Darwin tubercle B) Red, flaky cerumen C) Tender tragus D) Pearly gray tympanic membrane
B) "It helps to keep the ear drum soft and functioning well."
A client asks why cerumen is important, stating, "It just clogs up the ears anyway." How should the nurse best describe the purpose of cerumen? A) "It helps protect the delicate ear drum from loud noise that may be damaging." B) "It helps to keep the ear drum soft and functioning well." C) "It helps to amplify the sound waves through the inner ear." D) "It helps create the translucent, pearly color of the ear drum."
D) Difficulty chewing
A client complains of temporomandibular joint (TMJ) pain. Which of the following would the nurse most likely assess? A) Joint dislocation B) History of fracture C) History of dental abscess D) Difficulty chewing
B) "Do you take painkillers like aspirin on a regular basis?"
A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem? A) "Do you feel like you're able to adequately address the stress in your life?" B) "Do you take painkillers like aspirin on a regular basis?" C) "Do you tend to eat foods that are quite high in fat?" D) "Are you currently taking vitamin supplements?"
A) Hyperresonance
A client has a history of emphysema. During the respiratory assessment, the nurse percusses the client's chest, expecting to find which of the following? A) Hyperresonance B) Dullness C) Resonance D) Tympany
B) Explain the purpose of the interview.
A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first? A) Collaborate with the client to identify problems. B) Explain the purpose of the interview. C) Determine the client's vital signs. D) Obtain family health history data.
B) ED nurse
A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment? A) Gastroenterologist B) ED nurse C) Admissions clerk D) Diagnostic technician
B) Provide a laundry list of descriptive words.
A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client's complaint? A) Ignore the complaint for now and return to it later in the assessment. B) Provide a laundry list of descriptive words. C) Restate the question using simpler terms. D) Wait in silence until the client can determine the correct words.
B) Inability to wrinkle the forehead
A client has presented with signs and symptoms that are suggestive of Bell's palsy. What assessment finding is most consistent with this diagnosis? A) Inability to detect sharp and dull stimuli B) Inability to wrinkle the forehead C) Closure of the affected eye from swelling D) Muscle spasm of the lower face on the affected side
B) "What medications are you currently taking?"
A client has sought care at the clinic, telling the nurse, "This ringing in my ears has gone on for weeks, and it's driving me crazy." The patient denies exposure to excessive noise levels. The nurse recognizes the likely presence of tinnitus and should follow up with which of the following questions? A) "Did your parents even complain of something similar?" B) "What medications are you currently taking?" C) "How would you describe your overall level of health?" D) "How do you usually clean your ears?"
D) Glaucoma
A client has sought care because she states that she has begun to see halos around headlights and streetlights when she is out at night. The nurse should recognize the need to refer the client for further assessment related to what health problem? A) Episcleritis B) Strabismus C) Macular degeneration D) Glaucoma
B) Heart failure
A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessments should focus on the signs and symptoms of what health problem? A) Myocardial infarction B) Heart failure C) Atherosclerosis D) Heart block
D) Coordination
A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment? A) Vital signs B) Respiratory status C) Cardiac function D) Coordination
C) Pink and frothy
A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about which of the following assessment findings related to the client's sputum? A) White or cream-colored B) Yellowish and foul-smelling C) Pink and frothy D) Rust-tinged
C) Inspect the client's external ear canal.
A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first? A) Assess the client's tympanic membrane. B) Palpate the client's tragus. C) Inspect the client's external ear canal. D) Perform hearing assessments.
B) At the symphysis pubis
A client's bladder is found to be distended. At which location should the nurse begin palpating? A) At the umbilicus B) At the symphysis pubis C) In the right lower quadrant D) In the left lower quadrant
B) "Can I ask you some questions about your memory?"
A client's recent episode of becoming lost near his home has prompted the nurse to use the Saint Louis University Mental Status (SLUMS) Assessment Tool. The nurse should begin this assessment by asking what question? A) "How would you respond if someone said that you might have dementia?" B) "Can I ask you some questions about your memory?" C) "Do you generally consider yourself to be an intelligent person?" D) "I want to ask you some questions to see if you have Alzheimer's."
C) Inspect, auscultate, percuss, palpate
A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? A) Palpate, percuss, inspect, auscultate B) Auscultate, inspect, palpate, percuss C) Inspect, auscultate, percuss, palpate D) Percuss, inspect, auscultate, palpate
A) Myocardium
A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying this layer as which of the following? A) Myocardium B) Epicardium C) Endocardium D) Pericardium
D) External rotation
A nurse asks a client to bring his hands together behind his head with his elbows flexed. The nurse is testing which of the following? A) Abduction B) Adduction C) Internal rotation D) External rotation
A) Document this finding as normal.
A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following should the nurse do next? A) Document this finding as normal. B) Recheck in 5 minutes after elevating the arm. C) Reassess after applying warm compresses. D) Refer the client for medical follow-up.
A) It is a normal-sized liver.
A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following? A) It is a normal-sized liver. B) The liver is larger than normal. C) It is a smaller-than-normal liver. D) The liver has atrophied.
C) Maintaining an open mind
A nurse has identified a goal of developing his critical thinking skills. In order to facilitate this goal, what action should the nurse prioritize? A) Applying quick decision-making B) Seeking new experiences C) Maintaining an open mind D) Maintaining a stable and static knowledge base
B) Narcotic use
A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? A) Recent eye trauma B) Narcotic use C) Macular degeneration D) Recent peripheral nervous system injury
B) Student compresses the client's nail bed until it blanches.
A nurse instructor is observing a nursing student assess a client's capillary refill. Which action by the student indicates the proper technique? A) Student gently compresses the wrist area on the side of the thumb. B) Student compresses the client's nail bed until it blanches. C) Student applies firm pressure to the hand, noting any indentation. D) Student asks client to turn hands slowly over and back.
C) The client's report of her pain
A nurse is admitting a client to the postsurgical unit following breast reconstruction surgery. Which of the following would the nurse use as the primary assessment for the client's pain? A) The client's spiritual view of the pain B) Current pain therapies used preoperatively C) The client's report of her pain D) Psychosocial questions related to her perceptions of pain
B) Assess the client's pain according to COLDSPA.
A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the client from the stretcher to a bed and asked the client if he is experiencing pain. The client acknowledges that he is in pain. What should be the nurse's next action? A) Ask the client to briefly explain his cultural background. B) Assess the client's pain according to COLDSPA. C) Assess the client's self-management skills. D) Assess the client's pain by obtaining a set of vital signs.
B) Internally rotated lower extremities
A nurse is assessing a client who is exhibiting decorticate posturing. Which of the following would the nurse observe? A) Extended upper extremities B) Internally rotated lower extremities C) Pronated forearms D) Flexed hands at the side of the body
B) "Have you ever been tested for diabetes?"
A nurse is completing a comprehensive health history of a 69-year-old woman who is a new client of the clinic. Which of the nurse's interview questions most directly addresses the client's risk for developing cataracts? A) "Do you exercise regularly?" B) "Have you ever been tested for diabetes?" C) "Do you ever take over-the-counter pain medications?" D) "At what age did you first start wearing glasses?"
A) Inspection
A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data? A) Inspection B) Therapeutic communication C) Interviewing D) Active listening
B) Palpate the carotid pulse while auscultating the heart.
A nurse is having difficulty identifying a client's heart sounds, specifically S1 and S2. Which of the following would be most appropriate for the nurse to do? A) Use the bell of the stethoscope to help distinguish the sounds. B) Palpate the carotid pulse while auscultating the heart. C) Determine the pulse deficit. D) Palpate the apical impulse.
C) "Do you use tobacco, whether smoking or chewing?"
A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer? A) "Would you say that you're prone to getting mouth ulcers?" B) "Do you brush and floss daily?" C) "Do you use tobacco, whether smoking or chewing?" D) "How often do you usually go to the dentist in a year?"
B) Use of two middle fingers lightly applied to wrist area along the thumb side
A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates correct technique for this assessment? A) Application of firm pressure on the wrist area along the side of the fifth digit B) Use of two middle fingers lightly applied to wrist area along the thumb side C) Use of the thumb and index finger applied to obliterate the wrist area along the thumb side D) Application of the bell of the stethoscope to the antecubital area of the upper extremity
D) Nystagmus
A nurse is performing an eye and vision assessment on a client who has an inner ear disorder. This disorder may contribute to what finding during the client's eye positions test? A) Strabismus B) Phoria C) Tropia D) Nystagmus
C) History of smoking
A nurse is preparing a program on osteoporosis for a local women's group. Which of the following should the nurse cite as a risk factor? A) Obesity B) Multiparity (multiple pregnancies) C) History of smoking D) African-American ethnicity
B) The size and shape of children's eustachian tubes makes them vulnerable.
A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which of the following would the nurse describe? A) Young children have a tendency to stick objects into their ear canal. B) The size and shape of children's eustachian tubes makes them vulnerable. C) Children's immune systems lack the maturity to fight infections. D) Children generally have poorer hygiene than adults.
D) Balance
A nurse is preparing to assess a client's cerebellar function. Which of the following aspects of neurological function should the nurse address? A) Remote memory B) Sensation C) Judgment D) Balance
B) Compressing the arteries bilaterally
A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated? A) Asking the client to flex his or her neck B) Compressing the arteries bilaterally C) Performing the examination while the client is seated D) Asking the client to swallow water
C) "Are you allergic to any medications?"
A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement? A) "Tell me about your relationship with your children?" B) "Tell me what you eat in a normal day?" C) "Are you allergic to any medications?" D) "What is your typical day like?"
D) T wave
A nurse is reviewing a client's electrocardiogram (ECG). The nurse should identify which component as indicating ventricular repolarization? A) P wave B) QRS complex C) ST segment D) T wave
C) Sinoatrial node
A nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. The nurse should be aware that the electrical signal originates in which of the following locations? A) Bundle of His B) Purkinje fibers C) Sinoatrial node D) AV node
A) Inspection
A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first? A) Inspection B) Palpation C) Percussion D) Auscultation
C) Hyperextension of 15 degrees
A nurse is testing the range of motion of the thoracic and lumbar spine. Which of the following would the nurse document as an abnormal finding? A) Flexion of 80 degrees B) Lateral bending of 35 degrees C) Hyperextension of 15 degrees D) Rotation of 30 degrees
C) Palpate the brachial pulse.
A nurse is unable to palpate a client's radial and ulnar pulses. What is the nurse's most appropriate action? A) Refer the client for medical follow-up. B) Document the finding and proceed with the assessment. C) Palpate the brachial pulse. D) Auscultate the apical pulse.
C) The client's blood pressure will be slightly lower than standing readings.
A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the client's blood pressure reading in light of what principle? A) The client's blood pressure will be slightly highly than the client's norm. B) Position rarely affects the client's blood pressure. C) The client's blood pressure will be slightly lower than standing readings. D) There will be questionable accuracy of the blood pressure reading.
D) Making clinical judgments
A nurse on a post-surgical unit is admitting a client following the client's cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client? a. Collecting accurate data b. Assisting the primary care provider c. Validating previous data d. Making clinical judgments
B) Otitis externa
A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect which of the following health problems? A) Otitis media B) Otitis externa C) Ruptured tympanic membrane D) Mastoiditis
C) Consensual response
A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following? A) Direct reflex B) Optic chiasm C) Consensual response D) Accommodation
C) Cullen's sign
A nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion? A) Tenderness on palpation B) Diastasis recti C) Cullen's sign D Tympany on percussion
A) Hazardous and harmful alcohol use
A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted client, the nurse should recognize the possibility of which of the following? A) Hazardous and harmful alcohol use B) Imminent liver disease C) Acute pancreatitis D) Alcoholism
B) Neurologic
A nursing student has been assigned to the care of a client whose history suggests the need for a mental status assessment. This client most likely has a history of health problems affecting what body system? A) Respiratory B) Neurologic C) Cardiovascular D) Renal
C) The eye cannot look down when turned inward.
A review of a client's history reveals cranial nerve IV paralysis. Which of the following findings would the nurse expect to assess? A) The eye cannot look to the outside side. B) Ptosis will be evident. C) The eye cannot look down when turned inward. D) The eye will look straight ahead.
A) Read the order back to the surgeon for confirmation.
A surgical client's pain has become increasingly severe overnight, and she has received her maximum current doses of analgesics. The nurse has consequently phoned the surgeon to obtain a new order for analgesia. After the surgeon tells the nurse the new order, how should the nurse best validate this information? A) Read the order back to the surgeon for confirmation. B) Compare the order with the standard timing and dosage of the analgesic. C) Compare the order to the client's existing medication administration record (MAR). D) Have another nurse read the order that the nurse has transcribed.
B) Red marrow
After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following? A) Compact bone B) Red marrow C) Yellow marrow D) Spongy bone
C) Equilibrium
After teaching a group of students about the brain and spinal cord, the instructor determines that the students demonstrate the need for additional teaching when they identify which of the following as being controlled by the brain stem? A) Respiratory function B) Heart rate C) Equilibrium D) Reflex actions
A) Assessment
After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases? A) Assessment B) Planning C) Implementation D) Evaluation
C) Sonorous wheezes
An adult client has been diagnosed with bronchitis. Which of the following would the nurse most likely hear on auscultation? A) Sibilant wheezes B) Fine crackles C) Sonorous wheezes D) Coarse crackles
A) Arterial insufficiency
An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. Which of the following would the nurse suspect? An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. Which of the following would the nurse suspect? A) Arterial insufficiency B) Musculoskeletal weakness C) Venous insufficiency D) Diabetic neuropathy
A) Compare measurements of both extremities.
Assessment of a client's lower extremities reveals unilateral edema of the right foot and ankle. Which of the following would be most appropriate for the nurse to do next? A) Compare measurements of both extremities. B) Perform the Allen test. C) Check for bilateral varicosities. D) Palpate the femoral pulses.
C) 3+
Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
C) 4/5
Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? A) 2/5 B) 3/5 C) 4/5 D) 5/5
A) Practice risk prevention for fractures.
Assessment reveals that an older adult client has osteomalacia. Which of the following would be most important to include in the client's teaching plan? A) Practice risk prevention for fractures. B) Keep exercise to a minimum to decrease pain. C) Minimize movements to maintain joint stability. D) Treat secondary arthritis proactively.
C) Normal findings for client's age
During a health history, a 62-year-old male client reveals that he occasionally sees spots before his eyes. The nurse interprets this finding as the result of which of the following? A) Increased ocular pressure B) Vitamin A deficiency C) Normal findings for client's age D) Vascular spasm
A) Pain radiating from eye to temporal region
During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches? A) Pain radiating from eye to temporal region B) Throbbing and severe pain C) Report of ringing in the ears prior to headache D) Complaint of sensitivity to light
B) History of tobacco use
During a health screening event, the nurse is assessing a client's risk factors for lung cancer. When addressing the most significant risk factor for lung cancer, the nurse should question the client about which of the following? A) Childhood exposure to air pollution B) History of tobacco use C) History of working in a factory or smelter D) History of recurrent lung infections
A) Arteries have thicker walls than veins.
During a health visit, a client says, "I know that arteries and veins are both blood vessels, but what's the difference?" Which of the following would the nurse include in the response? A) Arteries have thicker walls than veins. B) Arteries carry 70% of the body's blood volume. C) Arteries have a lower pressure than veins. D) Arteries carry waste from the tissues.
B) Ask the client to bring all the medications and supplements to an interview.
During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? A) Ask the client to identify which medications taken every day. B) Ask the client to bring all the medications and supplements to an interview. C) Ask the caregiver whether the client is taking prescribed medications. D) Ask the client about the use of any over-the-counter medications.
D) Stop palpating and get medical assistance.
During palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6-cm mass above the umbilicus. What action should the nurse take? A) Refer the client to an oncologist. B) Provide a dietician consult for the client. C) Counsel the client regarding hernia repair. D) Stop palpating and get medical assistance.
D) Cerebellar ataxia
During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would interpret this finding as suggestive of which of the following? A) Spastic hemiparesis B) Parkinsonian gait C) Scissors gait D) Cerebellar ataxia
A) CN I
During the health history, a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve? A) CN I B) CN II C) CN VII D) CN IX
D) Heart failure
During the health interview, a client tells the nurse that he "can't breathe all that well" at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for which of the following health problems? A) Pneumonia B) Tuberculosis C) Bronchitis D) Heart failure
C) Checking for a deviated nasal septum
During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. Which of the following would be most important for the nurse to assess? A) Asking if the client experiences dry mouth often B) Inspecting for inflammation of the tonsils C) Checking for a deviated nasal septum D)Performing a focused respiratory assessment
B) Corticosteroids
During the nursing history of a newly admitted client, the nurse is reviewing a client's current medication regimen. What medication category creates a risk for decreased bone density? A) Beta-adrenergic blockers B) Corticosteroids C) Nonsteroidal anti-inflammatories (NSAIDs) D) Calcium channel blockers
A) Gouty arthritis
During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. Which of the following would the nurse suspect? A) Gouty arthritis B) Rheumatoid arthritis C) Degenerative joint disease D) Plantar fasciitis
B) Parkinsonian gait
Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait? A) Scissors gait B) Parkinsonian gait C) Spastic hemiparesis D) Footdrop
B) Hallux valgus
Inspection of a client's foot reveals an enlarged, painful, inflamed bursa (bunion) on the medial side of the foot. The nurse should make a referral for what health problem? A) Osteomalacia B) Hallux valgus C) Pes planus D) Gouty arthritis
C) Ballottement test
Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. Which of the following would the nurse use to confirm the suspicion? A) Phalen's test B) Tinel's test C) Ballottement test D) Leg raising test
C) An oral contraceptive
The clinic nurse is reviewing the medication history of a 39-year-old woman. Which medication would the nurse identify as a potential risk factor for thrombophlebitis? A) A beta-adrenergic blocker B) A selective serotonin reuptake inhibitor (SSRI) C) An oral contraceptive D) An antilipid agent
A) Validate the collected data.
The emergency department has collected extensive data from a client who has presented with a new onset of severe abdominal pain. What nursing action should the nurse perform before proceeding with data analysis? A) Validate the collected data. B) Formulate a nursing diagnosis. C) Make inferences about the data. D) Identify the client's strengths.
A) Refer the client immediately for further evaluation.
The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next? A) Refer the client immediately for further evaluation. B) Assess for foreign body impaction. C) Examine for postauricular cysts. D)Position the patient to facilitate drainage.
B) 2+
The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
C) 3+
The nurse assesses brisk reflexes in a client during a neurological assessment. The nurse should document this finding as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
C) Heart rate of 110 beats per minute
The nurse collects vital signs on a hospital client who has recently been experiencing pain. Which of the following would suggest most strongly to the nurse that the client is experiencing pain? A) Respiratory rate of 18 breaths per minute B) Temperature of 99.1°F C) Heart rate of 110 beats per minute D) Blood pressure of 120/70 mm Hg
C) Elevate the head of the client's bed to 30 degrees.
The nurse has assessed a client's neck vessels and is now preparing to auscultate the client's heart sounds. What action should the nurse perform during this phase of assessment? A) Rapidly auscultate all areas of the precordium and then repeat the assessments in greater detail. B) Stand on the client's left side, nearest the heart. C) Elevate the head of the client's bed to 30 degrees. D) Begin by auscultating the entire precordium with the bell of the stethoscope.
C) Document the finding and proceed with the assessment.
The nurse has attempted to palpate the client's popliteal pulses but is unable to feel them, despite confirming appropriate landmarking and client positioning. What is the nurse's best response? A) Advocate for a referral to a vascular surgeon. B) Have the client perform light physical activity to promote circulation and then reattempt. C) Document the finding and proceed with the assessment. D) Palpate the client's brachial pulse.
B) The cuff is placed about 1 inch above the antecubital area.
The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate? A) The cuff is wrapped loosely around the arm. B) The cuff is placed about 1 inch above the antecubital area. C) The bladder inside the cuff encircles 50% of the arm circumference. D) The nurse can fit three to four fingers under the inflated cuff.
D) Pinkish, spongy soft palate
The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which of the following findings would a nurse interpret as being normal? A) Absence of red glow on transillumination of sinuses B) Nasal mucosa pale pink and swollen C) Tonsils 2+ D) Pinkish, spongy soft palate
A) Reassess previously detected problems
The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason? A) Reassess previously detected problems B) Provide information for the client's record C) Address areas previously omitted D) Determine the need for crisis intervention
A) 44 mm Hg
The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure? A) 44 mm Hg B) 92 mm Hg C) 114 mm Hg D) 184 mm Hg
B) Meningitis
The nurse has placed her hands behind the client's head and flexed the client's neck forward as far as the client can tolerate. During the test, the client experiences leg pain and bends his knees. This assessment finding is suggestive of what health problem? A) Ischemic stroke B) Meningitis C) Bell's palsy D) Brain stem lesion
D) Closure of the atrioventricular valves
The nurse is analyzing the data from the assessment of a client's heart and neck vessels. The client's first heart sound corresponds with what event in the cardiac cycle? A) Isometric contraction B) Closure of the semilunar valves C) Beginning of diastole D) Closure of the atrioventricular valves
A) "Clench your teeth together tightly."
The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of assessment? A) "Clench your teeth together tightly." B) "Close your left eye and look at me with your right." C) "Look straight at me while I shine this light in your eye." D) "Open your mouth wide and say 'ah.'"
D) An oral contraceptive
The nurse is assessing a 39-year-old woman who has a 20 pack-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the woman's risk of stroke? A) Acetaminophen B) A beta-adrenergic blocker C) ASA D) An oral contraceptive
D) Alert and oriented
The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following? A) Deep coma B) Coma C) Obtunded D) Alert and oriented
A) "How often do you use over-the-counter nasal sprays?"
The nurse is assessing a client who enjoys good health overall but who has brought a complaint of chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize? A) "How often do you use over-the-counter nasal sprays?" B) "How often do you take Tylenol?" C) "How many drinks of alcohol do you have in a typical day?" D) "Would you say that you eat a balanced diet?"
A) Dry, shiny, hairless shins and feet
The nurse is assessing a client who has been referred to the clinic because of possible arterial insufficiency. What assessment finding should the nurse identify as most consistent with this diagnosis? A) Dry, shiny, hairless shins and feet B) Pitting edema to the feet and ankles C) Numbness and tingling of the lower extremities D) Reddish-blue coloration of the shins and feet
A) Increased jugular venous pressure
The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate? A) Increased jugular venous pressure B) Bradycardia C) Decreased blood pressure D) Dysrhythmias
B) The client may be experiencing symptoms of heart failure.
The nurse is assessing a client with a cardiac condition who complains of not sleeping well and of having to get up frequently at night to urinate. The nurse should recognize what implication of this statement? A) The client may have developed a cardiac conduction problem. B) The client may be experiencing symptoms of heart failure. C) The client's cardiac problem is being adequately compensated for. D) The client may be at increased risk for myocardial infarction.
D) Inspect the suprasternal notch or around the clavicles.
The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse? A) Perform the exam with the client in a supine position. B) Have the client look straight ahead with chin slightly lifted. C) Have the client sit up at a 90-degree angle. D) Inspect the suprasternal notch or around the clavicles.
A) "What were you doing when the pain first stated?"
The nurse is assessing a client's pain. Which question would be most appropriate to ask the client when the goal is to identify precipitating factors that might have exacerbated the pain? A) "What were you doing when the pain first stated?" B) "Do concurrent symptoms accompany the pain?" C) "When did the pain start?" D) "Is the pain continuous or intermittent?"
D) Continue the exam because this curve is normal.
The nurse is assessing an adolescent client and notes 45-degree flexion of the cervical spine. What is the nurse's most appropriate action? A) Facilitate a referral for medical follow up. B) Palpate the spinous processes. C) Perform the Lasègue test. D) Continue the exam because this curve is normal.
A) The client is more vulnerable to impaired nutrition due to decreased appetite.
The nurse is assessing the gastrointestinal system of an 81-year-old client. What age-related change should the nurse consider when collecting and analyzing assessment data? A) The client is more vulnerable to impaired nutrition due to decreased appetite. B) The client derives less nutritional value from food because of decreased enzyme production. C) The client's liver will be significantly larger than that of a younger client. D) The client will have greater bowel motility than a younger adult.
D) Pain on percussion
The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis? A) Resonance on percussion B) Dull sounds C) Tympanic sounds D) Pain on percussion
D) Right middle lobe
The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse must assess which lobe anteriorly? A) Left upper lobe B) Left lower lobe C) Right upper lobe D) Right middle lobe
D) Auscultate with the client in a variety of different positions.
The nurse is auscultating a client's heart sounds and hears what she believes to be a murmur. How should the nurse proceed with gathering further assessment data related to the suspected murmur? A) Auscultate with the bell and then without the stethoscope. B) Ask the client to "bear down" (perform the Valsalva maneuver) while auscultating. C) Ask the client to inhale and exhale deeply while auscultating. D) Auscultate with the client in a variety of different positions.
C) Absorbing large amounts of water
The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon? A) Absorbing electrolytes B) Secreting digestive enzymes C) Absorbing large amounts of water D) Secreting bile
C) 3+
The nurse is inspecting a client's tonsils and notes that they make contact with the client's uvula. The nurse would document this finding as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
D) "Your risk for heart disease will drop greatly if you're able to stop smoking."
The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease? A) "If you can eliminate red meat from your diet, your risk of heart disease will drop significantly." B) "Try to ensure that you're screened for heart disease at least once every six months." C) "Anything that you can do to reduce stress in your life will benefit your heart health." D) "Your risk for heart disease will drop greatly if you're able to stop smoking."
C) Tympany
The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen? A) Accentuated tympany B) Hyperresonance C) Tympany D) Dullness
A) Ulnar
The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients? A) Ulnar B) Radial C) Brachial D) Femoral
D) The client's gait
The nurse is performing an assessment of a client's musculoskeletal system. The nurse should begin the assessment by examining which of the following? A) The client's leg length B) The client's lateral bending ability C) The client's cervical ROM D) The client's gait
B) Document the lack of patency in the ulnar and/or radial arteries.
The nurse is performing the Allen test on a client who has a diagnosis of peripheral vascular disease. What action should the nurse take after a positive Allen test? A) Document the absence of dorsalis pedis or posterior tibial pulses. B) Document the lack of patency in the ulnar and/or radial arteries. C) Attempt to palpate the popliteal pulse with the client's leg in a dependent position. D) Corroborate the finding by assessing capillary refill in the client's great toes.
A) The client moves her feet apart to prevent herself from falling.
The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test? A) The client moves her feet apart to prevent herself from falling. B) The client is unable to consistently touch her finger to her nose while her eyes are close. C) The client experiences pain during neck flexion and extension. D) The client experiences pain when clenching her teeth.
A) Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation
The nurse is performing the bulge test during the assessment of a client's knee. This test will allow the nurse to make what determination? A) Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation B) Whether the size of the client's knee changes throughout the joint's range of motion C) Whether swelling in the knee joint is a normal age-related change or a pathological finding D) Whether the client's knee joint is capable of adduction and abduction
A) The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.
The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment? A) The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. B) The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time. C) The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. D) The nurse will briefly touch the client, and the client will identify where the touch occurred.
A) Palpate each artery individually to compare.
The nurse is preparing to assess a client's carotid arteries. Which of the following actions would be most appropriate? A) Palpate each artery individually to compare. B) Palpate the arteries before auscultating them. C) Use the diaphragm of the stethoscope. D) Ask the client to breathe in and out deeply.
A) Temperature
The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first? A) Temperature B) Pulse C) Respiration D) Blood pressure
A) Newspaper
The nurse is preparing to assess an older adult client's near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use? A) Newspaper B) Snellen chart C) Ophthalmoscope D) Penlight
D) Vital signs
The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations? A) Head and neck examination B) Palpation of lymph nodes C) Breast examination D) Vital signs
A) Far, then near
The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? A) Far, then near B) Lateral, then near C) Near, then far D) Lateral, then far
C) Thoroughly chew small amounts of food with each mouthful.
The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. Which of the following would be most appropriate for the nurse to include? A) Sit with the head of the bed at 45 degrees during meals. B) Be aware of the possibility of temporomandibular joint pain. C) Thoroughly chew small amounts of food with each mouthful. D) Drink fluids before and after, but not during, meals.
B) Leukoplakia
The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow-up? A) Thrush B) Leukoplakia C) Gingivitis D) Canker sore
B) The man has a diffuse rash on his torso.
The nurse is reviewing and analyzing data from the initial assessment of a newly admitted client who is a 79-year-old man. What assessment finding most clearly indicates a need for further data? A) The man has male pattern baldness. B) The man has a diffuse rash on his torso. C) The man's heart rate is 63 beats per minute. D) The man had an inguinal hernia repair in 2008.
A) "Do you have any other symptoms together with your chest pain, such as nausea, sweating?"
The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain. What interview question addresses the "A" in this assessment model? A) "Do you have any other symptoms together with your chest pain, such as nausea, sweating?" B) "In your experience, what kinds of activities tend to cause your chest pain?" C) "Would you describe your chest pain as being acute, or is it chronic?" D) "What changes do you have to make in order to accommodate your chest pain?"
C) Severity
The nurse is using the mnemonic "COLDSPA" to assess a client's complaint of lower abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint? A) Character B) Onset C) Severity D) Pattern
B) The nurse should implement interventions to address severe arterial insufficiency.
The nurse reads in a client's electronic health record that her most recent ankle-brachial index (ABI) was 0.42. How should this assessment finding inform the nurse's care? A) The nurse should inspect the client's feet and ankles for venous ulcers once per shift. B) The nurse should implement interventions to address severe arterial insufficiency. C) The nurse should assess the client's extremities for pitting edema at least once per shift. D) The nurse should position the client to promote venous return.
A) Venous insufficiency
The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral? A) Venous insufficiency B) Stasis ulceration C) Arterial occlusion D) Dependent edema
D) The client's toe is receiving an inadequate supply of blood.
The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound? A) Blood is returning from the client's toe more slowly than normal. B) There is a blockage or infection in the client's lymphatic system. C) There is a disruption in osmotic pressure in the client's extremities. D) The client's toe is receiving an inadequate supply of blood.
C) Area under the tongue
When assessing a client for possible oral cancer, the nurse should most closely inspect which area? A) Buccal mucosa B) Hard palate C) Area under the tongue D) Along the gum line
A) Have the client stand for the exam.
When assessing a client for possible varicose veins, the nurse should do which of the following actions? A) Have the client stand for the exam. B) Tell the client to raise his or her leg. C) Dorsiflex the client's foot. D) Obtain the ankle-brachial index.
D) Uvula and soft palate rising bilaterally
When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding? A) Stationary soft palate on phonation B) Deviation of uvula when client says "ah" C) Asymmetrical soft palate D) Uvula and soft palate rising bilaterally
A) Softly repeat the words "one-two-three."
When assessing whispered pectoriloquy, the nurse should instruct a client to do which of the following? A) Softly repeat the words "one-two-three." B) Say the number "ninety-nine." C) Cough each time the stethoscope is moved. D) Say the letter "e" until instructed to stop.
C) Flatness
When percussing the scapula of a client, which of the following would the nurse expect to hear? A) Resonance B) Dullness C) Flatness D) Hyperresonance
B) Ask the client to move the part against gravity.
When testing muscle strength, a client has difficulty moving her right arm against resistance. Which of the following should the nurse do next? A) Move the part passively through its range of motion. B) Ask the client to move the part against gravity. C) Inspect by touch for a palpable contraction of the muscle. D) Percuss the client's shoulder joint
C) Palpate temporal and masseter muscles while client clenches the teeth.
Which of the following tests would be most appropriate for the nurse to use when assessing motor function of a client's trigeminal nerve? A) Ask client to differentiate sharp and dull sensations on the face. B) Have the client smile, frown, and wrinkle the forehead. C) Palpate temporal and masseter muscles while client clenches the teeth. D) Assess dilatation of the client's pupils with direct light.
C) Inflate the cuff 30 mm Hg above where the radial pulse disappears.
Which of the following would be most important for the nurse to do when assessing a client's blood pressure? A) Palpate the pulsations of the ulnar artery. B) Hold the client's arm slightly flexed with palm down. C) Inflate the cuff 30 mm Hg above where the radial pulse disappears. D) Deflate the cuff about 5 mm Hg per second.
C) Flattened lumbar curve
Which of the following would the nurse expect to find when examining a client with a herniated lumbar disc? A) Rounded thoracic convexity B) Lumbar lordosis C) Flattened lumbar curve D) Lateral curvature of the spine
A) Numbness
Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A) Numbness B) Atrophy of the thenar prominence C) No tingling D) Hard, painless Bouchard nodes
C) Difficulty speaking
Which of the following would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident? A) Inability to hear high-pitched sounds B) Loss of tactile sensation C) Difficulty speaking D) Blurred vision
A) Straight leg test
Which test would be most appropriate for the nurse to perform when a client complains of low back pain? A) Straight leg test B) Muscle leg strength C) Lateral bending of cervical spine D) Internal rotation of the shoulders
B) Flexion
While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. Which of the following would the nurse include? A) Circumduction B) Flexion C) Abduction D) Internal rotation
D) Have the client cough, then listen again.
While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. Which of the following actions should the nurse do first? A) Refer the client for further medical evaluation. B) Auscultate for egophony. C) Perform bronchophony. D) Have the client cough, then listen again.
D) Bronchial breath sounds
While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document which of the following? A) Vesicular breath sounds B) Bronchovesicular breath sounds C) Adventitious breath sounds D) Bronchial breath sounds
D) Assess the client's cranial nerve function.
While examining a client's mouth, the nurse notes the presence of fasciculations (fine tremors) of the client's tongue. How should the nurse best respond to this assessment finding? A) Have the client provide a 24-hour diet recall. B) Review the client's medication regimen. C) Prepare the client for a thyroid screening. D) Assess the client's cranial nerve function.
C) Normal tympanic membrane
While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following? A) Scarring from previous infections B) Otitis media C) Normal tympanic membrane D) Otitis externa
