HEALTH ASSESSMENT PRACTICE QUESTIONS

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

A

The nurse has positioned a client supine and asked her to perform the heel-to-shin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain? A) Balance and coordination B) Light touch sensation C) Deep tendon reflexes D) Leg strength

A

The nurse is preparing to auscultate the client's thorax. Which of the following actions is the priority during this component of assessment? A) Listen at each site for at least one complete respiratory cycle. B) Have the client breathe deeply through his or her nose. C) Encourage the client to cough before auscultating each site. D) Have the client hold the breath for a few seconds after auscultating each site.

A

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

A. Inspection

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms? A) Parasitic infection B) Fungal infection C) Bacterial infection D) Allergic reaction

B.

Chapter 24 A client has suffered a suspected a rotator cuff tear. Which of the following would the nurse expect to find? A) Limitation of all shoulder motion B) Chronic pain C) Limited abduction D) Sharp catches of pain with movement

C

A client has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the "P"? A) "What makes it worse?" B) "When did it start?" C) "How does it feel?" D) "How would you rate your pain?"

A

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

A

A nurse is eliciting a client's health history and the client asks, "Can I take the herb ginkgo biloba with my other medications?" What action would be best if the nurse is unsure of the answer? A) Promise to find out the information for the client. B) Change the subject and return to this topic later. C) Teach the client to only take prescribed medications. D) Encourage the client to ask the pharmacist or primary care provider.

A

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

A

A client has been admitted following an unexplained weight loss of 15 pounds over the past 3 months. How should the nurse best assess the subjective component of the client's nutritional status? A) Ask the client to explain MyPlate. B) Obtain a 24-hour diet recall. C) Ask about the contents of one typical meal. D) Elicit the client's favorite foods.

B

A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview? A) Introductory B) Working C) Summary D) Closing

B

A nurse is testing a client's deep tendon reflex. The nurse taps the tendon above the olecranon process. The nurse is assessing which reflex? A) Brachioradialis B) Triceps C) Biceps D) Achilles

B

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade? A) 1 B) 2 C) 3 D) 4

B

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+

B

The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. The nurse should document this as which of the following? A) Limited expansion B) Normal expansion C) Hypoexpansion D) Hyperexpansion

B (5-10cm)

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

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

A young man has presented to the clinic with a 2-week history of head congestion, fever, and malaise. What assessment technique should the nurse utilize to assess for sinus tenderness? A) Light palpation B) Deep palpation C) Direct percussion D) Blunt percussion

C

An instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following? A) Plastic tubing should be longer than 3 feet. B) The bell is used after using the diaphragm. C) When using the bell, push on it lightly. D) A diaphragm picks up low-pitched sounds.

C

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

C

The nurse is gathering the necessary equipment preparatory to examining a client's ears. The nurse will be checking bone and air conduction of sound. Which of the following should the nurse obtain? A) Penlight B) Tongue depressor C) Tuning fork D) Otoscope

C

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

D

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

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral? A) An 80-year-old client who lives with her daughter B) A 50-year-old client newly diagnosed with diabetes C) An adult presenting for an influenza vaccination D) A teenager seeking information about contraception

D. A teenager seeking information about contraception

A nurse is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives? A) Circle B) Square C) Triangle D) Rectangle

A

An adult client has asked the nurse about actions that she can take to reduce her future risk of stroke. What health promotion activity should the nurse prioritize? A) Smoking cessation B) Annual MRI screening C) Nutritional supplementation D) Improved coping skills

A

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

A

The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What might the nurse expect to hear when auscultating the lungs of a client with this fluid volume deficit? A) Friction rub B) Decreased breath sounds C) Sibilant wheeze D) Stridor

A

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

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

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs? A) The right lung has three lobes, while the left lung has two lobes. B) The lungs are structurally symmetrical but functionally differently. C) The right lung is approximately one-third larger than the left lung. D) The lower lobes of both lungs are primarily located toward the anterior chest wall.

A

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

B

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

B

The nurse is conducting a focused musculoskeletal assessment of an older adult client. When analyzing assessment data, the nurse should be aware of what age-related physiological changes? Select all that apply A) Absence of knee flexion B) Decreased bone density C) Decreased joint flexibility D) Joint capsule calcification E) Reduced muscle strength

B, C, D, E

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

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

C

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

C

When assessing a client's deep tendon reflexes, which technique would be most appropriate for the nurse to use? A) Use the blunt end of the reflex hammer to strike a smaller area. B) Strike the area slowly and methodically. C) Hold the reflex hammer between the thumb and index finger. D) Percuss the area of the tendon to be struck for the reflex.

C

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

C

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

A

When asked to touch her ear to her shoulder, a client reports pain. Which of the following should the nurse do next? A) Perform muscle strength against resistance. B) Refer the client for further evaluation. C) Flex and then hyperextend the neck. D) Palpate the paravertebral muscles for pain.

B

When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first? A) Check for evidence of fever and chills. B) Ensure there is no injury to the cervical spine. C) Position the client prone. D) Check for a Babinski reflex.

B

A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, which of the following should the nurse do first? A) Collect objective data. B) Validate important data. C) Collect subjective data. D) Document the data.

B.

The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position? A) At the level of the diaphragm B) Near the level of the eighth rib C) Slightly above the clavicle D) At about the tenth rib

C

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

C

A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental? A) "How often do your adult children typically visit you?" B) "Your husband's death must have been very difficult for you." C) "You must quit smoking because it affects others, not only you." D) "How would you describe your feelings about getting older?"

C.

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? A) Comprehensive assessment B) Ongoing assessment C) Focused assessment D) Emergency assessment

C.

A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice? A) The focused assessment should be done before the physical exam. B) The focused assessment replaces the comprehensive database. C) The focused assessment addresses a particular client problem. D) The focused assessment is done after gathering subjective data.

C.

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable? A) The client's age B) The unit's protocols C) The client's acuity D) The nurse's potential for liability

C.

The nurse has been applying the nursing process in the care of an adult client who is being treated for acute pancreatitis. Place the nurse's actions in their proper sequence from first to last. A) Identifying outcomes B) Determining client's nursing problem C) Collecting information about the client D)Determining outcome achievement E.) Carrying out interventions

C. B. A. E. D.

A 20-year-old female client has presented to the clinic, and the nurse is preparing to perform a comprehensive assessment. The client states, ìI'd really like to have my mom in the room. That's okay, isn't it?î How should the nurse best respond to the client's request? A) ìOf course. There's a chair in the exam room where she can sit.î B) ìThat's no problem. I'll just have to get you to sign a privacy waiver first.î C) ìThat's fine, but be aware that some of the examinations might be embarrassing for you or her.î D) ìIt's best to undergo the examination alone in order to make sure I get accurate data, but if you really want her present, we can do that.î

A

A client has sustained a brain stem injury and is being treated in the intensive care unit. Which of the following would the nurse need to consider when assessing this client's respiratory status? A) The client will have a loss of involuntary respiratory control. B) The client will respond negatively to increased stimuli. C) The client will have greatly increased respiratory effort. D) The client will exhibit Cheyne-Stokes respirations.

A

A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify? A) The client's feelings of happiness B) The client's posture C) The client's affect D) The client's behavior

A

A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says ìAbsolutely not! There's no way I'll let you do that to me!î 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.

A

A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is a bit sporadic.How should the nurse best respond to this assessment finding? A) Identify a nursing diagnosis of Ineffective Health Maintenance. B) Identify a collaborative problem that should involve the occupational therapist. C) Make a referral to the unit's social work department. D) Reassess the client's blood glucose level.

A

A nurse is having difficulty eliciting a patellar reflex during a client's neurological assessment. Which of the following would be most appropriate for the nurse to have the client do? A) Lock the fingers together and pull against each other. B) Clench the jaw tightly. C) Squeeze a thigh with the opposite hand. D) Stretch the arms over head.

A

A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis? A) Caucasian B) African American C) South Asian D) Native American

A

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

A

A nurse provides care in a rural hospital that serves a community that has few minority residents. When interviewing a client from a minority culture, the nurse has enlisted the assistance of a "culture broker." How can this individual best facilitate the client's care? A) By interpreting the client's language and culture B) By evaluating the client's culturally based health practices C) By teaching the client about health care D) By making the client feel comfortable and safe

A

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a client's anxiety during the physical exam. Which of the following would be most appropriate? A) Ensuring client's privacy by providing an examination gown B) Providing a comfortable, warm room temperature C) Arranging exam equipment on a bedside tray table D) Explaining why standard precautions are being used

A

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.

A

Chapter 21 While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse should document which of the following? A) Pericardial friction rub B) Midsystolic click C) Summation gallop D) Aortic ejection click

A

During the nurse's assessment of the client's exercise and activity habits, the client laughs and then states, "Unless you're including channel surfing, I don't really do much of anything." How should the nurse best follow up this client's statement? A) Briefly describe some of the potential benefits of regular exercise. B) Ask the client if he understands the risk factors for heart disease and diabetes. C) Explain to the client that he should be performing aerobic exercise for 20 to 30 minutes at least three times a week. D) Document the nursing diagnosis of Risk for Activity Intolerance related to sedentary lifestyle.

A

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

A

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? A) Heart sounds B) Bowel sounds C) Breath sounds D) Femoral pulses

A

The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed, constricted pupils bilaterally. The nurse should consider what possible cause for this assessment finding? A) Recent narcotic use B) Hemorrhagic stroke C) Recent seizure activity D) Cerebellar lesion

A

The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be normal in a healthy client? A) The jugular venous pulse is not visible when the client is sitting upright. B) The jugular veins are fully distended when the client is in a high Fowler's position. C) The jugular veins are distended when the client sits at 45 degrees. D) The jugular venous pulse is visible when the client lies supine.

A

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.

A

The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age- related changes? A) Slight kyphosis B) Inaudible posterior lung sounds C) Audible wheeze D) Asymmetrical chest expansion

A

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

A

The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The nurse knows that a normal breathing rate is between approximately 10 and 20 breaths per minute, but the client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding? A) Ask the client if she has recently exerted herself. B) Report the finding to the client's primary care provider. C) Ask the client if she has smoked recently. D) Palpate the client's anterior and posterior thorax.

A

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 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

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) ìIn 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?

A

The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? A) The client's motivation for change B) The client's medical comorbidities C) The client's learning style D) The client's prognosis for recovery

A

The nurse's auscultation of the client's heart sounds reveals the presence of a split S1. What conclusion should the nurse draw from this assessment finding? A) The client's ventricles are not contracting simultaneously. B) The client's aortic valve is incompetent. C) The client has left ventricular hypertrophy. D) The client's atria are not synchronized with the ventricles.

A

When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. Which of the following would the nurse suspect? A) Meningitis B) Cervical strain C) Compression fracture D) Cervical disc degeneration

A

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

A

Chapter 19 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.

A (pectoriloquy, one two three!)

The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply. A) Risk for injury related to osteoporosis B) Risk for infection related to osteoporosis C) Activity intolerance related to osteoporosis D) Impaired physical mobility related to osteoporosis E) Disturbed sensory perception related to osteoporosis

A, C, D

The nurse is evaluating the setting prior to beginning a client's physical examination. The nurse should confirm the presence of which of the following? Select all that apply. A) Adequate lighting B) Cool room temperature C) Quiet surroundings D) Soft chair or table E) Table for equipment F) Door or curtain

A, C, E, F

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. A) I feel so tired sometimes. B) Weight: 145 lbs C) Lungs clear to auscultation D) Client complains of a headache E) My father died of a heart attack. F) Pupils equal, round, and reactive to light

A, D, E

The nurse is completing a review of systems for a client. Which of the following information would the nurse document related to the client's musculoskeletal system? Select all that apply. A) Joint stiffness B) Rhinorrhea C) Shortness of breath D) Chest pain E) Muscle strength F) Knee swelling

A, E, F

When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Select all the sensations that are carried by this tract. A) Pain B) Temperature C) Position D) Vibration E) Light touch

A,B,E

A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation? A) Guaranteeing a continual assessment process B) Identifying abnormal data C) Assuring valid conclusions from analyzed data D) Allowing for drawing inferences and identifying problems

A.

Chapter 2 A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? A) Establishing a trusting relationship B) Determining the client's strengths C) Identifying potential health problems D) Making clinical inferences

A.

The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first? A) The client's sensory abilities B) The client's general intelligence C) The presence of any phobias D) The client's judgment and insight

A.

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

A. Assessment

A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify? A) Expansion of health care networks B) Decrease in client participation in care C) The shrinking cost of medical care D) Public mistrust of physicians

A. Expansion of health care networks

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. Reassess previously detected problems

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

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

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

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

B

A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax? A) Midaxillary line B) Vertebral line C) Right midclavicular line D) Sternal line

B

A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which of the following actions? A) Depressing the skin 1 to 2 centimeters with the dominant hand B) Feeling the surface structures using a circular motion C) Placing the non-dominant hand on top of the dominant hand D) Using one hand to apply pressure and the other hand to feel the structure

B

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.

B

A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? A) Standing while the client is seated B) Using a moderate amount of eye contact C) Sitting across the room from the client D) Minimizing facial expressions

B

A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, which information would the nurse include? A) Caucasians usually possess greater lifestyle risks for CAD than African Americans. B) Hypertension is more prevalent in African Americans than among Caucasians. C) Hypertension is seen more in white women than in African-American women. D) Hispanic Americans have a higher rate of CAD than white Americans.

B

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following should the nurse do? A) Use a Snellen chart to test visual acuity. B) Ask a client to identify scents. C) Test extraocular eye movements. D) Perform the Weber test.

B

A nurse practitioner is performing a comprehensive physical examination of a 51-year- old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following? A) Parasites B) Blood C) Bacteria D) Fungus

B

A nurse practitioner refers clients for osteoporosis screening according to the latest U.S. Preventive Services Task Force (USPSTF) recommendations. According to these recommendations, what client should be screen for osteoporosis? A) A 71-year-old man who has type 2 diabetes B) A 69-year-old woman with no major risk factors for osteoporosis C) A 37-year-old woman who takes oral contraceptives D) A 49-year-old African-American woman who is obese

B

After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which of the following as Erb's point? A) Fifth intercostal space near the left midclavicular line B) Third to fifth intercostal space at the left sternal border C) Second intercostal space at the right sternal border D) Second or third intercostal space at the left sternal border

B

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

B

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.

B

During the interview, the client states, "Is today the 12th? My wife died 2 months ago today." Which of the following responses would be most appropriate? A) "What was the cause of your wife's death?" B) "How does that make you feel right now?" C) "You probably must be sad." D) "Are you feeling sad, depressed, angry, or upset?"

B

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

B

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

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

B

The nurse is assessing a client who has a complex cardiac history. The nurse has asked the client to lean forward while in a sitting position. This position will allow the nurse to do which of the following? A) Assess the client's heart sounds while preventing shortness of breath. B) Identify heart sounds that may be inaudible in other positions. C) Assess the impact of the client's heart disease on his mobility. D) Differentiate heart sounds from breath sounds.

B

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.

B

The nurse is assessing a client with mitral insufficiency. Which characteristic of the first heart sound should the nurse expect to hear? A) Split B) Diminished C) Accentuated D) Varying

B

The nurse is assessing an older adult client's heart and neck vessels. When attempting to palpate the client's apical impulse, what principle should guide the nurse's actions? A) The apical impulse will be irregular due to normal, age-related physiological changes. B) The apical impulse may be more difficult to palpate than in a younger client. C) The apical impulse will be found in a more medial location than in a younger client. D) The apical impulse will be easier to palpate if the client is in a standing position.

B

The nurse is conducting a focused neurological assessment of an 81-year-old client. When analyzing the assessment data, the nurse should be aware of what age-related neurological change? A) Impaired judgment B) Tremors accompanying intentional movements C) Loss of remote memory D) Loss of sensation in distal extremities

B

The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing? A) Extremity edema B) Joint flexion/extension C) Two-point discrimination D) Vibratory sensation

B

The nurse is inspecting the dominant hand of an older adult client and notes the presence of irregularly shaped brown lesions on the dorsal surface of the client's hand. What action should the nurse perform next? A) Obtain a tissue sample for pathology B) Compare the appearance of the client's other hand C) Palpate the lesions for tenderness and warmth D) Perform health promotion teaching about sun protection

B

The nurse is percussing the area over the client's lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following? A) Flatness B) Resonance C) Tympany D) Dullness

B

The nurse is preparing to assess the peripheral pulses of a client. The nurse should place the client in which position? A) Sitting upright B) Supine C) Sims position D) Prone

B

The nurse is preparing to examine an older adult client. Which of the following would be most appropriate for the nurse to do during the examination? A) Complete the examination as quickly as possible. B) Speak clearly and slowly when explaining a procedure. C) Begin the examination with auscultation instead of inspection. D) Maintain the supine position for each part of the examination.

B

The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which of the following actions would be most appropriate? A) Omit intrusive parts of the exam. B) Try to minimize position changes. C) Allow client to remain dressed. D) Dim the room light to ensure privacy.

B

When evaluating a client's risk for cerebrovascular accident, which client should the nurse identify as being at highest risk? A) A 42-year-old Caucasian female who smokes B) A 68-year-old African-American male with hypertension C) A 70-year-old Caucasian male who has one to two beers a day D) A 35-year-old African-American male who has sleep apnea

B

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

B

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

B

A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations should the nurse include as appropriate for reducing a person's risk? Select all that apply. A) Avoid eating carbohydrates. B) Eat foods low in sodium. C) Walk for at least 30 minutes/day. D) Limit alcohol intake to 3 drinks per day. E) Use relaxation techniques to manage stress.

B, C, E

A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, "I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?" How should the nurse best explain the rationale for obtaining a health history? A) "In general, it's necessary for us to gather as much information about each client as possible." B) "We want to make sure your nursing care matches your needs as closely as possible." C) "The care team needs to cross-reference your diagnostic testing with the information that I'm asking you about." D) "We don't want to make the mistake of focusing solely on the medical problem that brought you here."

B.

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? A) Review the client's medication administration record for analgesic use. B) Ask the client about the most recent experiences of pain. C) Meet with the client's spouse and daughter to discuss the client's pain. D) Collaborate with the physician who is treating the client.

B.

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which of the following statements should guide the nurse's use of a stethoscope during this phase of assessment? A) Auscultation can be performed through clothing. B) The diaphragm should be held firmly against the body part. C) The bell of the stethoscope can best detect bowel sounds. D) Use of the bell is reserved for advanced practice nurses.

B.

The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment? A) Focus the assessment on the client as a member of her age group. B) Interpret the information about the client in context. C) Corroborate the client's statements with trusted sources. D) Gather information from a variety of sources.

B.

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. ED NURSE

In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation? A) Current physiologic status B) Effect of health on functional status C) Past medical history D) Motivation for adherence to treatment

B. Effect of health on functional status

The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process? A) Each step is independent of the others. B) It is ongoing and continuous. C) It is used primarily in acute care settings. D) It involves independent nursing actions.

B. It is ongoing and continuous

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment? A) A 14-year-old girl who is crying because she thinks she is pregnant B) A 45-year-old man with chest pain and diaphoresis for 1 hour C) A 3-year-old child with fever, rash, and sore throat D) A 20-year-old man with a 3-inch shallow laceration on his leg

B. because duhhh

A client complains of headaches each morning that resolve after getting out of bed. Which of the following would be most appropriate for the nurse to do? A) Assess the client's level of consciousness. B) Assess the client's deep tendon reflexes. C) Refer the client for immediate medical follow-up. D) Refer the client for physical therapy and occupational therapy.

C

A client's elevated body mass index (BMI) has prompted the nurse to assess the client's activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise? A) "I walk briskly on the treadmill once or twice a week." B) "I play basketball with a team every Friday night without fail." C) "I go to a step class for an hour three times a week." D) "I swim for at least half an hour each Saturday morning."

C

A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history? A) "Do you have adequate health insurance coverage?" B) "Are you generally fairly healthy?" C) "What is your major health concern at this time?" D) "Did you bring all your medications with you?"

C

A medical nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems? A) "High school diploma plus 2 years of college" B) "Caregiver reliable source of information" C) "Menarche at age 13" D) "Lungs clear to auscultation bilaterally"

C

A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. Which of the following should the nurse do next? A) Inspect for a lift. B) Palpate for a thrill. C) Auscultate for pulse rate deficit. D) Listen for a ventricular gallop.

C

A nurse has gathered the necessary equipment for the physical assessment of an adult client. For which of the following assessments would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement? A) Mid-arm circumference B) Client's height C) Skin lesion size D) Pupillary size

C

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

C

A nurse is caring for a patient whose diagnosis of cystic fibrosis results in the production of large amounts of sticky mucus. The client has a history of repeated hospital admissions for complications of his disease and receives daily treatments to mobilize the secretions. When planning the care of this client, what nursing diagnosis is most plausible? A) Readiness for Enhanced Breathing Patterns B) Risk for Impaired Oral Mucous Membranes related to mouth breathing C) Ineffective Airway Clearance related to respiratory secretions D) Ineffective Breathing Pattern: Hyperventilation related to cystic fibrosis

C

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

C

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?"

C

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

C

A nurse is teaching a recent nursing graduate about the significance of verbal and nonverbal communication during client care. The new graduate demonstrates an understanding of these techniques by citing what example of verbal communication? A) Maintaining an open attitude B) Using silence appropriately C) Providing a laundry list of descriptors when needed D) Maintaining an open and encouraging facial expression

C

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

C

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

C

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

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

The nurse has had a client place the backs of both her hands against each other while flexing her wrists 90 degrees with fingers pointed downward and wrists dangling. The presence of pain or tingling during this test suggests what health problem to the nurse? A) Osteoarthritis B) Diabetic neuropathy C) Carpal tunnel syndrome D) Gouty arthritis

C

The nurse is conducting the health interview of an adult client who has sought care because of a wicked cough leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask? A) Does your cough often cause you to be short of breath? B) Do you experience chest pain when you cough? C) How long have you been experiencing your cough? D) Are you now or have you ever been a smoker?

C

The nurse is obtaining information about a client's past health history. Which client statement would best reflect this component of assessment? A) "My mom's still alive, but my dad died 10 years ago of heart failure." B) "I have a brother with leukemia and a sister with hypertension." C) "I had surgery 5 years ago to repair an inguinal hernia." D) "I have been having some pain when I urinate for the last several days."

C

The nurse is obtaining the health history of a young adult client. During the interview, the client tells the nurse, ìI banged my head pretty good when I was snowboarding last weekend.î The client states that he did not subsequently seek care. What is the nurse's most appropriate action? A) Promptly assess the client's balance and coordination. B) Teach the client about the warning signs of increased intracranial pressure. C) Refer the client for medical assessment and possible treatment. D) Teach the client about the importance of wearing head protection during sports.

C

Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would recognize this as a tripod position and suspect the presence of which of the following medical problems? A) Pleural effusion B) Heart failure C) Chronic obstructive pulmonary disease D) Pneumonia

C

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

When preparing to assess a client's thoracic cage, the nurse should locate which landmark when determining where to begin the assessment of the ribs and intercostal spaces? A) Scapula B) Suprasternal notch C) Sternal angle D) Sternal border

C

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

Which of the following would be most appropriate when the nurse notes limitation in active range of motion of a client's right shoulder? A) Test muscle strength. B) Perform passive range of motion test. C) Measure range of motion with a goniometer. D) Ask the client which is the dominant side.

C

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

C

The admission of a new resident to a long-term care facility has necessitated a thorough health history. Place the following focuses in the correct sequence in which the nurse should perform them, beginning with the section obtained first. A.) Family health history B) Reason for seeking care C) Biographic data D) Review of body systems E) History of present concern F) Past health history

C B E F A D

Which of the following client situations would the nurse interpret as requiring an emergency assessment? A) A pediatric client with severe sunburn B) A client needing an employment physical C) A client who overdosed on acetaminophen D) A distraught client who wants a pregnancy test

C. A client who overdosed on acetaminophen

The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? A) Family history B) Occupation C) Appearance D) History of present health concern

C. Appearance

A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following? A) Determine if pertinent data has been omitted B) Identify the need for referral C) Avoid biases and judgments D) Construct a plan of care

C. Avoid biases and judgments

A client has a documented history of hepatomegaly (liver enlargement), and the nurse recognizes the need to perform deep palpation during the physical assessment. The nurse should perform which of the following actions? A) Use one hand and depress the skin 1 centimeter. B) Use the dominant hand to depress the skin one-half to three-quarters of an inch. C) Use both hands to depress the skin one-half of an inch. D) Use both hands to depress the skin 1 to 2 inches.

D

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

D

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

D

A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe? A) "This helps us to complete your health record accurately." B) "This helps us to establish a trusting interpersonal relationship." C) "This helps us to evaluate the seriousness of your risk factors for disease." D) "This helps us have an appropriate focus for the physical examination."

D

A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment? A) Start by auscultating the client's breath sounds. B) Auscultate prior to inspection and palpation. C) Use the bell rather than the diaphragm. D) Systematically listen to the entire precordium.

D

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

D

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

D

A nursing instructor is discussing cultural variations in the size of the thorax and impact on lung capacity. Which group would the instructor identify as typically having a larger thorax? A) African Americans B) Asian Americans C) Native Americans D) Caucasians

D

CHAPTER 3 A client has presented to the clinic for the treatment of an ovarian cyst. Which of the following would be most important for the nurse to do immediately before performing this woman's physical exam? A) Explain the purpose of the interview to the client. B) Construct the client's family genogram. C) Establish the client's reliability as historian. D) Collect necessary equipment essential to the exam.

D

Chapter 25 The nurse is assessing the eyes of a client who has a lesion of the sympathetic nervous system. What assessment finding should the nurse anticipate? A) Bilateral dilated pupils B) Nystagmus (involuntary eye movement) C) Argyll-Robertson pupils D) Constricted pupils, unresponsive to light

D

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

D

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

D

The emergency department (ED) nurse is assessing for kidney tenderness in a client who has presented with complaints of dysuria and back pain. What assessment technique should the nurse utilize? A) Deep palpation B) Indirect percussion C) Moderate palpation D) Blunt percussion

D

The nurse assists a client into the dorsal recumbent position. Assessment of which area is contraindicated when the client is in this position? A) Chest B) Head C) Peripheral pulses D) Abdomen

D

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

D

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

The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states, It shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker.The nurse should recognize the need to teach the client about what topic? A) Strategies for making her husband quit smoking B) Genetic causes of lung cancer C) Age-related changes to respiratory function D) Health risks of secondhand smoke

D

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.

D

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 LasËgue test. D) Continue the exam because this curve is normal.

D

The nurse is assessing the carotid arteries of a client with a history of heart disease. What action should the nurse perform during this assessment? A) Palpate the client's left and right carotid arteries simultaneously. B) Palpate the client's carotid arteries prior to auscultation. C) Instruct the client to inhale and exhale forcefully during auscultation. D) Palpate the client's carotid arteries gently if an occlusion is audible.

D

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.

D

The nurse is completing an assessment of a 50-year-old female client who has sought care for recurrent migraines that have not responded to treatment. Following the review of systems, how should the nurse best document unremarkable results of the subjective portion of the gastrointestinal assessment? A) "Client's gastrointestinal health is within reference ranges for age." B) "Client denies GI signs and symptoms." C) "Gastrointestinal problems are absent." D) "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain."

D

The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment? A) The client takes medications to treat hypertension. B) The client suffered a fractured humerus 1 year earlier. C) The client has a diagnosis of type 1 diabetes. D) The client had a total hip replacement 2 years ago.

D

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.

D

The nurse is performing a respiratory assessment of a client who is palliative due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate? A) Biot's B) Bradypnea C) Kussmaul's D) Cheyne-Stokes

D

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

D

The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location? A) Second intercostal space, left sternal border B) Third intercostal space, left axillary line C) Fourth intercostal space, left sternal border D) Fifth intercostal space, left midclavicular line

D

The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data? A) "Do you always wear your seatbelt when driving?" B) "How much beer, wine, or alcohol do you drink?" C) "Do you use condoms with each sexual encounter?" D) "Could you describe how you perform self-breast exams?"

D

The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique? A) Keep the client's shirt or gown in place to maintain privacy. B) Begin with the bell of the stethoscope on the client's anterior chest. C) Tell the client that you will be asking him or her to breathe as quickly and deeply as possible. D) Place the diaphragm on the client's posterior chest wall.

D

The nurse is preparing to palpate the anatomic snuffbox. At which location would the nurse palpate? A) At the anterior area of the sternoclavicular joint B) At the posterior temporomandibular joint C) At the olecranon process of the elbow D) At the back of the wrist and extended thumb

D

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

D

The nurse is to collect a throat culture from a client who has signs and symptoms of a respiratory infection, including frequent, productive coughing. The nurse demonstrates the best adherence to standard precautions by using which of the following pieces of equipment? A) Eye goggles B) Face mask C) Cover gown D) Face shield

D

The nurse's auscultation of a 22-year-old client's apical heart rate reveals the presence of S3. When the client stands upright, the S3 is no longer audible. How should the nurse respond to this assessment finding? A) Make a referral to the client's primary care provider promptly. B) Perform a focused respiratory assessment. C) Recognize this as an early sign of left-sided heart failure. D) Recognize this as a normal assessment finding in this client.

D

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process? A) Air leaking from the alveoli into the pleural space B) Air being diverted from the trachea to the bronchi C) Air increasing in turbulence in a wide passage D) Air passing through constricted passageways

D

The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following should the nurse assess next? A) Lateral aspect of the thorax B) Lung volume C) Hip levels D) Spinal column

D

Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate? A) "Our schedule is very busy also. We got to you as soon as we could." B) "No one is forcing you to be here, and you are free to leave at any time." C) "Would you like to report your complaints to someone with power?" D) "You're certainly justified in being upset, but I am ready to begin your exam now."

D

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 ìahî C) Asymmetrical soft palate D) Uvula and soft palate rising bilaterally

D

While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment? A) When I say so, please exhale forcefully and hold the breath. B) Say the letter 'e' and keep saying it until I tell you to stop. C) Breathe in as deeply as you can and hold your breath until I say. D) Please say the number 'ninety-nine' for me.

D

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

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

CHAPTER ONE A nurse on a postsurgical 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

D making clinical judgements

A nurse is obtaining subjective data from an adult client who is new to the clinic. The nurse has asked the client, "Where do you usually turn for help in a time of crisis?" What domain is this nurse assessing? A) The client's family relationships B) The client's current level of social and relational stability C) The client's critical thinking and problem-solving abilities D) The client's stress management and coping strategies

D.

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? A) Identify the most appropriate forms of medical intervention for the client. B) Determine the most likely prognosis for the client's health problem. C) Identify the status of the client's airway, breathing, and circulation. D) Establish a baseline for the comparison of future health changes.

D.

An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem? A) Encourage the client to increase oral fluid intake. B) Provide the client with a bedtime protein snack. C) Assist the client with personal hygiene. D) Measure the client's blood glucose four times daily.

D. Measure the clients blood glucose four times daily.

When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force? A) Documentation B) Informatics C) Diversification D) Technology

D. Technology

An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession? A) Natural senses B) Biomedical knowledge C) Simple technology D) Critical pathways

Natural senses