Prep U Exam 1

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

Chief complaint

The middle layer of the eye is known as the

Choroid layer

A nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present?

Chronic dieting

Cachexia is characterized by a highly catabolic state with accelerated muscle loss. What is the other component of cachexia?

Chronic inflammatory response

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and

Cleans the cornea and lens

A male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks. He denies nausea or photosensitivity but states that he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?

Cluster headaches

An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of

Cluster headches

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Coin or key

The purpose of a health assessment includes what? (Select all that apply.)

Collecting information about the health status of the client Evaluating client outcomes Synthesizing collected data

A client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for this client?

Comprehensive

The results of a client's Rinne test are as follows: bone condcution > air conduction. How should the nurse explain these findings to the client?

Conductive hearing loss

A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following?

Conjunctiva (bulbar)

A client visits the health care clinic with reports of itchy and watery eyes for three days. The nurse observes a generalized redness to the conjunctiva. The nurse recognizes this as what condition?

Conjunctivitis

A nurse inspects the eyes of a young child and notices the inward turning of the eyes. What test should the nurse perform to assess whether this finding is normal or abnormal?

Corneal light reflex

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

Cranial Nerve VII

The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to

Decreased accomodation

The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism?

Decreased serum calcium level on review of labwork.

The nurse is preparing an educational program on effective hygiene methods for a group of highschool teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin?

Dermis

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

Dermis

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

Diabetes

An elderly client presents to the health care clinic with reports of decreased tearing in both eyes. The nurse observes the presence of ectropion. What is an appropriate action by the nurse?

Document this as a normal sign of aging

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface

What activity is known to aggravate a tension headache?

Driving

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones? Select all that apply

Eliminate distracting noises from the environment Readjust the ear pieces to ensure a snug fit Angle the binurals towards the nose

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones? Select all that apply.

Eliminate distracting noises from the environment Readjust the ear pieces to ensure a snug fit Angle the binurals towards the nose

A client is diagnosed with glaucoma. When performing the ophthalmic exam, what changes should the nurse anticipate finding?

Enlarged physiologic cup that occupies more than half of disc's diameter

A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure?

Ensuring that contact with the skin is maintained

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?

Equalizes the pressure in the middle ear with atmospheric pressure.

What are the nursing goals for the introductory phase of the nurse-patient interview? (Select all that apply.)

Establishing a trusting, respectful rapport with the patient. Agreeing upon the agenda for the interview.

Which of the following is a general procedural rule when performing a complete physical examination?

Examine the right then the left side of the body.

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?

Explain the importance of the examination and the risks of breast cancer

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should

Explain the role and purpose of the nurse

A male client who was transferred from intensive care and extubated less than 24 hours ago exhibits drooling and a weak voice. At meal time, what is the nurse's priority action?

Explain to the client why he should not eat anything by mouth yet.

Data being collected during a health assessment causes the nurse to believe there may be additional issues that are possibly affecting the client's health and wellness. What action should the nurse take to best address the suggestion of additional health concerns?

Extend the time originally allotted for the completion of the initial health assessment.

Primary headaches are more worrisome than secondary headaches.

False

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

Fixed to underlying tissue

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position his head to best facilitate this exam?

Flex the head toward the side being examined

It identifies a problem with the normal pathways for sound to travel to your inner ear."

Fluid collects in the middle ear causing an obstruction of the auditory tube.

The muscles of the ciliary body control the thickness of the lens, allowing the eye to:

Focus on near or distant objects

A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?

Focus on the bridge of the nose

What are the types of nursing assessments?

Focused Emergency Comprehensive

An assessment that concentrates on patterns of role performance that all humans share is called what?

Functional

The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment?

Functional

The nurse is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what?

Functional status

What are the primary frameworks used in conducting a health assessment? Select all that apply.

Functional systems Body systems Head to toe

Which of the following is an example of a recent trend in nursing roles?

Gathering forensic evidence for a legal proceeding

When assessing your new patient, you note that he has no hair on his legs. What might this indicate about the patient?

He has peripheral artery disease

A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection?

Head position

An adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in vision are often associated with

Head trauma

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Head-to-toe

The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?

Hearing intact bilaterally on whisper test

A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information?

History of present illness

The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?

How patient cleans the ears

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?

Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

The most commonly used method of percussion is

Indirect percussion

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use?

Indirect percussion

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?

Introducing hand gestures whenever it is appropriate

A nurse is testing a client's pupillary reaction to light, noting that the pupil constricts when shining light obliquely into it. The nurse understands that muscles in which of the following structures adjust to control the amount of light entering the eye through the aperture of the pupil?

Iris

A patient with a zosteriform rash has a rash that

Is distributed along a dermatome

Which statement made by the nurse demonstrates an understanding of the termination phase of the interviewing process?

Let me stress the importance of being medication adherent

When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck?

Limitations in movement

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply.

Moisture Activity Nutrition

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)

Notched border Diameter greater than 6cm Asymmetry

A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?

Nursing process

The nurse performs the action shown when assessing a client's eyes. What is the nurse assessing?

Ocular alignment

A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing?

Ongoing

An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse?

Open the client's airway

When conducting a health assessment, it is sometimes necessary to conduct specific physical assessments that use specialized tools. What are some of these special tools? Select all that apply

Ophthalmoscope Goniometer Skin-fold calipers

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's

Oral mucosa

A patient comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa

While positioning the head to examine the ears the client expresses pain when the area behind the ears is touched. On which health problem should the nurse focus during the assessment of this client?

Otitis media

Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?

Otosclerosis

Squamous cell carcinoma is associated with

Overall amount of sun exposure

What can cause edema in a patient with a weak heart?

Overhydration

Purposeful hourly rounding by the nurse should include which assessments? (Select all that apply.)

Pain Personal needs Position Fall prevention

You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa

Pain on manipulation of the auricle

You note anterior bulging of the physiologic cup when performing a funduscopic examination of your patient's eyes. What would you document?

Papilledema

Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition?

Parotid enlargement

While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an

Parotid gland enlargement

The admitting nurse has just met a new patient. As the nurse introduces himself, he begins the process of inspection on this patient. What does the admitting nurse know it is important to do while observing during the process of inspection?

Pay attention to the details while observing

The nurse is having difficulty visualizing the apical impulse during a physical examination of the cardiovascular system. Which assessment tool is required for a more accurate assessment?

Penlight

The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination?

Percussion

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?

Perform a physical exam

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Personal health history

A nursing instructor is discussing nutrition screening and assessment with a clinical group. What would this instructor identify for the students as parts of a complete nutrition screening assessment? Select all that apply.

Physical examination Focused history of common symptoms Serial laboratory values

A client presents at the emergency room reporting "the worst headache I have ever had." What are the critical initial nursing interventions for this client? (Select all that apply.)

Physical examination for neurologic changes Conducting a focused history interview

What occurs during the termination phase of an interview?

Planning for follow up care

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a:

Plaque

An older male with a history of consuming an increased amount of processed foods since the death of his wife is complaining of heart palpitations. Which lab result is priority for the nurse to assess?

Potassium levels

A nursing student will soon be graduating and beginning a new job at a local health clinic. The nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for this student to gain confidence in assessment skills?

Practice performing a physical examination on a classmate, friend, or relative.

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?

Preauricular

Which terms refers to the progressive hearing loss associated with aging?

Presbycusis

The nurse wears gloves to:

Prevent transmission of flora from patient to patient.

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

Primary

A 16-year-old white female is brought to the clinic by her mother with a chief complaint of a severe headache lasting more than 24 hours. The mother states, "Just before the headache started my daughter was craving food. I couldn't feed her enough." What is this called?

Prodrome

Malnutrition can be too much or too little nutrition. What can malnutrition do in the human body?

Prolong confinement to bed

A nurse needs to assess a client's range of motion in the hip joints. Which position is best to facilitate this examination?

Prone

A nurse needs to examine a client's hip joint. Which client position would be best for this assessment?

Prone

A way to use nonverbal communication is through silence. The purposeful use of silence during the interview allows clients to what?

Provide accurate answers

A client relates having nasal stuffiness and sneezing during the spring and fall of each year. Where should the nurse document this information in the comprehensive assessment?

ROS

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

Range of motion of the neck

Clients in health care settings often are anxious. What behaviors would lead a nurse to believe that a client is anxious? (Select all that apply.)

Rapid speech Nail-biting Defensive tone Sweating

A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this occurs at the child's hands and feet. She does not remember the child's lips turning blue. The mother says that the child is eating and growing well. What should the nurse do?

Reassure the mother that this is normal

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

Recent illness

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

Recent trauma to the inside of the ear

A client admitted with reports of nausea and vomiting has not reported any vomiting in the last 6 hours. What initial response should the nurse have regarding this assessment information and its effect on the client's nursing plan of care?

Recognize the need to reevaluate the client's plan of care.

A nurse obtains a height measurement on an elderly client and notes that the height has decreased from 5 years ago. What is an appropriate action by the nurse?

Record this measurement in the client chart and alert the health care provider

The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test

Requires covering each eye separately

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens?

Respiratory/cough hygiene

What part of the eye receives and transmits visual stimuli to the brain for processing?

Retina

Which of the following tests use a tuning fork between two positions to assess hearing?

Rinne

The nurse is presenting an educational event for gardeners. When discussing the ears, what would be an important topic to cover?

Skin cancer prevention

A 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should

Tell the patient that these occur with aging

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

The patient has chronic hypoxia

A patient has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply

blood pressure cholesterol activity level

An adult client visits a clinic and tells the nurse that she suspects she has urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing

blunt percussion.

A client is being admitted for elective surgery. What should the nurse instruct the client to do to ensure that the medication history is complete?

bring all medications and preparations used to the hospital

When evaluating data on a patient with an eating disorder, the nurse would expect to find

magenta tongue

A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?

"Can you tell me about your sleep problem from when it started until now?"

During a physical examination of the head and neck, a client reports frequently feeling cold. What additional questions should the nurse ask for more information about the client's symptoms? (Select all that apply.)

"Do you dress more warmly than other people? "Do you use more blankets that others at home? "Do you perspire less than others?"

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

"Do you experience any ringing, roaring, or crackling in your ears?"

When focusing on the client's perspective of a symptom or problem, the nurse will ask which questions? Select all that apply.

"Do you have any fears about the headaches you experience?" "Do you have any idea concerning why you are experiencing these headaches?" "Do the headaches negatively impact your day-to-day life?"

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

"Do you have difficulty swallowing?

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?

"Do you live alone or with someone?"

Which of the following is the BMI that indicates the lowest risk of developing health problems?

23 BMI

An individual is considered obese when his or her BMI is:

30-39

A nurse is advising a 40-year-old male client on his dietary fiber intake. Which of the following should the nurse indicate would be an adequate total fiber intake per day?

38 grams

A waist circumference of greater that which of the following is indicative of excess abdominal fat in men?

40

What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply.

A cancerous skin lesion located on the back Presence of a systemic disease like measles A rash triggered by taking the medication ibuprofen A reddened area on the heel that indicates a potential risk for pressure ulcer formation

The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of care. Which statement describes a nursing diagnosis?

A clinical judgment about client responses to health difficulties.

The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment?

A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment Correct response:

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?

A hard nodule composed of uric acid crystals

You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis?

A progressive, bilateral loss of hearing

The nurse practitioner is assessing the eyes of a client with long-standing uncontrolled hypertension. What might the nurse practitioner visualize during an assessment with an ophthalmoscope?

AV Nicking

A nurse palpates an enlarged, hard, and nontender left-sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding?

Abdomen and thoracic area for changes associated with malignancy

What data collected during an integumentary assessment should cause the nurse to be concerned that a patient is at risk for the development of skin cancer? (Select all that apply.)

Age 55 years Light-colored hair Actinic keratosis on face

What do retinal abnormalities include?

Age-related macular degeneration

Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? Select all that apply

Alcohol abuse Recreational drug use Smokeless tobacco use Multiple sex partners

The nurse understands that the preferred method of hand hygiene is what?

Alcohol-based rub

Diplopia present with one eye covered can be caused by which of the following problems?

An irregularity in the cornea or lens

When making rounds, the RN should prioritize follow-up care for which client?

An oncology client with a cough but no fever.

A client in a long term care facility has lost 5 lbs of body weight in the past month. Which of the following actions should the nurse take to determine the cause of the weight loss?

Analyze the client's intake record.

Which of the following terms is used to describe the arrangement of skin lesions?

Annular

Which of the following statements most accurately describes the maintenance of normal intraocular pressure?

Aqueous humor is continuously circulating through the eye with production equaling discharge

A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition?

Are the blind spots constant or intermittent

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action?

Ask permission to talk to the client in front of visitors.

A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?

Ask the client about previous trauma to the eyes

A client in the emergency department is short of breath and at risk for becoming fatigued. While collecting the history, what is the nurse's best action?

Ask the client's relatives about the client's history.

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

While conducting a comprehensive health history the client says a few sentences about the current problem but then explains how her deceased mother used to have the same problem because of having diabetes. What action should the nurse take?

Begin drawing a genogram

A nursing student is caring for a male patient who has been admitted in a severely malnourished state. For what signs of malnutrition would the student observe?

Bleeding of the gums

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

Blue

What can the nurse assess using percussion?

Borders of the heart

A client presents to the health care clinic with reports of sleeplessness and loss of appetite. The client tells the nurse that his wife is seriously ill in the hospital and he has not been able to visit her much because of transportation problems. Which open-ended question should the nurse ask the client to obtain more information about his presenting symptoms?

"Do you think your wife is getting better?"

A female client describes headache symptoms that seem to indicate a migraine. Which of the following questions during the client interview would, if answered in the positive, tend to confirm the nurse's suspicion?

"Does the headache occur regularly with your menstrual cycle?"

The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information?

"Has this been having an effect on your ability to carry out your routines and get around your home?"

A patient will require an extended period of intense physical therapy after having a compound fracture of the femur surgically repaired. What question should the nurse ask when assessing the client's perception of the injury and recovery plan? (Select all that apply.)

"How does experiencing such a trauma make you feel?" "How do you plan to support yourself financially while you recover?" "What frustrations are you experiencing since your accident?" "What do you expect from the physical therapy you will have?"

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

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

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?

"I'm going to assess the client now so that I can begin formulating the care plan."

A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?

"Nurses focus on the diagnosis of actual human responses to disease or life events."

Which statements made by the nurse demonstrate utilization of effective therapeutic communication techniques during an assessment interview? Select all that apply.

"Please describe exactly how your knee feels when you walk up the stairs." "Now let me summarize what you've told me about what seems to trigger your headaches." "Having such limited use of your right arm seems to make you angry."

Which statements demonstrate the nurse's attempt to empower the client during an assessment interview? Select all that apply.

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

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

"They make sure that any microorganisms on my hands do not touch your skin."

A client recently diagnosed with Grave's diseases exhibits protruded eyeballs. Which eye care instruction should the nurse discuss with this client?

"Wear an eyepatch and use moisturizing eye drops."

During a health assessment, a client shares, "I get a little dizzy when I get up from my chair too quickly." Which question will the nurse ask the client first when attempting to identify client needs and potential health risks?

"What do you mean by 'a little dizzy'?"

Which of the following questions is most useful in the assessment of a client's diabetes management?

"What is your routine for checking your blood sugar these days?"

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?

"What other symptoms occurred during the spell?"

A nurse is conducting a health history interview for an older adult. Which of the following questions or statements would be important for nutritional assessment?

"What prescribed and over-the-counter medicines do you take?"

After a patient describes abdominal pain to the nurse, which questions can the nurse use to help the patient provide more information about the pain? (Select all that apply.)

"Where do you feel the pain?" "Where does the pain travel?" "What other symptoms do you have with the pain?" "What makes the pain less or worse?"

When trying to explore a patient's perspective on his or her illness, the question that would best determine the patient's thoughts on the cause of the problem would be

"Why do you think you have (name the specific symptom)?"

When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be

"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."

A nurse is helping a sedentary 20-year-old female determine her dietary needs. Which of the following would be her estimated calorie needs per day?

1,800-2,000

A nurse is calculating the ideal body weight for a female client who 5 feet 5 inches and has a medium body frame. Which of the following is this client's ideal body weight?

125 lbs

A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this patient's ideal weight?

145 lbs

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as

15

A nurse assesses a 114-pound adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client?

19 BMI

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a

1½-inch diaphragm.

The nurse is caring for a healthy adult client with no history of vision problems. The nurse should tell the client that a thorough eye examination is recommended every

2 years

A patient in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?

20/200 or less

A nurse is working with a patient whose ideal body weight is 172 lb. At what weight would this client first be considered obese?

206.4 lb

A nurse assesses a 175-pound adult client who is 5 feet 11 inches tall. What is the estimated body mass index (BMI) for this client?

24.4

A nurse is calculating the ideal body weight for a male client who 6 feet 7 inches tall and has a large body frame. Which of the following is this client's ideal body weight?

242

A nurse is measuring an adult female client's mid-arm circumference (MAC) as part of her overall assessment of the client's nutritional status. Which of the following is the standard reference for the MAC for an adult female?

28.5 cm

A nurse is measuring an adult male client's mid-arm circumference (MAC) as part of the overall assessment of the client's nutritional status. Which of the following is the standard reference for the MAC for an adult male?

29.3

A nurse assesses a 350-pound adult client who is 6 feet 1 inch tall. What is the estimated body mass index (BMI) for this client?

46

When assisting a patient with health promotion, what must the nurse also nurture?

A healthy environment

As a pediatric nurse, it is important to assess each child for bruising. What might be indicated by ecchymoses in various areas of the body on a toddler or preschool-aged child? (Select all that apply.)

A hematologic problem Certain infections A coagulopathy

To quickly identify a client who may be at risk for nutritional problems, the nurse can use which of the following assessments?

A nutritional screening tool

"How many steps can you climb before you get short of breath?" is an example of what kind of question?

A question that elicits a graded response

A patient has Darwin tubercle. What is this?

A small painless nodule on the helix

Which of the following clients is most likely to be diagnosed with migraine headaches?

A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

Ideal Body Weight

Actual weight/IBW = % IBW 91-109%: IBW 80-90%: "Lean with possibility of malnutrition" 70-80%: Moderate malnutrition <70%: Definite malnutriton *** 10% over IBW: overweight *** 20% over IBW: obese Females: 100lb for 5 feet; +5lb for every inch over that - 10% for small frame + 10% for large frame Males: 106lbs for 5 feet; 6lb for every inch over that - 10% for small frame + 10% for large frame

After examining the client's tympanic membranes, the nurse documents "Right tympanic membrane, red and bulging with no light reflex." The nurse recognizes that these are signs of

Acute otitis media

The nurse is reviewing a client's medical history before surgery. The client has been taking ginseng, garlic, and aspirin daily. What's the nurse's best action?

Advise the client to notify his or her healthcare provider about stopping the supplments and aspirin.

The student nurse learns that examining the skin can do all of the following except?

Allow early identification of neurological deficits.

While examining a client, the nurse observes that he appears to be nodding his head involuntarily. Which of the following conditions should the nurse additionally assess for, based on this finding?

Aortic insufficiency

During one of your clinical placements you encounter a patient who becomes silent during the nursing interview. What would be appropriate for you to do? (Mark all that apply.)

Appear attentive Give brief encouragement to the patient Watch the patient closely for nonverbal cues

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to

Approach the client posteriorly

An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client?

Arthritis

A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database?

As many maternal and paternal relatives as the client can recall

During an interview with a client with a language barrier, what action does the nurse take first to assure mutual understanding?

Ask the client to repeat back in his or her own words what was asked.

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?

Ask the client to repeat the statement or question.

Upon inspection of an elderly client's ears using an otoscope, the nurse observes a cloudy appearance to the tympanic membranes with prominent landmarks. What action should the nurse perform first?

Ask whether the client is experiencing ear pain or pressure

What techniques encourage patient disclosures while minimizing the risk for distorting the patient's ideas or missing significant details? (Mark all that apply.)

Asking a series of questions, one at a time Using reflection Offering multiple choices for answers

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

Asking permission to draw the client's privacy curtain.

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

Assess BP

Nurses weave the individualization of the client interview through all aspects of the encounter. The nurse should avoid assuming that clients follow cultural beliefs. In place of making this assumption, what should a nurse do?

Assess the degree to which the client perceives the cultural beliefs

A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply.

Asymmetrical Change in size Itching Bleeding of a mole

What does the nurse assess the face for? (Select all that apply.)

Asymmetry Edema Involuntary movements

As a part of the ear examination for hearing loss, a nurse conducts a Weber test on a client. To accurately perform this test, the nurse should place the base of the tuning fork in which of the following locations?

At the center of the client's forehead

The triage nurse suspects malnutrition in an older adult with altered mental status who has been brought to the emergency department by family members. What visible signs might the nurse have noticed that would lead to the suspicion of malnutrition? Select all that apply.

Atrophied tongue Temporal muscle wasting Generalized muscle weakness Dry eyes

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

Attempting to roll the structure up and down and side to side

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate with the bell over the lateral lobes

Recommended protective measures to avoid skin cancer include which of the following?

Avoiding sun exposure

Waist circumference guidelines may not be accurate for adult clients who are shorter than 152.4 cm (5 ft) in height. This restriction is also a concern for which other anthropometric measurement?

BMI

A school nurse is assisting with taking baseline measurements of students at a middle school who are participating in a summer fitness program. Which pieces of equipment should the nurse gather specifically for taking anthropometric measurements? Select all that apply.

Balance beam scale with height attachment Metric measuring tape Marking pencil Skinfold calipers

When conducting the health assessment, the nurse interacts with the client in a caring manner. How would the nurse demonstrate caring to the client? Select all that apply.

Being nonjudgmental Showing respect to the client Valuing the client unconditionally

When is it necessary for a nurse to change gloves? Select all that apply.

Between tasks and procedures on the same client When going from a contaminated area to a cleaner area After contact with material that contains a high concentration of microorganisms

During an assessment the nurse suspects that a client has a vitamin C deficiency. What information did the nurse use to make this clinical determination?

Bleeding gums

A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment?

Blunt force trauma often results in a fracture of the orbit

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using

Blunt percussion

What assessment parameters are included when assessing a patient's nutritional status? (Mark all that apply.)

Body mass index Clinical examination findings Dietary data

A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment?

Body systems

An alternate pathway that bypasses the external and middle ear is called what?

Bone conduction

A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client?

Brain tumor

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?

Bruit

A client tells the nurse that his eyes "are not working right." When the nurse asks what the client means, the client states, "It is like one eye is moving faster than the other." What test would be most appropriate for the nurse to use to assess this client?

Cardinal fields

An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment?

Cardiovascular

A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?

Clustered

When inspecting the hair, what would the nurse note? (Select all that apply.)

Color Condition of hair shaft Hair shafts that are shiny

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

Comprehensive

The nurse has performed the Rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing

Conductive hearing loss

A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red colour remains. What should the nurse do?

Consider admission

During an interview, the nurse remains silent and nods the head periodically while the patient is talking. The therapeutic communication technique the nurse is using would be:

Continuers

What are you testing when you ask the patient to follow your finger or pencil as you move it in toward the bridge of the nose?

Convergence

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's

Corneal reflexes

During the introduction phase of the interview, the patient begins to talk nonstop about health problems, family issues, and fears related to illness. What can the nurse do to control the interview process?

Courteously interrupt the patient to clarify some information.

You are performing a physical examination on a new patient. What would you be assessing if you were testing the patient's sense of smell?

Cranial Nerves

A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?

Critical thinking

When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?

Cushings

One technique of therapeutic communication is silence. What does silence allow the patient to do?

Decide how much information to disclose

A nursing instructor is trying to convince the class of the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors should stressed that will promote opportunities for nurses with advanced assessment skills? Select all that apply.

Declining numbers of medical students due to rising costs and focus on primary care Increasing complexity of acute care Growing aging population with complex comorbidities Increasing impact of children and the homeless on communities

Which clinical manifestation should the nurse expect to find in a client with edema?

Decreased skin mobility

A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use?

Diagnostic reasoning

The nurse is preparing client teaching for an adult admitted to the hospital with bilateral pneumonia. What should the nurse know to include in this client teaching?

Dispose of tissues directly into trash cans

rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply.

Disturbed Body Image Ineffective Individual Coping Anxiety

When considering eye safety, what instructions should the nurse provide to a patient newly prescribed contact lenses? (Select all that apply.)

Do not share lenses. Keep the lenses clean. Wash hands before inserting or removing the lenses. Discard unused portions of contact solutions at the expiration date.

When a client reports a sudden but painless loss of vision in the right eye, which question should the nurse ask?

Do you have a history of diabetes?

A nurse assesses a young adult client who lost consciousness after a head-to-head collision while playing football. Which question should the nurse ask in order to determine characteristic symptoms of the head trauma?

Do you have a history of seizures?

Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?

Do you have family who visit you regularly?

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document as a normal finding

A nurse is inspecting the bulbar conjunctiva and sclera of a 67-year-old client, and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nursing action at this time?

Document the finding and proceed with the examination

During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse?

Document this as a normal findings

The nurse is conducting a physical examination of a patient who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?

Dorsiflexion of the foot

The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions?

EBP

In which disease process should a nurse expect to see a client with the presence of pitting edema?

ESRD

An adult client is being admitted to the hospital for a cardiac catheterization related to chest pain and shortness of breath on exertion. What kind of assessment is the admitting nurse going to perform?

Emergency

Apocrine glands are stimulated by what?

Emotional stress

An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph?

Enlargement of a node may be a sign of pathology that is distant from that node.

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

During the integument health history, the nurse asks the patient about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?

Existence of systemic diseases that have skin manifestations

What is a characteristic symptom of Graves hyperthyroidism?

Exophthalmos

A nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation?

Explain the reason for taking down notes

How would the nursing instructor explain the goal of guided questioning to his or her students?

Facilitating the patient's fullest communication

The nurse asks a client "is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing with this question?

Family violence

A client's lab results reveal thyroid stimulating hormone level of 7.0 mU/L; Free T4 0.5 ng/dl; Total T3 60 ng/dl; and Total T4 3mdmg/dl. Based on these lab results what symptoms should the nurse expect the client to reveal?

Fatigue, cold intolerance, and constipation

The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head?

Flex the neck forwards

A middle aged client is admitted to the observation unit with right lower quadrant pain. The client has not kept down any food or drink for 24 hours. The client's temperature is 38.6°C orally (101.5°F). The client describes the pain as "achy with periods of sharp, stabbing sensations." What would be the most appropriate nutritional nursing diagnosis for a client with these assessment data?

Fluid volume less than body requirements related to an inability to tolerate fluids

An adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. The nurse should assess the client for

Foreign body

A client has been receiving intravenous antibiotics for several weeks. Which prevention strategy would be best for the nurse to recommend for this client?

Formal hearing test

For which patient should a nurse perform a focused assessment?

Four-day history of sore throat and fever with enlarged lymph nodes

Learning about the effects of the illness does what for the nurse and the patient?

Gives them the opportunity to create a complete and congruent picture of the problem

A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder?

Glaucoma

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems would the nurse want to rule out?

Graves disease

A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear?

Gray

The nurse is assessing a 5-month-old Asian American infant whose mother has brought him to the clinic with reports that the baby is pulling at the ear and is sleepless and crying at night. When assessing the infant's ears, what color cerumen would the nurse expect to find?

Gray

A nurse is working with a client who has just been given a prescription for warfarin (Coumadin). Which foods should the nurse warn this client to avoid due to its interference with the effectiveness of warfarin?

Green, leafy vegetables

When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head?

Hair color

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify?

Handle of malleus short process of malleus cone of light

Which of the following findings from a nutritional history most likely indicate the client is showing signs of an eating disorder? (Select all that apply.)

Has body mass index of 16 Discusses feeling fat in clothes

What information, acquired during an eye assessment and history, would the nurse document as lifestyle habits? (Select all that apply.)

Has smoked for last 12 years Uses sunglasses when outdoors Uses protective eyewear when appropriate

The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what?

Head to toe

A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?

Health maintenance

The nurse is caring for an adult female client whose BMI is 38.7. The nurse should instruct the client that she is at greater risk for

Heart attack

When assessing the head and neck, the nurse should realize that variations in skull or neck shape or size relate most to what?

Height and weight

A diagnostic finding which is unrelated to nutritional deficiency is

High serum albumin

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?

History of cigarette smoking

Student nurses are spending time in the laboratory learning the proper use of an otoscope. What technique would these students learn for best visualization of the tympanic membrane in an adolescent?

Hold the ear at the helix and lift up and back

A client has anisocoria on examination. Pathological causes of this include which of the following?

Horners syndrome

The student nurse is caring for a patient with emphysema. What sound would the student nurse expect to hear when percussing the patient's lungs?

Hyperresonant

The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?

Hyperthyroidism

A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition?

Hyphema

A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?

Hypothyroidism

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?

Hypothyroidism

The nurse prepares to analyze a list of a client's health problems. In which order will the nurse complete critical thinking of these problems? Drag statements into the proper order.

Identify abnormal data and strengths Cluster the data Draw inferences and identify problems Propose possible nursing diagnoses Check for defining characteristics of the diagnoses Confirm or rule out nursing diagnoses

What is the use of dietary assessment data gathered from a client by a nurse?

Identify patient outcomes

A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states that her appetite has been low for the past 3 months, and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this data?

Imbalanced nutrition

At the beginning of the shift, an older adult hospitalized for pneumonia reports shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time?

Immediate

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?

Impetigo

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

In the midline of the client's skull or in the center of the forehead.

The nurse is using the ophthalmoscope to examine the patient's eyes. The nurse holds the scope

In the right hand for the right eye, and the left hand for the left eye

An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible

Increased ICP

A patient is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the patient's medical record supports this diagnosis?

Increased IOP

What features would most likely be noted on fundoscopic examination of someone with glaucoma?

Increased cup-to-disc ratio

A nurse is describing the importance of fats to the diet to a client. Which of the following functions of fat in the body should the nurse mention? Select all that apply.

Insulating skin and nerve fibers Protecting internal organs Lubricating skin to slow water loss

Which statement made by the nurse demonstrates an understanding of the termination phase of the interviewing process?

Interrupting only if absolutely necessary

The patient asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse?

It identifies a problem with the normal pathways for sound to travel to your inner ear."

Which of the following statements is true of the role of inspection in the physical examination?

It is often the source of the most physical signs.

During a neck assessment, where would the nurse focus palpation of the thyroid isthmus?

Just below the cricoid cartilage

A 60-year-old client is concerned about developing cataracts in her eyes. She asks the nurse whether there is anything she can do to reduce her risk. Consumption of which of the following foods should the nurse recommend to the client for this purpose? Select all that apply.

Kale Eggs Oranges

In examining a client's external auditory canal with an otoscope, the nurse discovers impacted ear wax, known as cerumen. Which of the following is characteristic of cerumen? Select all that apply.

Keeps the tympanic membrane soft Has bacteriostatic properties Serves as a defense against foreign bodies Has a sticky consistency

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision

As nurse becomes more proficient and comfortable in their role, what increases?

Knowledge base and expertise

In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism?

Lab results

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for

Lacrimal obstruction

An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.)

Location

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)

Location Distribution pattern Elevation Color

The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next?

Look for information from family and records regarding any problems that may have occurred at least 3 months ago.

As the density of tissue decreases, the percussion note becomes:

Lower pitched

An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing?

Macular degeneration

What are appropriate dietary instructions that a nurse should provide to a client who is overweight? Select all that apply.

Make half your grains whole Consume calcium-rich foods Choose lean protein sources

A nurse is instructing a client on the importance of protein in the diet. Which of the following should the nurse mention as functions of proteins in the body? Select all that apply.

Making hormones such as insulin Acting as enzymes for chemical reactions such as digestion Helping transport oxygen and lipids through the circulatory system

What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.)

Male gender Tobacco use Age older than 50 years

Body Frame Sizes

Males: Large: >10.4 Medium: 10.4-9.6 Small <9.6 Women: Large >10.9 Medium 10.9-9.9 Small <9.9

As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?

Malignancy

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially

Malignant melanoma

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight.

The nurse is caring for a client recovering from surgery with an open wound. The nurse should encourage this client to increase the intake of which foods?

Meat and dairy products.

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?

Medially towards the nose

What are the glands that are located on the tarsal plates and open on the lid margins?

Meibomian glands

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of

Metastasis

A client visits the outpatient center with a complaint of sudden head and neck pain and stiffness. The client's oral temperature is 37.7 °C (100 °F). The nurse suspects the client is experiencing symptoms of

Migraine

A nurse is assessing the nutritional status of an elderly client. Which of the following tools would be best for the nurse to use for this client?

Mini nutritional assessment (MNA-SF)

Which statement about weight should a nurse keep in mind when evaluating a client's nutritional status?

Muscle, bone, fat, and fluid can account for excessive weight

Which statement by a client about the skin needs validation by the collection of objective data by the nurse?

My feet hurt and are always cold to the touch

The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from?

Myopia

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?

Nasolabial folds

When using an interpreter to facilitate an interview, where should the interpreter be positioned?

Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client

The nurse measures the height and body weight of a female client with high muscle mass. The client weighs 175 pounds (79.4 kg) and is 68 inches (173 cm) tall. In which of these categories does the client's body mass index (BMI) fit best?

Normal

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?

Notify the healthcare provider immediately

A client presents to the clinic reporting sudden visual loss in the left eye. What is the nurse's priority action?

Notify the healthcare provider immediately

A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?

Palmar surface

Your lab instructor explains that physical examination relies on what cardinal assessment technique?

Percussion

A client has been diagnosed with conductive hearing loss. The nurse understands that which of the following could be the cause of this type of hearing loss?

Perforated eardrum

A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?

Physiologic, psychological, sociocultural, developmental, and spiritual data

A nurse assesses the pupillary reaction to light for a client. Which precaution should the nurse follow to get an accurate result of consensual response?

Place an opaque card between the eyes of the client

A college student presents with a sore throat, fever, and fatigue for several days. Exudates are on her enlarged tonsils. A careful lymphatic examination reveals some scattered small mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this?

Posterior cervical

What is the best action by a nurse when a client has difficulty describing the chief complaint?

Provide the client with a laundry list of words to choose from

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

Psoriasis

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?

Psoriasis

An client presents at the ophthalmologist's office after being referred by his family physician. The referral was made after a benign growth of the conjunctiva was found growing from the nasal side of the sclera to the limbus in the client's right eye. The client asks the nurse what this growth is. What is the best answer the nurse can give?

Pterygium

What action should the nurse implement using an otoscope when assessing the ear of an adult client?

Pull the auricle out, up, and back

You are teaching a health class. What would you tell older adults is necessary when they are exposed to heat stress or when they perform sustained vigorous physical activity?

Purposeful drinking

While assessing a patient's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?

Purpuric

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?

Pustular acne

During the physical examination of a 65-year-old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client?

Recognize the weakened pulsation as an age-related change

Straight movements of the eye are controlled by the

Rectus muscles

The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?

Red cheeks

The nurse notes otitis media with effusion in the left ear of a 3-year-old child. Which assessment data is consistent with otitis media with effusion?

Redness and bulging of the eardrum

After conducting a health history, the nurse decides to perform the assessment shown. What finding did the nurse use to make this clinical determination?

Reduced hearing in one ear

A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should

Refer them to an optometrist

A client is admitted to the health care facility with new onset of abdominal pain. The client becomes angry with the nurse when questions about personal information are asked. How should the nurse proceed with the interview?

Remain in control and allow the client to vent feelings

The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test

Requires the covering of each eye separately

A nurse is caring for a client that was in a motor vehicle accident and suffered damage to the external ear. The client asks the nurse how hearing will be affected on a long-term basis. Based on this information, what is the best description the nurse can tell the client about the function of the external ear?

Responsible for protecting internal structures of the ear from foreign substances.

A nurse performs a Rinne test on a client who relates a history of decreased hearing in the right ear. The test demonstrates that the client has conductive hearing loss in the right ear. What is the correct documentation of this test by the nurse?

Right: BC greater than AC; left AC greater than BC

During a physical examination the nurse performs the action shown. What assessment is the nurse performing?

Rinne test

Which diagnostic test distinguishes between conductive and sensorineural hearing loss?

Rinne test

An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that is has become difficult to cut the toenails because the nails have become hard and brittle. The client also states that the feet are always cold and they must wear socks to bed. Which nursing diagnosis can be confirmed from this data?

Risk for impaired skin integrity

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a patient. The nurse should be aware of what risk when using this assessment technique?

Risk for injury

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

Scabies

Jacob, a 33-year-old construction worker, complains of a "lump on his back" over his scapula. It has been there for about 1 year and is getting larger. He says his wife has been able to squeeze out a cheesy textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?

Sebaceous cyst

The nurse expects what change in a client's hair as a result of aging?

Sebaceous glands will secrete less causing hair to be drier.

For which of the following assessments would the nurse plan to use deep palpation? (Select all that apply.)

Shape of abdominal mass Size of liver Pulsation of abdominal aorta

Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.)

Shape of the lips Shape of the nose Shape of the eyes

A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

Short process of the malleous

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

Significantly impaired hearing

The nurse in the dermatology clinic is assessing an adult who has presented at the clinic with a lesion on the left inner thigh. The client tells the nurse that the lesion was discovered one month ago and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subject for this client?

Signs and symptoms of melanoma

For which assessment would the nurse plan to use direct percussion?

Sinuses

The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown?

Skin that feels boggy on palpation

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?

Small pits in the surfaces of the nails

When assessing a patient with Graves disease, how would you expect the thyroid gland to be?

Soft

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

Spooning

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that

Squamous cell carcinomas are most common on body sites with heavy sun exposure

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

Stage 2

A patient is diagnosed with otosclerosis, a condition in which the auditory ossicles develop a spongy consistency, which results in conductive hearing loss. It appears that the worst site is the inner most bone, which transmits sound waves through the oval window. Which bone is this?

Stapes

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

Stiff neck

What is used to gauge central and peripheral nervous system disorders?

Strength of a reflex

A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point?

Summarization

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?

Superficial

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for

Symptoms of stress

Which portion of the middle ear equalizes pressure?

TM

A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for symptoms of hyperthyroidism. What are some of the symptoms of hypermetabolism? Select all that apply.

Tachycardia Anxiety Diarrhea

When inspecting structures such as the jugular venous pulse, what would be the best lighting to use?

Tangential lighting

A nurse is interviewing a client who uses an expression with which the nurse is unfamiliar. What is the most appropriate expression for the nurse to use to clarify the expression's meaning from the client?

Tell me what you mean by ________?

The ulnar edge of the hand is highly receptive to which of the following sensations?

Temperature and vibrations

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

Tension headache

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

Tension headache

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of

Tension headaches

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?

Tension pneumothorax

A nurse has completed assessment of a client and is now validating the information gathered and reviewing goals with the client. Which phase of the interview process is this?

Termination

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

The area around the sac is inflamed

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

The clien exhibits no signs or symptoms of infection

A nurse is admitting a client to the hospital. When reviewing the client's medical record, the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means?

The client has unilateral hearing loss

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?

The client's acuity

Why is it important for the nurse to ask the client what they think caused a skin condition?

The client's perception affects the approach and effectiveness in treating the skin condition

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?

The cyanosis may be a result of a prolonged period of exposure to the cold.

A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?

The larger the bottom number, the worse the visual acuity

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique?

The middle finger of one hand is placed on the body surface and the other middle finger strikes.

Which of the following statements most accurately provides the underlying rationale for the use of auscultation and percussion as assessment techniques?

The nature and elasticity of tissue and body structures influence sound.

The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage?

The notch on its superior edge

Which action by the nurse is consistent with Weber's test?

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

Which is an example of inspection? Select all that apply.

The nurse notes a fine rash covering the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects foul odor of the urine.

Which is an example of percussion? Select all that apply.

The nurse notes dullness over the patient's liver. The nurse notes resonance over the patient's thorax. The nurse notes tympany over the patient's lower abdomen.

Which action by the nurse is consistent with the Rinne test?

The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction.

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary?

The patient

When the client begins to cry, the nurse recognizes the need to focus the assessment on the client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying?

The rapport that exists between the nurse and the client

What are the bordering landmarks of the anterior triangle of the neck? (Mark all that apply.)

The sternomastoid The mandible The midline of the neck

What are the openings to the middle ear? Select all that apply

The tympanic membrane The round window The oval window The eustachian tube

Which of the following findings from the health history of a 70-year-old woman with tinnitus is likely most significant to her diagnosis?

The woman takes aspirin 4 times daily to treat her rheumatoid arthritis.

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

There is no reaction in the opposite pupil to light

What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client?

Thick, purulent drainage is noted at inner corner of both eyes.

Palpation is a necessary skill in nursing. Many of the body's structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation?

Thyroid gland

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

Tinea corpus

During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensoineural hearing loss

Why is the nurse always reassessing the patient for changes?

To achieve the best results

What is the principle of percussion?

To create vibration in a body wall

What is the primary function of the health care team?

To decide the best overall care

Sometimes it is necessary to use a tuning fork when performing a physical assessment. What would be one instance where a tuning fork would be used?

To determine vibration sense in the neuromuscular system

What is the primary purpose of the health history in relation to the eyes?

To identify changes

What is the nurse's primary role in subjective data collection?

To improve the client's health status

When would a nurse obtain a mid-arm circumference measurement?

To provide percentage of body fat and muscle tissue

What is the best measure of protein stores in the body when assessing nutritional status?

Total protein

Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination?

Touch the cornea with a whisp of cotton

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar aspect of the three middle fingers

A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina?

Transforms light rays into nerve impulses that are conducted to the brain

It is recommended that a left-handed examiner adopt a right-sided position.

True

Local redness of the skin warns of impending necrosis.

True

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a

Tumor-related headache

A nurse in the community is completing a manual blood pressure assessment. Which action should the nurse take to ensure the assessment is accurate?

Turn down the TV volume

A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound?

Tympany

A nurse begins a comprehensive physical examination on a client and notes that the client has a large amount of adipose tissue around the waistline. The nurse recognizes that this client should be assessed for an increased risk of which diseases? Select all that apply.

Type II diabetes mellitus Hypertension Stroke

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is

UV light exposure

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply.

Use sunlight, if possible, to inspect the skin Have the client remove his toupee Wear gloves when palpating lesions Keep the room door closed

During an interview with an adult client, the nurse can keep the interview from going off course by

Using closed-ended questions

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be:

Using reputable health-education strategies to reduce risk behaviours

The nurse reviews information obtained from the admission's department about a client seeking medical care for a chronic problem. What should the nurse expect to complete when assessing this client? Select all that apply.

Validate data Document data Collect objective data Collect subjective data

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?

Value-belief

A nurse is teaching a class on diet and nutrition to a group of mothers who are breast-feeding their infants. What would the nurse tell the group is the emphasis of nutritional guidelines?

Variety

Short, pale, and fine hair that is present over much of the body is termed

Vellus

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

Vertigo

A 52-year-old patient fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

Vestibular portion of the inner ear

A comprehensive physical examination of the eye includes tests for which of the following? Select all that apply.

Visual acuity Eye muscle function Internal ocular structures The external eye

A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with

Vitamin A deficiency

When performing a nutritional assessment on a client, a nurse observes that the client has a red, beefy tongue. The nurse recognizes this finding as a deficiency of which essential nutrient?

Vitamin B

In her assessment of a client, a nurse finds that the client has soft, spongy, and bleeding gums. The nurse recognizes that this client most likely has a deficiency in which of the following?

Vitamin C

During a physical assessment, a client reports he has had an inflamed sore on his arm for 2 weeks with no signs of healing. The nurse notes the client also has bleeding gums. What do these findings suggest regarding the client's nutritional status?

Vitamin C deficiency

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin

Vitamin D

The nurse is assessing a school aged client who has been brought to the clinic because the parents are concerned that the client is obese. For what is this child at risk?

Vitamin deficiencies

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect?

Vitiligo

What is the largest chamber of the eye?

Vitreous

A nurse is examining the eyes of a 7-year-old boy. The boy asks the nurse, "What's inside my eyeball?" The nurse explains that the biggest space inside the eyeball contains a clear, gelatinous substance that light passes through. Which of the following is the technical name for this gelatinous substance?

Vitreous humor

The nurse assesses sunken eyes and poor skin turgor in a client. What should the nurse consider as a potential cause for these findings?

Vomiting

What is the most common measurement used to determine abdominal visceral fat?

Waist circumference

A client tells the nurse that it is difficult to hear normal conversation when in a room with a lot of noise. Which test should the nurse perform to assess the hearing ability of the client?

Weber test

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Weber test

BMI

Weight (kg)/ height (meters) x2

The nurse is assessing functional health patterns. Which question should be used to determine a client's role-relationships?

What is your job?

The nurse is conducting a physical examination of a client who reports finding a lump in the neck. Which of the following questions should be included in when the nurse is collecting subjective data? (Select all that apply).

When did you first notice the lump? How recently have you consumed alcohol? Has the lump changed?

When should the nurse perform hand washing? Select all that apply.

When hands are visibly soiled After removing gloves After providing mouth care

When should the nurse wear gloves? Select all that apply.

When touching blood or body fluids In anticipation of body fluid contact

A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear:

Whispered sounds

The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead?

White

A nurse cares for a client with optic atrophy. The nurse recognizes that an ophthalmoscopic examination of the eye should reveal which characteristic finding in the optic disc?

White colored

A client on the orthopedic unit is being discharged home. The client is elderly and has a broken right humerus; the client is right handed. The client's closest family member lives 50 miles away. What should the nurse consider before discharging the client? Select all the apply. (select all that apply.)

Who will be there to help the client with ADLs? How will the client get home from the hospital? How will the client cook and eat?

A nurse assesses a client who reports the onset of a severe headache. During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care?

Working

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed

Working

When a client responds to a question with a "yes" or "no" answer, what appropriate responses by the nurse encourage the client to elaborate? (Select all that apply.)

Yes Um hum Go on

The review of systems is to be completed next while conducting a comprehensive assessment. Which type of question should the nurse use for this review?

Yes or No

A patient comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse?

You will need to be seen by the doctor

The nurse should make it a priority to assess which client for papilledema?

a 45-year-old suspected of experiencing a subarachnoid hemorrhage

A client's tongue and oral mucosa are blue-tinged in color. What health problem should the nurse suspect this client is experiencing?

advanced lung disease

The nurse documents that a 45-year-old male is 177.8 cm (5 ft 10 in) tall and weighs 97.5 kg (215 lb). He tells the nurse that he "has a good appetite, but doesn't get much exercise because of his busy work schedule." An appropriate NANDA nursing diagnosis for this client is

altered nutrition, more than body requirements related to intake greater than calories expended.

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to

arrive at conclusions about the client's health.

A client is experiencing periodic abdominal pain. Which technique should the nurse plan to use immediately after inspecting the area?

auscultation

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should

avoid premature judgments about the client.

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next

check for the presence of defining characteristics.

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

collecting information regarding the client's health status

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should

document the findings

The nurse is preparing to interview a newly admitted client. What should be done prior to hearing the client's story?

establish the agenda for the interview

When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals?

fundus is grayish brown with a purplish cast

During a client interview, the nurse asks questions about the client's past health history. The primary purpose of asking about past health problems is to

identify risk factors to the client and his or her significant others.

The nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. The nurse should

indicate acceptance of the client's cultural differences.

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have

knowledge of his or her own thoughts and feelings about these issues.

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should

maintain eye contact while asking the questions from the form.

The nurse assesses a client with noisy breathing including a gasping sound with respiration. The nurse notes tracheal deviation from the usual midline position. Which conditions should the nurse assess for further? Select all that apply.

mediastinal mass atelectasis pneumothorax goiter

The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client, the nurse should

observe the client's response to the explanations.

A nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this?

on the medial border of the mandible

During the interview of an adult client, the nurse should

provide the client with information as questions arise.

While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should

refer the client to a physician for further evaluation

A client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his right eye. The nurse should

refer the client to an ophthalmologist.

The nurse is preparing to measure the triceps skinfold of an adult client. The nurse should

repeat the procedure three times and average the measurements.

While interviewing an adult client about her nutrition habits, the nurse should

review the ChooseMyPlate information with the client.

The nurse should ask about or assess which associated factors when a patient complains of cluster headaches? Select all that apply.

rhinorrhea ptosis miosis lacrimation

The nurse conducts the physical examination of a client with a diagnosis of chronic obstructive pulmonary disease. The nurse observes the point of maximal impulse (PMI) is located in the epigastric region. What condition explains this finding?

right ventricular hypertrophy

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to

strike a tuning fork and place it on the center of the client's head or forehead.

Connecting the skin to underlying structures is/are the

subcutaneous tissue

The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? Select all the apply.

throbbing photophobia recurrent

The nurse notes that a client with an anxiety disorder has a small patch of baldness behind the left ear. What should the nurse suspect as the reason for this hair inconsistency?

trichotillomania

A client's skin color depends on melanin and carotene contained in the skin, and the

volume of blood circulating in the dermis

Before beginning a physical assessment of a client, the nurse should first

wash both hands with soap and water.

To adhere to standard precautions, the nurse should remember to (Select all that apply.)

wash hands before and after patient contact change white coat frequently