Developmental Stages - Health Assessment/Physical Exam

Card Set Information

Author:
nursedaisy98
ID:
256713
Filename:
Developmental Stages - Health Assessment/Physical Exam
Updated:
2014-04-20 10:28:23
Tags:
NCLEX RN
Folders:
Developmental Stages
Description:
Health Assessment/Physical Exam
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user nursedaisy98 on FreezingBlue Flashcards. What would you like to do?


  1. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? 
    1. Have one of the client's family members interpret. 
    2. Have the Spanish-speaking triage receptionist interpret. 
    3. Page an interpreter from the hospital's interpreter services. 
    4. Obtain a Spanish-English dictionary and attempt to triage the client.
    3. Page an interpreter from the hospital's interpreter services.
  2. The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? 
    1. An involuntary rhythmic, rapid, twitching of the eyeballs. 
    2. A dorsiflexion of the ankle and great toe with fanning of the other toes. 
    3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed. 
    4. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference.
    3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed.
  3. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 
    1. Rhythmic respirations with periods of apnea 
    2. Regular rapid and deep, sustained respirations 
    3. Totally irregular respiration in rhythm and depth 
    4. Irregular respirations with pauses at the end of inspiration and expiration
    1. Rhythmic respirations with periods of apnea
  4. The nurse notes documentation that a client has conductive hearing loss. The nurse understands that this type of hearing loss is caused by which problem? 
    1. A defect in the cochlea 
    2. A defect in the 8th cranial nerve 
    3. A physical obstruction to the transmission of sound waves 
    4. A defect in the sensory fibers that lead to the cerebral cortex
    3. A physical obstruction to the transmission of sound waves
  5. While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. Which describes the sound of a heart murmur? 
    1. Lub-dub sounds 
    2. Scratchy, leathery heart noise 
    3. Gentle blowing or swooshing noise 
    4. Abrupt, high-pitched snapping noise
    3. Gentle blowing or swooshing noise
  6. The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 
    1. Tests the corneal reflexes 
    2. Tests the six cardinal positions of gaze 
    3. Tests visual acuity, using a Snellen eye chart 
    4. Tests sensory function by asking the client to close eyes and then lightly touching the forehead, cheeks, and chin
    2. Tests the six cardinal positions of gaze
  7. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 
    1. After a shower or bath 
    2. While standing to void 
    3. After having a bowel movement 
    4. While lying in bed before arising
    1. After a shower or bath
  8. The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 
    1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 
    2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 
    3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 
    4. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.
    3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
  9. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 
    1. Stridor 
    2. Crackles 
    3. Wheezes 
    4. Diminished
    3. Wheezes
  10. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 
    1. Auscultating lung sounds 
    2. Obtaining the client's temperature 
    3. Assessing the strength of peripheral pulses 
    4. Obtaining information about the client's respirations 
    5. Performing a musculoskeletal and neurological examination 
    6. Asking the client about a family history of any illness or disease
    • 1. Auscultating lung sounds 
    • 2. Obtaining the client's temperature 
    • 4. Obtaining information about the client's respirations
  11. The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? 
    1. To examine the testicles while lying down 
    2. That the best time for the examination is after a shower 
    3. To gently feel the testicle with one finger to feel for a growth 
    4. That testicular self-examinations should be done at least every 6 months
    2. That the best time for the examination is after a shower
  12. The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? 
    1. At the onset of menstruation 
    2. Every month during ovulation 
    3. Weekly at the same time of day 
    4. 1 week after menstruation begins
    4. 1 week after menstruation begins
  13. The clinic nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 
    1. The right eye is tested, followed by the left eye, and then both eyes are tested. 
    2. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 
    3. The client is asked to stand at a distance of 40 feet from the chart and is asked to read the largest line on the chart. 
    4. The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision.
    1. The right eye is tested, followed by the left eye, and then both eyes are tested.
  14. The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. 
    1. Set the room temperature at a comfortable level. 
    2. Remove distracting objects from the interviewing area. 
    3. Place a chair for the client across from the nurse's desk. 
    4. Ensure comfortable seating at eye level for the client and nurse. 
    5. Provide seating for the client so that the client faces a strong light. 
    6. Ensure that the distance between the client and nurse is at least 7 feet.
    • 1. Set the room temperature at a comfortable level. 
    • 2. Remove distracting objects from the interviewing area. 
    • 4. Ensure comfortable seating at eye level for the client and nurse.
  15. The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area? 
    1. Left shoulder 
    2. Right scapula 
    3. Right shoulder 
    4. Small of the back
    1. Left shoulder
  16. The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The most appropriate instruction regarding when the BSE should be performed is at which time? 
    1. At ovulation time 
    2. 7 to 10 days after menses 
    3. Just before menses begins 
    4. At a specific day of the month and on that same day every month thereafter
    4. At a specific day of the month and on that same day every month thereafter
  17. The nurse is conducting a problem-based or focused assessment on a client. Which is accurate about this type of assessment? 
    1. Mostly used in a walk-in clinic or emergency department 
    2. Focused on disease detection and conducted in a HCP's office 
    3. Conducted on admission in a primary care or long-term care setting 
    4. Conducted as a follow-up examination by a health care provider (HCP)
    1. Mostly used in a walk-in clinic or emergency department
  18. An emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely supports this suspicion? 
    1. Poor hygiene 
    2. Difficulty walking 
    3. Fear of the parents 
    4. Bald spots on the scalp
    2. Difficulty walking
  19. The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions regarding breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which information should the nurse give to the client? 
    1. "You need to perform BSE on the same day of every month." 
    2. "It is not necessary to do BSE because you are postmenopausal." 
    3. "You are not at risk for breast cancer because you are in the postmenopausal phase." 
    4. "Mammograms performed every 10 years are sufficient in the postmenopausal phase."
    1. "You need to perform BSE on the same day of every month."
  20. The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction? 
    1. "TSE is performed once a month." 
    2. "TSE should be performed on the same day of each month." 
    3. "It is best to do TSE first thing in the morning before a bath or shower." 
    4. "The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand."
    3. "It is best to do TSE first thing in the morning before a bath or shower."
  21. The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination? 
    1. Sims position 
    2. Supine with the head and feet flat 
    3. Supine with the head raised slightly and the knees slightly flexed 
    4. Semi-Fowler's position with the head raised 45 degrees and the knees flat
    3. Supine with the head raised slightly and the knees slightly flexed
  22. The clinic nurse is performing an assessment for a client who is complaining of shortness of breath. The client tells the nurse that he is a cigarette smoker and admits to smoking one pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack years? Fill in the blank.
    10 pack years
  23. The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? 
    1. Wheezes 
    2. Rhonchi 
    3. Crackles 
    4. Pleural friction rub
    4. Pleural friction rub
  24. The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? 
    1. Ataxia 
    2. Nystagmus 
    3. Pronator drift 
    4. Hyperreflexia
    3. Pronator drift
  25. The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action? 
    1. Identify an object placed in the client's hand. 
    2. Identify three numbers or letters traced in the client's palm. 
    3. State whether one or two pinpricks are felt when the skin is pricked bilaterally in the same place. 
    4. Identify the smallest distance between two detectable pinpricks, made with two pins held at various distances.
    1. Identify an object placed in the client's hand.
  26. The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty in answering the questions and should perform which action? 
    1. Ask a second nurse to be present during the interview. 
    2. Defer both the health history and the neurological examination. 
    3. Defer the health history and proceed with the neurological examination. 
    4. Ask the client to give permission for a family member to stay during the interview.
    4. Ask the client to give permission for a family member to stay during the interview.
  27. The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. 
    1. Allergy to pollen 
    2. History of headaches 
    3. Previous back injury 
    4. History of hypertension 
    5. History of diabetes mellitus
    • 2. History of headaches 
    • 3. Previous back injury 
    • 4. History of hypertension 
    • 5. History of diabetes mellitus
  28. The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? 
    1. Turn the flashlight on directly in front of the eye and watch for a response. 
    2. Ask the client to follow the flashlight through the six cardinal positions of gaze. 
    3. Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. 
    4. Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.
    2. Ask the client to follow the flashlight through the six cardinal positions of gaze.
  29. The nurse is performing a neurological assessment on a client who had a brain attack (stroke). The nurse checks for proprioception by which assessment technique? 
    1. Tapping the Achilles tendon using the reflex hammer 
    2. Gently pricking the client's skin on the dorsum of the foot in two places 
    3. Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument 
    4. Holding the sides of the client's great toe and, while moving it, asking what position it is in
    4. Holding the sides of the client's great toe and, while moving it, asking what position it is in
  30. A nursing student is performing an otoscopic examination in an adult client. The nursing instructor observes the student perform this procedure. Which observation by the instructor indicates that the student is using correct technique for the procedure? 
    1. Using the smallest speculum available 
    2. Pulling the earlobe down and back before inserting the speculum 
    3. Pulling the pinna down and back before inserting the speculum 
    4. Tilting the client's head slightly away and holding the otoscope upside down before inserting the speculum
    4. Tilting the client's head slightly away and holding the otoscope upside down before inserting the speculum
  31. The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action? 
    1. Whisper a statement while the client blocks both ears. 
    2. Quietly whisper a statement and test both ears at the same time. 
    3. Whisper a statement with the examiner's back to the client. 
    4. Stand 1 to 2 feet away from the client and ask the client to block one external ear canal.
    4. Stand 1 to 2 feet away from the client and ask the client to block one external ear canal.
  32. The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? 
    1. A tuning fork 
    2. A stethoscope 
    3. A tongue blade 
    4. A reflex hammer
    1. A tuning fork
  33. The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex? 
    1. Stroking the foot from the heel to the toe 
    2. Gently inserting a gloved finger in the rectum 
    3. Directing a flashlight onto the pupils of the eyes 
    4. Using a tongue depressor and stimulating the back of the throat
    1. Stroking the foot from the heel to the toe
  34. The nurse in the health care clinic is preparing to perform an otoscopic examination on an adult client. What should the nurse do when performing the examination? 
    1. Pull the pinna up and back before inserting the speculum. 
    2. Tilt the client's head forward before inserting the speculum. 
    3. Pull the ear lobe down and back before inserting the speculum. 
    4. Position the client lying flat on the side of the ear to be examined.
    1. Pull the pinna up and back before inserting the speculum.
  35. A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? 
    1. Palpating over the lung apices in the supraclavicular area 
    2. Asking the client to repeat the word ninety-nine during palpation 
    3. Palpating over the breast tissue to assess and compare vibrations from one side to the other 
    4. Comparing vibrations from one side to the other as the client repeats the word ninety-nine
    3. Palpating over the breast tissue to assess and compare vibrations from one side to the other
  36. The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? 
    1. Separate the client's jaw by pushing down on the chin. 
    2. Bring a wisp of cotton in from the side of the eye and lightly touch the cornea. 
    3. Place a small amount of sugar on the client's tongue and ask him or her to identify the taste. 
    4. Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.
    1. Separate the client's jaw by pushing down on the chin.
  37. The clinic nurse is preparing to assess the client's apical pulse. The nurse correctly palpates over which area?

    1. A 
    2. B 
    3. C 
    4. D
    1. A
  38. The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status? 
    1. The client's ability to ambulate 
    2. The intactness of the tympanic membrane 
    3. The intactness of the retinal structure of the eye 
    4. The functional status of the vestibular apparatus in the inner ear
    4. The functional status of the vestibular apparatus in the inner ear
  39. A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used.
    1. Asks the client to cover one eye
    2. Examiner covers eye opposite to the eye covered by the client
    3. Asks the client to report when object is first noted
    4. Stands 2 to 3 feet in front of and faces the client
    5. The examiner brings in an object gradually from periphery
    • 4. Stands 2 to 3 feet in front of and faces the client
    • 3. Asks the client to report when object is first noted
    • 2. Examiner covers eye opposite to the eye covered by the client
    • 5. The examiner brings in an object gradually from periphery
    • 3. Asks the client to report when object is first noted
  40. The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? 
    1. Focus on a close object. 
    2. Focus on a distant object. 
    3. Close one eye and read letters on a chart. 
    4. Raise one finger when the sound is heard.
    2. Focus on a distant object.
  41. A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The clinic nurse should teach the group which point about this procedure? 
    1. Do the exam on the same day of every month. 
    2. Do the exam 7 days after the start of the menstrual cycle. 
    3. Examine the left breast with the left hand and vice versa. 
    4. Use the tips of the fingers to increase the likelihood of feeling lumps.
    1.Do the exam on the same day of every month.
  42. The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas least helpful in assessing for pallor or cyanosis? 
    1. Sclera 
    2. Tongue 
    3. Nail beds 
    4. Mucous membranes
    1. Sclera
  43. The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if one of the students states that which action should be performed? 
    1. Perform the exam after a cold shower. 
    2. Expect the exam to be slightly painful. 
    3. Perform the self-examination every other month. 
    4. Roll the testicle between the thumb and forefinger.
    4. Roll the testicle between the thumb and forefinger.
  44. The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? 
    1. Flashlight 
    2. Snellen chart 
    3. Reflex hammer 
    4. Ophthalmoscope
    2. Snellen chart
  45. The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for? 
    1. A yellow tinge to the skin 
    2. Bluish discoloration of the skin 
    3. Loss of normal red tones in the skin 
    4. An ashen-gray appearance to the skin
    3. Loss of normal red tones in the skin
  46. The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area? 
    1. Sclera 
    2. Oral mucosa 
    3. Sole of the foot 
    4. Palm of the hand
    2. Oral mucosa
  47. The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? 
    1. Assess for drainage from the wound. 
    2. Assess for redness around the wound edges. 
    3. Palpate for swelling around the wound edges. 
    4.P alpate for increased skin temperature around the wound edges.
    4. Palpate for increased skin temperature around the wound edges.
  48. A nurse is conducting a health screening clinic and is preparing to test the visual acuity of a client using a Snellen chart. Which statement by the nurse includes the correct client instructions? 
    1. "Stand 10 feet from the chart and cover the one eye." 
    2. "Stand 20 feet from the chart and cover the one eye." 
    3. "Stand 30 feet from the chart and read the largest line on the chart." 
    4. "Stand 40 feet from the chart and read the largest line on the chart."
    2. "Stand 20 feet from the chart and cover the one eye."
  49. A client's vision is tested with a Snellen chart. The results of testing are documented as 20/40. Which statement is a correct interpretation of the client's test result? 
    1. The client's vision is normal, but the client may require reading glasses. 
    2. The client is legally blind, and glasses or contact lenses will not be helpful. 
    3. The client can read at a distance of 40 feet what a person with normal vision can read at 20 feet. 
    4. The client can read at a distance of 20 feet what a person with normal vision can read at 40 feet.
    4. The client can read at a distance of 20 feet what a person with normal vision can read at 40 feet.
  50. A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test? 
    1. "I will tell you when I see the colored dots." 
    2. "I will tell you when I see the flash of bright light." 
    3. "I will tell you when the small object is in my visual field." 
    4. "I will tell you when the blocks and shapes are in my visual field."
    3. "I will tell you when the small object is in my visual field."
  51. A nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? 
    1. Mitral area 
    2. Right atrium 
    3. Right ventricle 
    4. Pulmonic valve
    1. Mitral area
  52. A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? 
    1. Near the lateral 12th rib 
    2. Just under the left clavicle 
    3. In the fifth intercostal space 
    4. Posteriorly under the left scapula
    2. Just under the left clavicle
  53. A nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? 
    1. Over the second intercostal space at the left sternal border 
    2. Over the fourth intercostal space at the right sternal border 
    3. Over the second intercostal space at the right sternal border 
    4. Over the fifth intercostal space in the left midclavicular line
    4. Over the fifth intercostal space in the left midclavicular line
  54. The nurse is preparing to perform a Weber test on a client who reports a loss of hearing in one ear. To perform the test, the nurse places the tuning fork in which area?

    1. A 
    2. B 
    3. C 
    4. D
    1. A
  55. A nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data? 
    1. Temperature is 99.6° F. 
    2. Pedal pulses are present. 
    3. Client reports difficulty sleeping at night. 
    4. Client has an apical pulse rate of 56 beats/min.
    3. Client reports difficulty sleeping at night.
  56. A nurse is reviewing the findings on a physical examination that are documented in a client's record. The nurse notes which as a piece of documented objective data? 
    1. The client has difficulty urinating. 
    2. The client has a rash on the chest and arms. 
    3. The client experiences migraine headaches. 
    4. The client reports taking atenolol (Tenormin) for blood pressure.
    2. The client has a rash on the chest and arms.
  57. A nurse is making an initial home visit to a client who was recently discharged from the hospital after treatment for a myocardial infarction. The nurse should use which type of database initially to obtain information from the client? 
    1. An episodic database 
    2. A follow-up database 
    3. An emergency database 
    4. A complete health database
    4. A complete health database
  58. A client experiencing "skipped heart beats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate (Toprol XL). The client returns to the health care provider's office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment? 
    1. Follow-up database 
    2. Emergency database 
    3. Complete health database 
    4. Problem-centered database
    1. Follow-up database
  59. A nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. What should the nurse interpret this finding to mean about the client? 
    1. Has normal vision 
    2. Has some degree of blindness 
    3. Can read at a distance of 20 feet what a client with normal vision can read at 30 feet 
    4. Can read at a distance of 30 feet what a client with normal vision can read at 20 feet
    3. Can read at a distance of 20 feet what a client with normal vision can read at 30 feet
  60. A nurse is preparing to test cranial nerve V in a client. The nurse should obtain which item to test this nerve? 
    1. Coffee beans 
    2. A tuning fork 
    3. A wisp of cotton 
    4. An ophthalmoscope
    3. A wisp of cotton
  61. A nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? 
    1. The major bronchi 
    2. The trachea and larynx 
    3. The peripheral lung fields 
    4. The lower posterior thorax
    1. The major bronchi
  62. The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment as an abnormal finding? 
    1. Presence of fasciculations 
    2. Muscle strength graded 5/5 
    3. Symmetrical movements bilaterally 
    4. A 1-cm hypertrophy of right upper arm
    1. Presence of fasciculations
  63. A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the nurse include in the client's focused assessment? 
    1. Ability to drive a car 
    2. The normal everyday routine in the home 
    3. Self-care needs such as toileting, feeding, and ambulating 
    4. Ability to do light or heavy housework, and to pay the bills
    3. Self-care needs such as toileting, feeding, and ambulating
  64. The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the health care provider (HCP)? 
    1. Absence of a bruit 
    2. Concave, midline umbilicus 
    3. Pulsation between the umbilicus and the pubis 
    4. Bowel sound frequency of 15 sounds per minute
    3. Pulsation between the umbilicus and the pubis
  65. The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment regarding the client's smoking history? 
    1. Number of pack-years 
    2. Desire to quit smoking 
    3. Brand of cigarettes used 
    4. Number of past attempts to quit smoking
    1. Number of pack-years
  66. A 52-year-old male client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet 8 inches and his weight is 220 pounds. Vital signs are as follows: temperature, 98.6° F orally; pulse, 86 beats/minute; and respirations, 18 breaths per minute. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL. Which question should the nurse ask the client first? 
    1. "Do you exercise regularly?" 
    2. "Are you considering trying to lose weight?"
    3. "Is there a history of diabetes mellitus in your family?" 
    4. "When was the last time you had your blood pressure checked?"
    4. "When was the last time you had your blood pressure checked?"
  67. The nurse is preparing to interview a client to collect data about the client's health history. The nurse should take which actions to make sure that the physical environment is ready? Select all that apply. 
    1. Provide sufficient lighting. 
    2. Set the room temperature at a comfortable level. 
    3. Ensure that the distance between the nurse and client is no more than 3 feet. 
    4. Arrange seating so that the nurse sits behind the desk across from the client. 
    5. Make sure that the client will be seated comfortably at eye level with the nurse. 
    6. Leave equipment needed for the physical exam on the desk so that they are readily available.
    • 1. Provide sufficient lighting. 
    • 2. Set the room temperature at a comfortable level. 
    • 5. Make sure that the client will be seated comfortably at eye level with the nurse.
  68. The nurse is planning to test the function of the trigeminal nerve (cranial nerve V). The nurse would gather which items to perform the test? 
    1. Tuning fork and audiometer 
    2. Snellen chart, ophthalmoscope 
    3. Flashlight, pupil size chart, or millimeter ruler 
    4. Safety pin, hot and cold water in test tubes, cotton wisp
    4. Safety pin, hot and cold water in test tubes, cotton wisp
  69. The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what should the nurse test? 
    1. The corneal reflex 
    2. The six cardinal fields of gaze 
    3. The pupillary response to light 
    4. Pupillary response to light and accommodation
    2. The six cardinal fields of gaze
  70. A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test? 
    1. The client is asked to discriminate numbers from a chart composed of colored dots. 
    2. The room is darkened, and the client is asked to identify colored blocks and shapes when they appear in the visual field. 
    3. The examiner and client cover the same eyes and stare at each other's uncovered eye, and a small object is brought into the visual field. 
    4. The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.
    4. The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.
  71. A nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this examination? 
    1. Pull the pinna up and back before inserting the speculum. 
    2. Pull the earlobe down and back before inserting the speculum. 
    3. Tilt the client's head forward and down before inserting the speculum. 
    4. Use the smallest speculum available to decrease the discomfort of the exam.
    1. Pull the pinna up and back before inserting the speculum.
  72. After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds? 
    1. Waves of loud gurgles auscultated in all four quadrants 
    2. Low-pitched swishing auscultated in one or two quadrants 
    3. Relatively high-pitched clicks or gurgles auscultated in all four quadrants 
    4. Very high-pitched loud rushes auscultated especially in one or two quadrants
    3. Relatively high-pitched clicks or gurgles auscultated in all four quadrants
  73. A nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment technique should the nurse perform next? 
    1. Palpate the abdomen for size. 
    2. Palpate the liver at the right rib margin. 
    3. Listen to bowel sounds in all four quadrants. 
    4. Percuss the right lower abdominal quadrant.
    3. Listen to bowel sounds in all four quadrants.
  74. The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive? 
    1. Absent bowel sounds 
    2. Client complaints of wound pain 
    3. Pain with dorsiflexion of the foot 
    4. Crackles on auscultation of the lungs
    3. Pain with dorsiflexion of the foot
  75. A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique? 
    1. "I will ask the client to raise her legs up to her waist and then to lower her legs slowly." 
    2. "I will ask the client to raise her legs and to try to lower them against pressure from my hand." 
    3. "I will ask the client to extend her legs flat on the bed, and I will gently dorsiflex her foot forward." 
    4. "I will ask the client to extend her legs flat on the bed, and I will grasp her foot and sharply extend it backward."
    3. "I will ask the client to extend her legs flat on the bed, and I will gently dorsiflex her foot forward."
  76. The nurse is performing a voice test to assess the hearing of a client. Which describes the accurate procedure for performing this test? 
    1. Whisper a statement while the client blocks one ear. 
    2. Whisper a statement while the client blocks both ears. 
    3. Whisper a statement with the examiner's back facing the client. 
    4. Stand 4 feet away from the client to ensure that the client can hear at this distance.
    1. Whisper a statement while the client blocks one ear.
  77. When assessing a client's liver during an assessment, the nurse should palpate which abdominal quadrant? 
    1. Left upper quadrant 
    2. Left lower quadrant 
    3. Right upper quadrant 
    4. Right lower quadrant
    3. Right upper quadrant
  78. A clinic nurse is performing a cardiovascular assessment on a client and auscultates the chest over the apex of the heart.Play SoundThe nurse should document this finding as which sound? 
    1. First heart sound, S1 
    2. Ventricular gallop 
    3. Third heart sound, S3 
    4. Fourth heart sound, S4
    1. First heart sound, S1
  79. In what area of the chest would the nurse expect to auscultate these breath sounds?
    1. Over the peripheral lung fields 
    2. Over the manubrium in the large tracheal airways 
    3. Anteriorly and posteriorly over the major bronchi 
    4. Throughout the chest and in the bases of the lungs
    3. Anteriorly and posteriorly over the major bronchi
  80. In what area of the chest would the nurse expect to auscultate these breath sounds?
    1. Over the trachea 
    2. Over the peripheral lung fields 
    3. Posteriorly at the T4 level medial to the scapula 
    4. Between the first and second intercostal spaces at the sternal border anteriorly
    2. Over the peripheral lung fields
  81. The nurse is performing a physical examination on a hospitalized client. On abdominal assessment, the nurse listens to the bowel sounds and hears these sounds.Play SoundThe nurse documents that which sound is heard? 
    1. Bruits 
    2. Normal bowel sounds 
    3. Hypoactive bowel sounds 
    4. Hyperactive bowel sounds
    2. Normal bowel sounds
  82. A nurse is preparing to take an apical pulse on an assigned client. The nurse should place the diaphragm of the stethoscope at which cardiac site? 
    1. Aortic area 
    2. Mitral area 
    3. Tricuspid area 
    4. Pulmonic area
    2. Mitral area
  83. A nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)? 
    1. Elevate the shoulders. 
    2. Swallow a sip of water. 
    3. Open the mouth and say "ah." 
    4. Vocalize the sounds "la-la," "mi-mi," and "kuh-kuh."
    1. Elevate the shoulders.
  84. A nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse shouldnext ask the client to take which action? 
    1. Identify three objects placed in the hand, one at a time. 
    2. Identify three numbers or letters traced in the client's palm. 
    3. Identify the smallest distance between two skin pricks after pricking the skin with two pins at varying distances. 
    4. State whether one or two skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client's skin.
    2. Identify three numbers or letters traced in the client's palm.

What would you like to do?

Home > Flashcards > Print Preview