3035 Exam Flashcards
1
Q
A client has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the “P”?
“How does it feel?”
“What makes it worse?”
“When did it start?”
“How would you rate your pain?”
A
Correct! - “What makes it worse?”
2
Q
A clinic nurse has reviewed a new client’s available health record and will now begin taking the client’s health history. Which of the following questions should the nurse ask first when obtaining the health history?
“What is your major health concern at this time?”
“Did you bring all your medications with you?”
“Are you generally fairly healthy?”
“Do you have adequate health insurance coverage?”
A
Correct - “What is your major health concern at this time?”
3
Q
To alleviate a client’s anxiety during a comprehensive assessment, the nurse should do which of the following?
Begin with intrusive procedures first to get them completed quickly
Ask the client to sign a consent for the physical exam
Explain each procedure being performed and the reason for the procedure
Remain in the exam room while the client changes into a gown
A
Correct! - Explain each procedure being performed and the reason for the procedure
4
Q
A nurse is interviewing a client in the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?
Limiting all facial expressions
Sitting across the room from the client
Using a moderate amount of eye contact
Standing while the client is seated
A
Correct! - Using a moderate amount of eye contact
5
Q
A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?
Collaborate with the client to identify problems.
Explain the purpose of the interview.
Obtain family health history data.
Determine the client’s vital signs.
A
Correct! - Explain the purpose of the interview.
6
Q
The nurse is obtaining information about a client’s past health history. Which client statement would best reflect this component of assessment?
“I have a brother with leukemia and a sister with hypertension.”
“My mom’s still alive, but my dad died 10 years ago of heart failure.”
“I have been having some pain when I urinate for the last several days.”
“I had surgery 5 years ago to repair an inguinal hernia.”
A
Correct! - “I had surgery 5 years ago to repair an inguinal hernia.”
7
Q
A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client’s complaint?
Document “unable to assess client’s discomfort”.
Restate the question using simpler terms.
Provide a laundry list of descriptive words.
Ignore the complaint for now and return to it later in the assessment.
A
Correct! - Provide a laundry list of descriptive words.
8
Q
A nurse is interpreting and validating the information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview?
Summary
Closing
Introductory
Working
A
Correct! - Working
9
Q
A client comes to the health care provider’s office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
Comprehensive assessment
Focused assessment
Ongoing assessment
Emergency assessment
A
Correct! - Focused assessment
10
Q
The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first?
The client’s ability to see and hear
The client’s judgment and insight
The client’s general intelligence
The presence of any phobias
A
Correct - The client’s ability to see and hear
11
Q
A nurse is providing feedback to a colleague after observing the colleague’s interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement?
“Are you allergic to any medications?”
“What is your typical day like?”
“Describe what you eat in a normal day.”
“Tell me about your relationship with your children.”
A
Correct - “Are you allergic to any medications?”
12
Q
A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize?
Establishing a trusting relationship
Determining the client’s strengths
Making clinical inferences
Identifying potential health problems
A
Correct - Establishing a trusting relationship
13
Q
A client has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as biased?
“Your husband’s death must have been very difficult for you.”
“How often do your adult children typically visit you?”
“How would you describe your feelings about getting older?”
“You know you should quit smoking because it affects others, right?”
A
Correct! “You know you should quit smoking because it affects others, right?”
14
Q
The nurse has completed the review of systems component of the client’s health history. Which finding should the nurse document under the review of systems?
“Menstruation began at age 13”
“High school diploma plus 2 years of college”
“Lungs clear to auscultation bilaterally”
“Caregiver reliable source of information”
A
Correct - “Menstruation began at age 13”
15
Q
As part of a mental status assessment, the nurse asks the client how they would respond if they found a wallet lying on the sidewalk. This will allow the nurse to assess which domain of mental status?
Abstract reasoning
Constructional ability
Concentration
Judgment
A
Correct! - Judgment
16
Q
The nurse asks a client to recall five words after 5, 10, and 30 minutes. Which of the following is the nurse assessing?
Client’s memory of new information
Client’s thought process and perceptions
Client’s recent memory
Client’s concentration
A
Correct - Client’s memory of new information
17
Q
The nurse is performing hourly assessments of the client’s level of consciousness. During the assessment, the client remains unresponsive after multiple attempts of the nurse calling their name. Which of the following would the nurse perform next?
Gently shake the client’s shoulders.
Call the rapid response team
Press down on one of the client’s nail beds.
Rub the client’s sternum with the knuckles.
A
Correct - Gently shake the client’s shoulders.
18
Q
During the interview of a client, the client states to the nurse, “I am just so overwhelmed with everything in my life right now. I think it would be better for everyone if I just wasn’t around anymore.” What statement by the nurse would be most appropriate?
“Everyone gets overwhelmed at times. I’m sure things will get better.”
“Have you been thinking about killing yourself?”
“I’m sure things aren’t that bad. Have you tried medications for your depression?”
“You should try looking at the bright side of things.”
A
Correct! - “Have you been thinking about killing yourself?”
19
Q
The nurse is assessing the orientation of a client. The nurse understands which of the following is typically the last level of orientation to be lost?
Situation
Place
Time
Person
A
Correct! - Person
20
Q
The nurse is evaluating a client using the Glasgow Coma Scale (GCS). Which of the following components would not be used during this evaluation?
Pupillary response
Eye opening response
Verbal response
Motor response
A
Correct - Pupillary response
21
Q
The nurse is preparing to obtain information about a client’s mental and psychological status. Which of the following actions would the nurse take first?
Check the client’s level of consciousness for any changes.
Explain the purpose of the exam and the types of questions that will be asked.
Perform a neurologic examination to determine any deficits.
Question the patient about their usual lifestyle and behaviors.
A
Correct Answer - Explain the purpose of the exam and the types of questions that will be asked.
22
Q
The nurse is beginning the initial assessment of a 92-year-old client admitted from the long-term care facility. The client does not seem to be responding to the nurse’s questions or following her movements. What is the appropriate next action by the nurse?
Document “unable to assess client”.
Check the client’s vision and hearing before proceeding with the assessment.
Skip the subjective data collection and proceed to the physical assessment.
Defer the assessment until the client is more responsive.
A
Correct! - Check the client’s vision and hearing before proceeding with the assessment.
23
Q
The nurse notes decorticate posturing in a client following a traumatic brain injury. Which of the following assessments by the nurse would be consistent with this posturing?
Extended elbows and pronated wrists
Dorsiflexion of the feet
Flexion of the elbows
Externally rotated thighs
A
Correct! - Flexion of the elbows
24
Q
The nurse is preparing to assess the abstract reasoning of a client who has a diagnosis of early stage Alzheimer disease. Which of the following questions would be most appropriate for the nurse to ask?
“Can you tell me what you have eaten in the last 24 hours?”
“How are an apple and orange the same?”
“When did you get your first job?”
“Can you draw the face of a clock for me?”
A
Correct! - “How are an apple and orange the same?”
25
What four questions might you ask to determine if your client is alert and oriented x 4?
Type your four questions in the text box below.
Can you tell me your name?
Where are we at right now?
What is the year?
Why are you being seen today?
26
The nurse is assessing a client admitted to the unit with pleuritis. Which of the following sounds would the nurse expect to hear on auscultation?
Bubbling, moist sounds during early inspiration
Low-pitched, snoring sounds during expiration
Sound like rolling hair between the finger
Low-pitched grating sound on inspiration and expiration
Correct! - Low-pitched grating sound on inspiration and expiration
27
When auscultating the left carotid artery, the nurse notes a blowing, swishing sound. What does the nurse suspect is the cause of this finding?
Decreased cardiac output
Turbulent blood flow through a vessel
Increased venous pressure
Right ventricular failure
Correct! - Turbulent blood flow through a vessel
28
The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes?
Slight kyphosis
Asymmetrical chest expansion
Audible wheeze
Inaudible posterior lung sounds
Correct - Slight kyphosis
29
During the assessment of a client with a heart murmur, the nurse places the palm of their hand on the client’s precordium and feels a moderate vibration. The nurse would document this finding as which of the following?
Fremitus
Within normal limits
Thrill
Bruit
Correct! - Thrill
30
A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about what assessment finding related to the client's sputum?
Pink and frothy
White or cream-colored
Brown-tinged
Yellowish and foul-smelling
Correct! - Pink and frothy
31
The clinical faculty is reviewing heart sounds with the student nurse. Which of the following would indicate understanding of the S1 heart sound by the student nurse?
S1 is the beginning of diastole
S1 is the closure of the atrioventricular valves
S1 indicates valve stenosis
S1 is the closure of the semilunar valves
Correct! - S1 is the closure of the atrioventricular valves
32
A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following should the nurse do next?
Reassess after applying warm compresses.
Recheck in 5 minutes after elevating the arm.
Document this finding as normal.
Refer the client for medical follow-up.
Correct! - Document this finding as normal.
33
The nurse is assessing a client admitted with exacerbation of his congestive heart failure (CHF). Which of the following would be consistent with this diagnosis?
Jugular venous distention with the client positioned greater than 45 degrees
Increased cardiac output
Jugular veins visible with the client positioned supine
Increased urination during the day
Correct - Jugular venous distention with the client positioned greater than 45 degrees
34
The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position?
At about the tenth rib
Near the level of the eighth rib
At the level of the diaphragm
Slightly above the clavicle
Correct! - Slightly above the clavicle
35
The hospitalized client complains of pain in the right calf. The nurse notices red streaks along the leg and it is warm and swollen. The nurse would anticipate which of the following diagnoses?
Venous insufficiency
Deep vein thrombosis
Systemic infection
Arterial insufficiency
Correct! - Deep vein thrombosis
36
The emergency department nurse is assessing a client who was hit by a car while on his bike. The nurse notes the client has irregular respirations of varying depth and rate followed by periods of apnea. The nurse would document the respirations as which of the following?
Kussmaul respirations
Hyperventilation
Biot’s respirations
Cheyne-Stokes respirations
Correct! - Biot’s respirations
37
The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following?
2+
4+
1+
3+
Correct - 2+
38
The nurse is using COLDSPA to assess a client’s history of chest pain. Which question best addresses “A” in the assessment model?
“Would you describe your chest pain as being acute, or is it chronic?”
“In your experience, what kinds of activities tend to cause your chest pain?”
“Does your pain radiate to another location?"
“Do you have any other symptoms with your chest pain, such as nausea?”
Correct! - “Do you have any other symptoms with your chest pain, such as nausea?”
39
The nurse is auscultating the lung sounds of a client with asthma and notes sibilant wheezes during expiration. The nurse understands the cause of the wheezes to be which of the following?
Air passing through secretions in the bronchi and trachea
Air passing through constricted passages
Inflamed parietal and visceral pleura rubbing together
Air suddenly opening small air passages coated with exudate
Correct! - Air passing through constricted passages
40
While inspecting the lower extremities of a client, the nurse observes an ulcer. What would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply.
```
Circular in shape
Client reports severe pain
Deep
Irregular border
Leg edema
```
Correct! - Circular in shape
Correct! - Client reports severe pain
Correct! - Deep
41
The clinical faculty is observing a student nurse perform auscultation of breath sounds. Which of the following demonstrates correct technique by the student nurse?
Listens as the client inhales and then goes to the next site during exhalation
Listens to the right lung first and then proceeds to the left lung
Listens to at least one full inspiration and expiration at each site
Listens laterally to three locations on the left and two locations on the right.
Correct! - Listens to at least one full inspiration and expiration at each site
42
Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would suspect the presence of which condition?
Chronic obstructive pulmonary disease
Pneumonia
Pleural effusion
Heart failure
Correct - Chronic obstructive pulmonary disease
43
The nurse is unable to palpate the dorsalis pedis pulse on a client. Which action should the nurse take next?
Call the physician for further follow-up
Document “absence of dorsalis pedis pulse” in the medical record
Use a Doppler device to locate the pulse
Auscultate the anatomic area with a stethoscope
Correct! - Use a Doppler device to locate the pulse
44
The nurse notes unequal chest expansion during inspection of the client’s chest. Which of the following does the nurse expect as the cause of this finding?
Bulging of the intercostal spaces is present
Part of the lung is obstructed or collapsed
The client has chronic obstructive pulmonary disease (COPD)
Accessory muscles are used to augment respiratory effort
Correct! - Part of the lung is obstructed or collapsed
45
During the assessment of a client with a chest tube, the nurse notes crepitus around the insertion site. The nurse recognizes which of the following as the cause of the crepitus?
Fluid or pus in the lungs
Air leaking into the subcutaneous tissues
Infection at the insertion site
Consolidation of the lung
Correct! - Air leaking into the subcutaneous tissues
46
When auscultating a client’s breath sounds, the nurse notes a high, harsh sound with short inspiration and long expiration over the trachea. The nurse understands these sounds to be which of the following?
Bronchovesicular breath sounds
Adventitious breath sounds
Bronchial breath sounds
Vesicular breath sounds
Correct! - Bronchial breath sounds
47
The nurse is preparing to assess a client’s lungs by auscultation. The nurse demonstrates correct use of the stethoscope for auscultating high-pitched sounds in the lungs when they do which of the following?
Listens over the client’s gown to provide for privacy
Uses the bell of the stethoscope
Uses both the bell and the diaphragm
Uses the diaphragm of the stethoscope
Correct! - Uses the diaphragm of the stethoscope
48
The nurse is preparing to assess a client's carotid arteries. Which nursing action would be most appropriate?
Palpate the arteries before auscultating them.
Palpate each artery individually to compare.
Use the diaphragm of the stethoscope.
Ask the client to breathe in and out deeply.
Correct! - Palpate each artery individually to compare.
49
A nurse is obtaining a client's radial pulse. Which action demonstrates correct technique for this assessment?
Use of the thumb and index finger applied to obliterate the wrist area along the thumb side
Application of the bell of the stethoscope to the antecubital area of the upper extremity
Application of firm pressure on the wrist area along the side of the fifth digit
Use of two fingerpads lightly applied to wrist area along the thumb side
Correct! - Use of two fingerpads lightly applied to wrist area along the thumb side
50
The nurse is auscultating the apical pulse on a healthy adult client. Which of the follow would indicate correct placement of the stethoscope by the nurse?
Second intercostal space, right sternal border
Third intercostal space, left sternal border
Fifth intercostal space, left midclavicular line
Second intercostal space, left sternal border
Correct! - Fifth intercostal space, left midclavicular line
51
The nurse is assessing the client’s temporomandibular joint (TMJ). Which of the following findings by the nurse would be documented as normal?
Swelling around the joint space
Clicking when the mouth opens
Popping and grating sounds
Tenderness on palpation
Correct! Clicking when the mouth opens
52
A client shows the nurse a “bump” on his neck. The nurse observes a palpable, raised, solid, 0.3 cm by 0.2 cm lesion. The nurse would document the presence of which of the following?
Pustule
Macule
Nodule
Papule
Correct! - Papule
53
The nurse notes that a client’s capillary refill is 5 seconds. What should this finding indicate to the nurse?
A normal finding
Hypoxia
Infection of the nailbed
Vitamin deficiency
Correct! - Hypoxia
54
A client tells the nurse that she is having a hard time bringing her hand to her mouth during meals. To assess the client’s range of motion in the elbow, the nurse would have the client demonstrate which of the following?
Circumduction
Internal rotation
Abduction
Flexion
Correct! - Flexion
55
The nurse asks a client to bring his hands together behind his lower back with his elbows flexed. Which range of motion movement is the nurse assessing?
External rotation
Abduction
Adduction
Internal rotation
Correct! - Internal rotation
56
The nurse is caring for an African American client admitted to the unit for cirrhosis of the liver. Which of the following areas would the nurse inspect to determine if the client has jaundice?
Eyes
Legs
Ears
Face
Correct - Eyes
57
During a skin assessment, an adult client asks the nurse, "Why do you need to know about sunburns I had as a kid?" Which of the following is the best response by the nurse?
“Having bad sunburns as a child puts you at risk for skin cancer later in life.”
“When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older.”
"Repeated sunburns in childhood may explain the presence of some of your moles."
“This is one of the assessments we use to determine how well you took care of your skin when you were young.”
Correct - “Having bad sunburns as a child puts you at risk for skin cancer later in life.”
58
Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following?
Vitamin B deficiency
Prolonged oxygen deficiency
Acute illness
Psoriasis
Correct! - Acute illness
59
The nurse is checking an elderly client for signs of dehydration. Which of the following would be a correct action by the nurse when assessing the client's skin turgor?
The nurse pinches the skin on the back of the client's hand.
The nurse pinches the skin on the client's forearm.
The nurse pinches the skin over the client's clavicle.
The nurse pinches the skin on the back of the client's upper arm.
Correct! - The nurse pinches the skin over the client's clavicle.
60
The nurse is caring for a client with eczema and extremely dry skin. The nurse notes deep linear cracks to the client's heels. The nurse would document the assessment findings as which of the following?
Erosion
Fissure
Ulcer
Scar
Correct! - Fissure
61
An older client is concerned about new seborrheic keratoses appearing on the skin. How should the nurse respond to this client’s concern?
“These are considered a normal age-related change in the skin.”
“I will report these to the health care provider so that medication can be prescribed.”
“It means you have skin cancer and need to have them removed.”
“These areas need to be cleansed daily and and treated with a topical antibiotic ointment.”
Correct - “These are considered a normal age-related change in the skin.”
62
Which of the following findings related to hair would the nurse most likely assess in an older adult female client?
Patchy hair loss on the scalp
Increased hair in the axilla and on the legs
Terminal hair growth on chin
Thick elastic scalp hair
Correct! - Terminal hair growth on chin
63
The nurse is assessing a client's gait. Which of the following would indicate to the nurse that further evaluation is warranted?
Weight evenly distributed
Stands on heels and toes
Shuffling of feet
Arms swinging in opposition to legs
Correct! - Shuffling of feet
64
During the history, a young adult woman tells the nurse, “My mother has osteoporosis. What can I do to help reduce my risk?” Which response by the nurse would be most appropriate?
“Increase the amount of non-weight-bearing physical activity that you do.”
“Avoid being out in the sun for long periods of time.”
“Decrease your calcium intake to around 800 milligrams each day.”
“Try to avoid drinking too much coffee or other caffeinated fluids.”
Correct! - “Try to avoid drinking too much coffee or other caffeinated fluids.”
65
While inspecting the skin of a client, the nurse notes multiple pinpoint, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?
Ecchymosis
Purpura
Cherry angioma
Petechiae
Correct! - Petechiae
66
While examining the muscle tone of a client, the nurse finds only a slight flicker of contraction. The nurse would document this finding on the strength table as which of the following?
0
3
1
5
Correct! - 1
67
The nurse asks the client to perform dorsiflexion of the foot. Which of the following actions should the client perform?
Turn toes outward away from midline of body
Turn toes inward toward midline of body
Point their toes to the ceiling
Point toes toward the floor
Correct! - Point their toes to the ceiling
68
The nurse is performing the ballottement test during the assessment of a client’s knee. The nurse understands that performing this test would give further information on which of the following?
Whether the client is experiencing increased fluid in the knee joint
Whether the client experiences pain during range of motion
Whether the swelling in the knee joint is a normal age-related change or an infection
Whether the client’s knee joint is capable of flexion and extension
Correct - Whether the client is experiencing increased fluid in the knee joint
69
When assessing muscle strength, the nurse notes that the client is unable to move her right arm against both resistance and then gravity. Which of the following actions would the nurse perform next?
Move arm passively through its range of motion
Palpate the client’s shoulder joint
Inspect the arm for palpable contraction of the muscle
Document strength of 0
Correct - Move arm passively through its range of motion
70
A male construction worker asks the nurse if the mole on his arm is skin cancer. Using the mnemonic device ABCDE, which finding by the nurse would suggest skin cancer?
Asymmetric, irregular borders
Diameter of 2 mm
Flat with waxy, crusty scales
Solid, dark brown color
Correct - Asymmetric, irregular borders
71
During the assessment of a client’s deep tendon reflexes, the nurse notes a few short taps while dorsiflexing the foot. The nurse would document this finding as which of the following?
3+
2+
5+
4+
Correct Answer 4+
72
Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following?
Discrete
Annular
Confluent
Linear
Correct - Discrete
73
When performing a musculoskeletal assessment on an elderly client, which of the following considerations should the nurse keep in mind?
The elderly client may have an increase in the curvature of the lumbar spine.
The elderly client my have decreased flexibility and need frequent breaks.
The elderly client may have an increased elasticity of tendons, increasing the risk of injury.
The elderly client may point their toes outward during ambulation.
Correct! - The elderly client my have decreased flexibility and need frequent breaks.
74
The nurse suspects a client has carpal tunnel syndrome and asks her to perform Tinel’s test. To perform this test, the client would demonstrate which of the following?
Hold hands back to back while flexing the wrists 90 degrees for 60 seconds
Hyperextend the wrists and hold for 90 seconds
Tap the inner aspect of the wrist over the median nerve
Hold hands palm to palm while extending the wrists 90 degrees for 60 seconds
Correct! - Tap the inner aspect of the wrist over the median nerve
75
During the musculoskeletal assessment of a pregnant client, the nurse notes an increased concave curvature of the lumbar spine. The nurse would document this finding as which of the following?
Lordosis
Scoliosis
Osteoporosis
Kyphosis
Correct - Lordosis
76
During a routing eye assessment of a 55-year-old client, the client states they see “floaters” in their eyes. Which of the following actions by the nurse would be most appropriate?
Document this as a normal physiological change with aging
Provide immediate referral for suspected retinal detachment
Ask the client if they have any eye pain or itching
Ask the client if they see halos or rings around lights
Correct - Document this as a normal physiological change with aging
77
The nurse is assessing the external eye structures of an elderly client. Which of the following age-related findings would the nurse anticipate observing?
Arcus senilis
Tophi
Exophthalmos
Episcleritis
Correct - Arcus senilis
78
The nurse is assessing the superficial reflexes of a client who has sustained a head injury. The nurse strokes the sole of the foot from heel to ball, noting that the client's toes fan out. The nurse document this finding as which of the following?
Positive Babinski reflex
Sustained clonus
Positive Cremasteric reflex
Document as a normal finding
Correct - Positive Babinski reflex
79
The nurse records a client’s visual acuity as 20/50 using the Snellen eye chart. The nurse correctly interprets the finding as which of the following?
The client can read at 20 feet what a person with normal vision can read at 50 feet.
At 50 feet the client can read the whole chart
The client can read the chart from 20 feet in the left eye and from 50 feet in the right eye
The client can read at 50 feet what a person with normal vision can read at 20 feet
Correct - The client can read at 20 feet what a person with normal vision can read at 50 feet.
80
During a neurologic examination of a client, the nurse holds alternating hot and cold packs to the client's lower extremities. The client reports that they can barely feel the packs on the skin and states, "I'm having a hard time telling if it's hot or cold". The nurse correctly documents this findings as which of the following?
Hypesthesia
Hypalgesia
Anesthesia
Hyperesthesia
Correct - Hypesthesia
81
The nurse is testing for accommodation during a client's eye examination. The nurse correctly performs the exam when they demonstrate which of the following?
The nurse asks the client to focus on the penlight, and then asks the client to follow the penlight to about 7 cm from the nose.
The nurse shines a penlight onto the bridge of the client’s nose and inspects for pupillary constriction.
The nurse asks the client to follow the penlight in 6 directions and observes for abnormal movement.
The nurse shines a light into the pupil and observes for direct and consensual pupillary constriction.
Correct - The nurse asks the client to focus on the penlight, and then asks the client to follow the penlight to about 7 cm from the nose.
82
During a neurologic assessment, a client in the supine position is unable to run each heel smoothly down each shin. The nurse would want to perform further evaluation of which of the following?
Balance and coordination
Light touch sensation
Deep tendon reflexes
Leg strength
Correct - Balance and coordination
83
The nurse has completed the assessment of a client’s direct pupillary response and is now assessing consensual response. To test for consensual response, the nurse would use which of the following techniques?
Observe the pupil reaction when a light is shone into the opposite eye
Compare the measurement between the client’s pupils when dilated and when constricted
Observe for eye movement when the opposite eye is covered with an opaque card
Have the client state when they see the nurse’s fingers enter their peripheral field of vision
Correct - Observe the pupil reaction when a light is shone into the opposite eye
84
The nurse is performing the positions test on a client. During the assessment, the nurse notes oscillating movements of the client’s eyes. The nurse would correctly document this finding as which of the following?
Nystagmus
Entropion
Extropion
Strabismus
Correct - Nystagmus
85
The nurse is assessing the client’s eyes and vision. When performing the confrontation test for peripheral vision, which of the following would the nurse ask after covering one of the client’s eyes?
The student compares the reflection of the light on the client's eye surface
The student compares the speed of pupillary constriction
The student compares how quickly the client blinks each eyelid
The student compares direct and consensual dilation
Correct - Ask the client to state when they can see the nurse’s finger enter their visual field.
86
The clinical instructor is observing a student nurse perform eye exams. Which technique by the student nurse demonstrates correct understanding of testing the corneal light reflex?
The student compares the reflection of the light on the client's eye surface
The student compares the speed of pupillary constriction
The student compares how quickly the client blinks each eyelid
The student compares direct and consensual dilation
Correct - The student compares the reflection of the light on the client's eye surface
87
During the examination of the client’s mouth, the nurse notes a decrease in tongue strength. The nurse interprets this finding as a problem with which of the following?
Cranial nerve XII (hypoglossal)
Cranial nerve V (trigeminal)
Cranial nerve VI (abducens)
Cranial nerve IX (glossopharyngeal)
Correct - Cranial nerve XII (hypoglossal)
88
When assessing the client’s sensation, the nurse draws a number on the client’s palm and asks him to identify it. Which of the following tests is the nurse performing?
Graphesthesia
Stereognosis
Extinction
Tactile discrimination
Correct - Graphesthesia
89
During the physical examination of a client, the nurse suspects impairment of cranial nerve II (optic). Which of the following findings would lead the nurse to this suspicion?
Impaired near vision
Ptosis of the right eye
Nystagmus with lateral movements
Sluggish pupil constriction
Correct - Impaired near vision
90
During the assessment of a client’s internal eye structures, the nurse notes a white optic disc. The nurse understands which of the following to be the cause of this finding?
Optic nerve atrophy
Glaucoma
Macular degeneration
Absence of rods and cones
Correct - Optic nerve atrophy
91
The nurse is performing an otoscopic examination of a healthy client’s left tympanic membrane. At which location would the nurse anticipate seeing the cone of light?
In the 7 o’clock position
In the center of the membrane
In the 5 o’clock position
In the upper left quadrant
Correct - In the 7 o’clock position
92
While obtaining the health history of an elderly client, the client complains that his food "just doesn't smell right anymore". The nurse would make sure to assess which cranial nerve during the physical assessment?
```
CN I (olfactory)
CN IV (trochlear)
CN VI (abducens)
CN X (vagus)
```
Correct - CN I (olfactory)
93
The nurse is assessing a client for possible meningitis. The nurse flexes the client's neck and head towards the client's chest. The nurse is performing which of the following?
Brudzinski's sign
Kernig's sign
Bulge test
Phalen's test
Correct - Brudzinski's sign
94
The nurse is performing a neurological check on a client with a head injury from a motor vehicle accident four hours ago. The nurse suspects the client has developed increased intracranial pressure. Which of the following would lead the nurse to suspect this diagnosis?
Fixed and dilated pupils
Esotropia
Exotropia
Pinpoint pupils
Correct - Fixed and dilated pupils
95
The nurse is preparing to test the client's cranial nerve VIII (acoustic). Which of the following actions would the nurse perform?
Perform the whisper test
Touch the face with sharp and dull objects
Test the client's peripheral vision
Place sugar on the anterior portion of the tongue
Correct - Perform the whisper test
96
A client comes to the clinic complaining of a sore throat. After assessing the throat, the nurse documents the tonsils as 3+. The nurse explains to the client that “3+ tonsils” are which of the following?
Visible beyond the anterior pillars
Extend ¾ midway to midline, nearly touching the uvula
Barely visible on inspection
Extend to the midline, touching each other
Correct! - Extend ¾ midway to midline, nearly touching the uvula
97
The nurse is assessing a client’s cranial nerves XI (spinal accessory). Which of the following would the nurse expect to observe?
The client is able to shrug shoulders against resistance
The client can repeat words whispered into the ear
The client can identify the taste of sugar on the tongue
The client’s uvula and soft palate rise symmetrically
Correct - The client can repeat words whispered into the ear
98
The nurse is assessing a client for possible oral cancer. Which of the following areas should the nurse closely inspect?
Ventral surface of the tongue
Buccal mucosa
Hard palate
Along the gum line
Correct - Ventral surface of the tongue
99
During the examination of an 8-year-old child’s ears, the nurse notes white spots on the tympanic membrane. No redness or drainage is noted. Which of the following actions by the nurse would be most appropriate?
Ask the mother whether the child has had numerous ear infections
Assess the child for previous head trauma
Determine whether impacted cerumen is present
Assess the child for further symptoms of an acute ear infection
Correct! - Ask the mother whether the child has had numerous ear infections
100
The nurse is assessing a client's deep tendon reflexes (DTRs). When striking the patellar tendon with the reflex hammer, the nurse notes a brisk reaction of the lower extremity. The nurse would document this finding as which of the following?
3+
2+
4+
5+
Correct - 3+
101
A client comes into the clinic with complaints of shortness of breath and begins to hyperventilate. The nurse should take action to slow the client’s breathing in order to prevent which acid-base disturbance related to hyperventilation?
Respiratory alkalosis
Respiratory acidosis
Metabolic acidosis
Metabolic alkalosis
Correct! - Respiratory alkalosis
102
The nurse is preparing to assess a client's ileostomy. Which of the following would the nurse anticipate to find in the ileostomy bag?
Liquid feces
Hard, formed feces
Flatus without any feces
Semi-formed, soft feces
Correct! - Liquid feces
103
A client in the clinic complains that his urine has turned a dark red color. When reviewing the client’s current medications, which medication would the nurse suspect as the cause of the red urination?
Warfarin (anticoagulant)
Pyridium
B-complex vitamin
Spironolactone (diuretic)
Correct! - Warfarin (anticoagulant)
104
The nurse is caring for a client who has returned from South America and has been experiencing diarrhea for the past 3 days. The nurse would anticipate the client’s lab values to demonstrate which of the following?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Correct! - Metabolic acidosis
105
The nurse is prepping the client for abdominal surgery. Which type of enema would the nurse anticipate administering?
Cleansing
Anthelmintic
Oil retention
Medicated
Correct! - Cleansing
106
The nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which of the following findings would most likely lead the nurse to this suspicion?
Cullen’s sign
Positive Murphy’s sign
Tenderness on palpation
Diastasis recti
Correct! - Cullen’s sign
107
The nurse is caring for a client with a spinal cord injury following a motor vehicle accident. The client tells the nurse that he continues to “wet the bed” without having any sensation that he needs to void. The nurse would suspect this client is experiencing which type of urinary incontinence?
Reflex
Stress
Overflow
Mixed
Correct! - Reflex
108
The nurse is reviewing a client’s arterial blood gas (ABG) and notes the following: pH 7.49; PaCO2 30; HCO3- 20. The nurse correctly identifies that the client is experiencing which of the following?
Partially compensated respiratory alkalosis
Fully compensated respiratory alkalosis
Uncompensated respiratory acidosis
Partially compensated metabolic acidosis
Correct! - Partially compensated respiratory alkalosis
109
The nurse is evaluating a new nursing graduate’s ability to perform a rebound tenderness test for suspected appendicitis. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?
Right lower quadrant
Left lower quadrant
Right upper quadrant
Left upper quadrant
Correct! - Right lower quadrant
110
The nurse is assessing a client for possible gallbladder disease. Which of the following techniques would the nurse perform to elicit a positive Murphy’s sign?
Press the fingertips under the right costal margin and have the client take a deep breath.
Apply deep pressure and then release at the site of McBurney’s point.
Have the client lie on their left side and hyperextend the right leg.
Have the client lie supine and internally and externally rotate the leg.
Correct! - Press the fingertips under the right costal margin and have the client take a deep breath.
111
The nurse is preparing to infuse a liter of Dextrose 5% in ½ Normal Saline (hypertonic solution) for a client in diabetic ketoacidosis. The nurse understands that infusing this solution would help pull fluid from the _________ space to the ___________ space.
Intracellular; interstitial
Intravascular; intracellular
Intracellular; intravascular
Interstitial; intracellular
Correct! - Intracellular; intravascular
112
When assessing a client’s abdomen, the nurse palpates a pulsating, nontender, 6-centimeter mass above the umbilicus. Which of the following actions should the nurse take next?
Stop palpating and call the physician
Refer the client to an oncologist
Provide a dietician consult for constipation
Counsel the client about hernia repair
Correct! - Stop palpating and call the physician
113
A nursing student is preparing to perform an abdominal assessment on a client. The student performs the assessment correctly when they demonstrate the techniques in which order?
Inspect, auscultate, percuss, palpate
Palpate, percuss, inspect, auscultate
Auscultate, inspect, palpate, percuss
Percuss, inspect, auscultate, palpate
Correct! - Inspect, auscultate, percuss, palpate
114
During an abdominal assessment, the nurse notes a bulge down the center of the client’s abdomen as she is lying supine and raising her head. The nurse suspects this finding is due to which of the following?
Hernia
Cancerous mass
Aortic aneurysm
Small bowel obstruction
Correct! - Hernia
115
A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma?
Deep red
Pale gray
Purple-blue
Light brown or tan
Correct! - Deep red
116
The nurse is caring for a client admitted with severe vomiting and dehydration. The client’s lab results show a sodium level of 130. Which of the following complications would the nurse assess for?
Seizure activity
Cardiac arrest
Tetany
Respiratory depression
Correct - Seizure activity
117
A client is admitted with complaints of abdominal pain for the past two weeks. A physical examination does not reveal the cause of the pain. Which of the following indirect visualization studies would the nurse anticipate prepping the client for?
Abdominal CT scan
Esophagogastroduodenoscopy (EGD)
Colonoscopy
Wireless capsule endoscopy
Correct! - Abdominal CT scan
118
The nurse is administering intravenous magnesium sulfate to a pregnant client to stop premature labor. When performing a check on the IV pump, the nurse realizes the infusion is running too fast, and suspects the client has developed hypermagnesemia. What assessment finding by the nurse would help confirm this suspicion?
Blood pressure of 98/56
Client complains of bone pain
Hyperactive deep tendon reflexes (DTRs)
Absent deep tendon reflexes (DTRs)
Correct! - Absent deep tendon reflexes (DTRs)
119
After assisting a client to have a bowel movement on a bedpan, the nurse notes the stool has a white discoloration. The nurse would check the client’s medication record for administration of which medication?
Maalox (antacid)
Aspirin
Vancomycin (antibiotic)
Iron
Correct! - Maalox (antacid)
120
The intensive care nurse is caring for a client on mechanical ventilation. The morning arterial blood gas shows: pH 7.48; PaCO2 32; HCO3- 24. The nurse understands that this client should be treated for which of the following?
Uncompensated respiratory alkalosis
Partially compensated respiratory alkalosis
Partially compensated respiratory acidosis
Fully compensated respiratory alkalosis
Correct! - Uncompensated respiratory alkalosis
121
A client comes to the clinic with complaints of muscle weakness, leg cramps, and fatigue. The nurse anticipates the lab results to confirm which of the following?
Hypokalemia
Hyperkalemia
Hyponatremia
Hypercalcemia
Correct! - Hypokalemia
122
The nurse is inspecting the abdomen of a client with liver disease. Which of the following assessments would reflect this diagnosis?
Dilated veins
Scaphoid abdomen
Grey-Turner's sign
Pale blue abdomen
Correct! - Dilated veins
123
The nurse is auscultating a client’s abdomen and is unable to discern any bowel sounds. How should the nurse proceed with the assessment?
Listen for at least five minutes before documenting absence of bowel sounds
Repeat auscultation in four hours
Palpate the client’s abdomen to stimulate bowel motility
Perform abdominal percussion, wait five minutes, then repeat auscultation
Correct! - Listen for at least five minutes before documenting absence of bowel sounds
124
The nurse is caring for a client admitted with a small bowel obstruction. After drawing and arterial blood gas, the nurse notes the following: pH 7.48; PaCO2 59; HCO3- 37. The nurse correctly identifies this client as being in which of the following imbalances?
Partially compensated metabolic alkalosis
Fully compensated metabolic alkalosis
Uncompensated metabolic acidosis
Partially compensated metabolic acidosis
Correct! - Partially compensated metabolic alkalosis
125
A nurse is caring for a client who is being treated for bladder infection. The client complains to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition?
Dysuria
Polyuria
Oliguria
Anuria
Correct - Dysuria
126
The nurse is assessing the breasts of a Caucasian client who has just been diagnoses with Paget disease. Which of the following assessments would the nurse expect to find?
Red and scaly skin on the areola
Nipple retraction
Dark pink areola
Orange-peel skin
Correct - Red and scaly skin on the areola
127
The nurse is assessing an adult client's areolas and nipples. Which assessment finding would most clearly warrant referral?
Small Montgomery tubercles are present on the areolas
Supernumerary nipples are present
One breast is slightly larger than the other
The patient's nipple has recently become inverted
Correct! - The patient's nipple has recently become inverted
128
When taking a health history for a female client, which factor should the nurse identify as placing the client at increased risk for breast cancer?
The client has a low body mass index
The client eats a high fiber, low fat diet
The client breast-fed her child for a full year
The client had her first child at age 38
Correct! - The client had her first child at age 38
129
The nurse is assessing the pain of a client who is alert and oriented. Which of the following assessment tools would be the most appropriate for the nurse to use?
Graphic Rating Scale
Faces Pain Scale-Revised
FLACC Scale
Numeric Rating Scale
Correct! - Numeric Rating Scale
130
During an admission interview, the client reveals she has vaginal discharge. She is worried that it may be a sexually transmitted disease. The most appropriate response by the nurse would be:
“This is nothing to worry about. Some cyclic vaginal discharge is normal”
“I’d like some information about the discharge. What color is it?”
“Have you been engaging in unprotected sexual intercourse?”
“Have you had any urinary incontinence associated with the discharge?”
Correct! “I’d like some information about the discharge.
131
The nurse has completed the physical assessment of a male client. The nurse has ended the assessment by offering to teach the client how to perform testicular self-examination (TSE). The client states, “That's alright. I already know how to do that.” What should the nurse do next?
Reiterate the correct technique for TSE
Ask the client to demonstrate TSE on a training model
Encourage the client to promote TSE to his peers
Encourage the client to perform TSE as often as possible
Correct! - Ask the client to demonstrate TSE on a training model
132
A woman reports a sudden onset of spontaneous nipple discharge. Which of the following would be the nurse’s most appropriate action?
Observe the breast for eversion of the nipple
Reassure the client that this is a normal result of hormonal fluctuations
Collect a sample for culture and sensitivity testing
Refer the client to an oncologist for follow-up
Correct - Collect a sample for culture and sensitivity testing
133
A client with a fractured arm is complaining of pain. The nurse determines that this type of pain is most likely which of the following?
Radiating pain
Visceral pain
Cutaneous pain
Deep somatic pain
Correct! - Deep somatic pain
134
The nurse is teaching a class on breast self-examination (BSE). Which of the following would the nurse inform the class as the best time to perform BSE?
The day the menstrual period begins
Three to 7 days after the menstrual period begins
On the 14th day of the menstrual cycle
Immediately before the menstrual period begins
Correct! - Three to 7 days after the menstrual period begins
135
The nurse collects vital signs on a hospital client who has recently been experiencing pain. Which finding would indicate the client is currently experiencing pain?
Respiratory rate of 28 breaths/min
Blood pressure of 120/70 mm Hg
Temperature of 37.3°C (99.1°F)
Heart rate of 80 beats/min
Correct! - Respiratory rate of 28 breaths/min
136
A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following?
“Is there anything that makes the pain worse or better?”
“Would you describe the pain as being constant or as intermittent?”
“How would you describe your pain? Is it sharp? Is it an ache?”
“Has the pain changed over time?”
Correct! - “How would you describe your pain? Is it sharp? Is it an ache?”
137
A nurse is preparing to palpate a client’s submental lymph nodes. At what anatomic location would the nurse position his fingertips?
Under the tip of the chin
On the area behind the client’s ears
At the base of the client’s skull
At the angle of the client’s mandible
Correct - Under the tip of the chin
138
The nurse is instructing a young male client on how to perform a testicular self-exam (TSE). Which of the following would the nurse NOT include in the instructions?
Roll the testis between the thumbs and middle finger, starting at the epididymis and ending at the base of the testis
A spermatic cord that feels rope-like is a normal finding
Report any nodules or swelling to the healthcare provider
Perform once a month after a shower
Correct - Roll the testis between the thumbs and middle finger, starting at the epididymis and ending at the base of the testis
139
During a scrotal exam, the nurse notes swelling around the right testicle. The nurse would suspect which of the following as a potential cause of the swelling?
Tumor
Cryptorchidism
Hydrocele
Hernia
Correct! - Hydrocele
140
The nurse is performing a breast exam on a client. Which area would be most important for the nurse to include in the assessment?
Lower inner quadrant
Upper outer quadrant
Upper inner quadrant
Lower outer quadrant
Correct! - Upper outer quadrant
141
When examining a newborn male infant, the nurse notes that neither testicle is descended. How would the nurse document this finding?
Orchitis
Varicocele
Epididymitis
Cryptorchidism
Correct! - Cryptorchidism
142
The nurse is assessing a client's complaint of upper abdominal pain. Which of the following questions would the nurse ask at the beginning of the assessment?
“How would you rate your pain on a 10-point scale?”
“Is your pain affecting your ability to cope?”
“Would you describe your pain as acute, or as chronic?”
Can you describe to me how your pain feels?”
Correct! - Can you describe to me how your pain feels?”
143
When assessing a male client’s genitalia, the nurse notes that once the foreskin has been retracted, the foreskin cannot be easily returned over the glans of the penis. The nurse would document this finding as which of the following?
Paraphimosis
Epispadius
Phimosis
Hypospadius
Correct - Paraphimosis
144
A nurse has completed an assessment of a client's epitrochlear lymph nodes. Which of the following data would the nurse document as an abnormal finding?
0.5 cm in diameter
Tender
Discrete
Mobile
Correct! - Tender
145
The nurse asks the client who is currently experiencing pain and refusing pain medication, "what is your concern about taking medication for your pain?" The nurse is collecting data on which dimension of pain?
Behavioral
Cognitive
Sensory
Sociocultural
Correct Answer - Cognitive
146
The nurse is assessing a client who is experiencing severe pain. Which assessment data would be considered normal under those circumstances?
Hypoglycemia
Decreased heart rate
Decreased gastric motility
Increased urinary output
Correct! - Decreased gastric motility
147
A nurse is admitting a client to the postsurgical unit following an appendectomy. What would the nurse use as the primary assessment for the client's pain?
Current pain therapies used preoperatively
Spiritual questions related to her perceptions of pain
The client's cultural view of the pain
The client's report of her pain
Correct! - The client's report of her pain
148
While assessing a woman's breasts, the nurse notes a pronounced and asymmetric pattern of veins on the client's breasts. Follow-up care is ordered because the nurse should suspect which of the following?
A low platelet count
Menopause
Malignancy
Fibrocystic changes
Correct! - Malignancy
149
A client who is sedated and intubated has become increasingly agitated throughout the day. The nurse suspects the client is experiencing pain. Knowing the client is unable to self report pain, which of the following actions would the nurse take next?
Search for a potential cause of the client's pain.
Observe the client's behavior.
Ask the client's spouse if they think the client is having pain.
Attempt an analgesic trial.
Correct! - Search for a potential cause of the client's pain.
150
The nurse is caring for a client diagnosed with chronic pain related to a below the knee amputation. The nurse should understand that this client has experienced this pain for at least _________ months.
6
