EXAMS 1 Flashcards
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
A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview?
Working
A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental?
“You must quit smoking because it affects others, not only you.”
A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?
Using a moderate amount of eye contact
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?”
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?
Provide a laundry list of descriptive words.
A nurse is eliciting a client’s health history and the client asks, “Can I take the herb ginkgo biloba with my other medications?” What action would be best if the nurse is unsure of the answer?
romise to find out the information for the client.
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 sensory abilities
A nurse provides care in a rural hospital that serves a community that has few minority residents. When interviewing a client from a minority culture, the nurse has enlisted the assistance of a “culture broker.” How can this individual best facilitate the client’s care?
By interpreting the client’s language and culture
Upon entering an exam room, the client states, “Well! I was getting ready to leave. My schedule is very busy and I don’t have time to waste waiting until you have the time to see me!” Which response by the nurse would be most appropriate?
“You’re certainly justified in being upset, but I am ready to begin your exam now.”
A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe?
“This helps us have an appropriate focus for the physical examination.”
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?
C) “What is your major health concern at this time?”
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”?
“What makes it worse?”
A medical nurse has completed the review of systems component of the client’s health history. Which assessment finding should the nurse document under the review of systems?
“Menarche at age 13”
A client has been admitted following an unexplained weight loss of 15 pounds over the past 3 months. How should the nurse best assess the subjective component of the client’s nutritional status?
Obtain a 24-hour diet recall.
A client’s elevated body mass index (BMI) has prompted the nurse to assess the client’s activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise?
“I go to a step class for an hour three times a week.”
During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would
be most appropriate to determine a client’s current medication regimen?
Ask the client to bring all the medications and supplements to an interview.
The nurse is preparing to assess an adult woman’s activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data?
“Could you describe how you perform self-breast exams?”
A nurse is creating a genogram of a client’s family health history. The nurse should use which of the following symbols to denote the client’s female relatives?
Circle
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?
Explain the purpose of the interview.
During the interview, the client states, “Is today the 12th? My wife died 2 months ago today.” Which of the following responses would be most appropriate?
“How does that make you feel right now?”
The nurse is using the mnemonic “COLDSPA” to assess a client’s complaint of lower abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint?
Severity
The nurse is obtaining information about a client’s past health history. Which client statement would best reflect this component of assessment?
“I had surgery 5 years ago to repair an inguinal hernia.”
A nurse is teaching a recent nursing graduate about the significance of verbal and nonverbal communication during client care. The new graduate demonstrates an understanding of these techniques by citing what example of verbal communication?
Providing a laundry list of descriptors when needed
The admission of a new resident to a long-term care facility has necessitated a thorough health history. Place the following focuses in the correct sequence in which the nurse should perform them, beginning with the section obtained first.
- Biographic data
- Reason for seeking care
- History of present concern
- Past health history
- Family health history
- Review of body systems
The nurse is completing a review of systems for a client. Which of the following information would the nurse document related to the client’s musculoskeletal system?
- Joint stiffness
- Muscle strength
- Knee swelling
The nurse is completing an assessment of a 50-year-old female client who has sought care for recurrent migraines that have not responded to treatment. Following the review of systems, how should the nurse best document unremarkable results of the subjective portion of the gastrointestinal assessment?
“Client denies recent constipation, diarrhea, bowel incontinence, or abdominal
pain.”
. A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, “I’m sure I’ve been asked these questions before. Can’t we just focus on my foot and not all these other topics?” How should the nurse best explain the rationale for obtaining a health history?
“We want to make sure your nursing care matches your needs as closely as possible.”
During the nurse’s assessment of the client’s exercise and activity habits, the client laughs and then states, “Unless you’re including channel surfing, I don’t really do much of anything.” How should the nurse best follow up this client’s statement?
Briefly describe some of the potential benefits of regular exercise.
A nurse is obtaining subjective data from an adult client who is new to the clinic. The nurse has asked the client, “Where do you usually turn for help in a time of crisis?” What domain is this nurse assessing?
The client’s stress management and coping strategies
client has presented to the clinic for the treatment of an ovarian cyst. Which of the following would be most important for the nurse to do immediately before performing this woman’s physical exam?
Collect necessary equipment essential to the exam.
A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a client’s anxiety during the physical exam. Which of the following would be most appropriate?
Ensuring client’s privacy by providing an examination gown
A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which of the following actions?
C) Wearing gloves to palpate the tongue and buccal membranes
The nurse is using a Wood’s light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client’s symptoms?
Fungal infection
A nurse has gathered the necessary equipment for the physical assessment of an adult client. For which of the following assessments would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement?
Skin lesion size
The nurse is preparing to assess an older adult client’s near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use?
Newspaper
nurse practitioner is performing a comprehensive physical examination of a 51-year- old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following?
Blood
The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing?
Joint flexion/extension
A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says ìAbsolutely not! There’s no way I’ll let you do that to me!î Which response by the nurse would be most appropriate?
Explain the importance of the pelvic exam and Pap smear, but respect the client’s
wishes and omit the exam.
The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations?
Vital signs
The nurse is to collect a throat culture from a client who has signs and symptoms of a respiratory infection, including frequent, productive coughing. The nurse demonstrates the best adherence to standard precautions by using which of the following pieces of equipment?
Face shield
The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which of the following actions would
be most appropriate?
Try to minimize position changes.
The nurse is preparing to assess the peripheral pulses of a client. The nurse should place the client in which position?
Supine
When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate assessment data?
Dorsal hand surface
A client has a documented history of hepatomegaly (liver enlargement), and the nurse recognizes the need to perform deep palpation during the physical assessment. The nurse should perform which of the following actions?
Use both hands to depress the skin 1 to 2 inches.
he emergency department (ED) nurse is assessing for kidney tenderness in a client who has presented with complaints of dysuria and back pain. What assessment technique should the nurse utilize?
Blunt percussion
In the course of performing a client’s physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following?
Heart sounds
An instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following?
ìWhen using the bell, push on it lightly.î
A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which of the following statements should guide the nurse’s use of a stethoscope during this phase of assessment?
The diaphragm should be held firmly against the body part.
A nurse is appraising a colleague’s assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which of the following actions?
Feeling the surface structures using a circular motion
The nurse is preparing to examine an older adult client. Which of the following would be most appropriate for the nurse to do during the examination?
Speak clearly and slowly when explaining a procedure.
The nurse assists a client into the dorsal recumbent position. Assessment of which area is contraindicated when the client is in this position?
Abdomen
The nurse is gathering the necessary equipment preparatory to examining a client’s ears. The nurse will be checking bone and air conduction of sound. Which of the following should the nurse obtain?
Tuning fork
The nurse is evaluating the setting prior to beginning a client’s physical examination. The nurse should confirm the presence of which of the following? Select all that apply.
Adequate lighting
Quiet surroundings
Table for equipment
Door or curtain
the nurse is using her fingerpads to palpate a client’s body part during the physical examination. Which of the following would the nurse best be able to detect?
Pulses
A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first?
Inspection
The nurse is percussing the area over the client’s lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following?
Resonance
A 20-year-old female client has presented to the clinic, and the nurse is preparing to perform a comprehensive assessment. The client states, ìI’d really like to have my mom in the room. That’s okay, isn’t it?î How should the nurse best respond to the client’s request?
ìOf course. There’s a chair in the exam room where she can sit.î
The nurse is inspecting the dominant hand of an older adult client and notes the presence of irregularly shaped brown lesions on the dorsal surface of the client’s hand. What action should the nurse perform next?
compare the appearance of the client’s other hand
A young man has presented to the clinic with a 2-week history of head congestion, fever, and malaise. What assessment technique should the nurse utilize to assess for sinus tenderness?
Direct percussion
A nurse has completed the general survey of a client who has been transferred to the unit. The information gathered during the general survey primarily provides the nurse with which of the following? Select all that apply.
- An indication of the level of physical distress experienced by the client
- Clues about the overall health of the client
- Indications about normal variations in the status of body systems
A nurse is preparing to assess an adult client’s body temperature. At which time of the day would the nurse expect to obtain the lowest body temperature?
Early morning
The nurse is preparing to assess a client’s vital signs. Which vital sign should the nurse assess first?
Temperature
A nurse is reviewing a colleague’s documentation of a client assessment. The nurse reads that the client’s radial pulse was 2+. How should the nurse interpret this assessment finding?
The client’s radial pulse occluded with moderate pressure.
The nurse is conducting an assessment of an older adult client who has a diagnosis of chronic heart failure. How can the nurse best assess the effects of the client’s stroke volume?
Calculate the difference between the diastolic and systolic pressures.
A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the client’s blood pressure reading in light of what principle?
The client’s blood pressure will be slightly lower than standing readings.
The nurse is completing an initial assessment of a client who is new to the ambulatory clinic. Before assessing the client’s blood pressure, a nurse asks him what his usual blood pressure is. The nurse bases this action primarily on what rationale?
It indicates the client’s involvement in his health care.
The nurse has begun a client’s assessment and is applying the blood pressure cuff on a client’s arm. Which action would be most appropriate?
The cuff is placed about 1 inch above the antecubital area.
Which of the following would be most important for the nurse to do when assessing a client’s blood pressure?
Inflate the cuff 30 mm Hg above where the radial pulse disappears.
The nurse is auscultating a client’s blood pressure and identifies the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds. This is known as which of the following?
Auscultatory gap
When assessing an older adult client with osteoporotic thinning and vertebral collapse, which of the following findings would the nurse expect to identify?
Kyphosis
A nurse observes the posture of a male client and finds him leaning forward and bracing himself while sitting on the exam table. Which of the following would the nurse most likely suspect?
Chronic obstructive pulmonary disease
The nurse is completing the general survey of a client and determines that the client’s temperature is 102∞F. Which of the following would the nurse also expect to find?
Heart rate greater than 100 bpm
The nurse is completing the assessment of a client who takes a beta-adrenergic blocker and a diuretic. Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents?
Evaluating for orthostatic hypotension
A nurse is obtaining a client’s radial pulse. Which of the following actions demonstrates correct technique for this assessment?
Use of two middle fingers lightly applied to wrist area along the thumb side
The nurse is assessing the skin condition and color of an African-American client. Which of the following would the nurse document as an abnormal finding?
Ashen gray skin color
The nurse is admitting a client to surgical daycare and is assessing the client’s vital signs. When obtaining the client’s oral temperature, where should the nurse insert the thermometer?
Deep in the posterior sublingual pocket
An older adult client has been admitted to the medical unit after suffering an exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following should the nurse do to assess the depth of the client’s respirations?
Observe the client’s chest expansion bilaterally.
Due to a change in the client’s level of consciousness, a nurse is now assessing a client’s temperature by the axillary route. Previously, the client had an oral temperature of 98.4∫F. Which finding would the nurse interpret as corresponding most closely to the client’s previous temperature?
97.4∫F
A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably ìstoopedî posture. How should the nurse best follow up this abnormal assessment finding?
Perform a focused assessment of the client’s musculoskeletal system
A nurse is completing a general survey of a client’s health and is beginning by measuring the client’s vital signs. What assessment question constitutes the ìfifth vital signî?
ìAre you having any pain right now?î
An 84-year-old man has been admitted to the emergency department from an extended care facility. Facility staff suspect that the client has pneumonia, and his malaise, productive cough, shortness of breath, and adventitious breath sounds are consistent with this diagnosis. However, the nurse’s assessment of the client’s vital signs yields an oral temperature of 97.5∞F. How should the nurse best interpret this assessment finding?
The client’s normothermic temperature does not rule out the presence of an
infection.
The nurse is performing an assessment of a hospital client at the beginning of a shift. When assessing the client’s heart rate, the nurse will most likely palpate what artery?
Radial artery
The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client’s pulse pressure?
44 mm Hg
A nurse at an ambulatory clinic is preparing to begin the collection of objective assessment data from a female client. After meeting the client and bringing her into the examination room, what instruction should the nurse provide?
ìPlease have a seat on the edge of the exam table.î
The nurse has assisted a 74-year-old woman from a chair to the examination table during an assessment, and the nurse observes that the client moves particularly slowly and stiffly. The nurse should question the client regarding a possible history of what health problem?
Arthritis
- A community health nurse is conducting a home visit to a client who requires wound care. The nurse observes that the client is diaphoretic and wishes to measure the client’s temperature. The nurse asks if the client has a thermometer in her home, and she states that she owns an ìear thermometer.î What principle should guide the nurse’s use of a tympanic thermometer?
Tympanic temperature is slightly higher than oral temperature.
The nurse palpates a client’s pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. How should the nurse respond to this assessment finding?
Assess the client’s pulse at the carotid site.
The nurse palpates a client’s pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding?
Auscultate the client’s apical pulse.
A palliative care nurse is explaining the basis of pain to a group of nurses who provide care on a general medical unit. Which of the following factors would the nurse include? Select all that apply
Physiologic
Psychosocial
A group of students is reviewing information about pain transmission and the fibers involved. The students demonstrate understanding when they state that A-delta primary afferent fibers transmit pain that is felt as which of the following?
Sharp
A nurse is assessing the pain of a client who has had major surgery. The client also has been experiencing depression. Which of the following principles should guide the nurse’s assessment of a client’s pain?
It is likely that the client’s pain rating will be influences by his emotional state.
A client has received a diagnosis of chronic nonmalignant pain. The nurse who is planning this client’s nursing care should understand that this client has experienced this pain for at least how many months?
6
A nurse educator is presenting an in-service program to a group of nurses who will be working on an oncology unit. Which of the following characteristics of cancer pain should the nurse describe?
It is typically caused by compressed peripheral nerves.
A nurse is admitting a client to the postsurgical unit following breast reconstruction surgery. Which of the following would the nurse use as the primary assessment for the client’s pain?
The client’s report of her pain
The nurse is using the Verbal Descriptor Scale to assess a client’s pain. The nurse will prioritize which of the following data?
The client’s explanation of how her pain feels
The nurse collects vital signs on a hospital client who has recently been experiencing pain. Which of the following would suggest most strongly to the nurse that the client is experiencing pain?
Heart rate of 110 beats per minute
Based on the analysis of assessment data from a client with pain, the nurse writes a health promotion diagnosis. Which of the following diagnoses would be most appropriate?
Readiness for enhanced spiritual well-being related to coping with prolonged
physical pain
A nurse is preparing to document a collaborative problem for a client with pain. Which of the following would be most appropriate?
ìRC: peripheral nerve compressionî
The nurse is assessing a client whose chronic pain is poorly controlled. Which assessment finding should the nurse expect under these circumstances?
Decreased gastric motility
A client rates his pain as 9 on a scale of 1 to 10. The nurse would expect to assess which of the following?
Increased serum glucose
The nurse is assessing a client’s pain. Which question would be most appropriate to ask the client when the goal is to identify precipitating factors that might have exacerbated the pain?
What were you doing when the pain first stated?î
A client has questioned why the nurse asked him how his family members usually treat their pain. Which of the following would be the most appropriate response by the nurse?
ìIt helps me to determine how the family understands and perceives pain.î
When assessing pain in an older adult client who is alert and oriented, which assessment tool would be most appropriate to use?
Numerical rating scale
The nurse is observing a client for evidence of pain. Which of the following would most likely lead the nurse to suspect that the client may be experiencing pain?
Slumped posture
A nurse is creating a concept map of the pathophysiology of pain. The nurse should identify which of the following as being responsible for transmitting pain sensations to the central nervous system?
Nociceptors
A client who has fractured her arm is describing her pain as ìexcruciating.î The nurse determines that the client is most likely experiencing what type of pain?
Deep somatic
he nurse is assessing the client’s perception of pain and the client’s description of its intensity and quality. Which dimension of pain is the nurse evaluating?
Sensory
When attempting to assess a client’s pain, which of the following actions should the nurse perform first?
Obtain a client self-report.
A hospital’s protocols for assessment have been modified in light of standards established by the Joint Commission. What change would bring practice into alignment with these standards?
Identifying pain as the fifth vital sign and assessing clients accordingly
An emergency department nurse is assessing a client’s complaint of upper abdominal pain. Using the COLDSPA mnemonic, with what assessment question would the nurse begin?
ìCan you describe to me how your pain feels?î
A nurse is providing care for an 84-year-old client who has diagnoses of middle-stage Alzheimer disease and a femoral head fracture. What assessment tool should the nurse use to assess the client’s pain?
Faces Pain Scale-Revised (FPS-R)
A female client with bone cancer is experiencing pain that has become more severe over the past several days. When modifying the client’s plan of care, the nurse identifies a need to assess the affective dimension of the client’s pain. How can the nurse best accomplish this goal?
Closely monitor the effects of the client’s pain on her emotions.
A nurse is attempting to apply the principles of cultural competency in the care of a 72- year-old Asian-American woman who has a spinal cord compression. Which of the following statements should guide the nurse’s care?
The client may be reluctant to accept opioids.
A female client with advanced-stage vascular dementia has been showing signs of pain over the past several hours. The nurse is unable to obtain a self-report from the client due to her cognitive impairment. When applying the Hierarchy of Pain Assessment Techniques, how should the nurse proceed with assessment?
Search for potential causes of pain.
A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the client from the stretcher to a bed and asked the client if he is experiencing pain. The client acknowledges that he is in pain. What should be the nurse’s next action?
Assess the client’s pain according to COLDSPA.
A nurse is providing care to a client who has been in a motor vehicle accident and who has facial lacerations and a pelvic fracture. How can the nurse best determine the reliability and accuracy of data obtained during a pain assessment?
Validate the assessment data with the client.
A nurse is performing a detailed pain assessment of a client who has sought care for debilitating migraines. When assessing for precipitating factors, what question should the nurse ask?
ìWhat were you doing immediately before your last migraine?î
An older adult client with osteoarthritis has tearfully admitted to the nurse that she is no longer able to climb the stairs to the second floor of her house due to her knee pain. What nursing diagnosis is suggested by this client’s statement?
Activity intolerance related to knee pain
The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. During health promotion, the nurse should focus education on which of the following topics?
Risks of sun exposure
The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis?
Oral mucosa
A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following should the nurse do next?
Perform a random blood sugar test.
An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?
Sebum production
The nurse’s assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system?
Endocrine
During an integumentary assessment, the nurse notes that the client’s fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition?
Iron deficiency anemia
In which health condition would the nurse most likely expect to assess a capillary refill
time that is longer than 2 seconds?
Peripheral vascular disease
A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident’s skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident’s sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?
Stage II
A 15-year-old boy shows the school nurse a ìbumpî on his neck. The nurse observes a raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the presence of which of the following?
Papule
While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?
Petechiae
A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. During assessment using the mnemonic ABCDE, which finding would the nurse identify as being most suggestive of melanoma?
Asymmetric, irregular borders
An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess?
Vesicle
The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an ìitching rash.î Which question would be most important for the nurse to ask?
ìAre you allergic to foods, medications, or other substances?î
A client’s history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client’s skin to have what characteristic?
Increased thinness
An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess?
Circulatory
Assessment of a client’s nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies?
Bacterial infection
The nurse is preparing to examine a client’s skin. Which of the following actions would
be most important for the nurse to do?
Expose only the body part that is being examined.
A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency?
Monthly
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
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?
Acute illness
A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?
The client’s ability to change position
A nurse is assessing a 49-year-old client who questions the nurse’s need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment?
ìHaving bad sunburns when you’re a child puts you at risk for skin cancer later in
life.î
A nurse is implementing appropriate infection control precautions while performing a client’s skin assessment. During which of the following components of the assessment should the nurse wear gloves?
When palpating lesions on the client’s skin
The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client’s nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon?
Vasoconstriction
A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which of the following assessment findings would be indicative of a stage I pressure ulcer?
There is a nonblanching reddened area on the client’s coccyx region.
A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion?
Illuminate the area using a Wood’s light.
The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client’s ethnicity. What assessment question should the nurse consequently ask?
ìDo you take steroid medications on a regular basis?î
The nurse is assessing a dark-skinned client whose forearms are hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?
Vitiligo
A nurse is assessing an older adult client’s risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client’s current health status would be reflected in her score on this scale?
The client is consistently incontinent of urine.
A nurse is preparing for an assessment by reviewing a new client’s electronic health record, which documents the presence of macules on the client’s left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions?
The lesions will not be palpable.
The nurse is preparing to palpate a client’s temporal artery. The nurse would place the hands at which location?
On each side between the top of the ear and the eye
A nurse is preparing to assess an adult client’s carotid pulses. Which of the following actions would be contraindicated?
Compressing the arteries bilaterally
The nurse’s assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve?
Accessory (XI)
During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem?
Trigeminal neuralgia
A client describes her frequent headaches as being severe and lasting for days. The client’s positive response to what question would most clearly suggest to the nurse that these headaches are migraines?
ìDo you have any visual changes before the headache?î
Which factor, if present in a client’s lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment?
Smokeless tobacco use
A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause?
Falls prevention
A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client’s skull and facial bones are larger and thicker than normal?
Acromegaly
When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. Which of the following should the nurse examine first?
Hearing acuity
The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health?
Vision
A nursing educator is evaluating a colleague’s examination of a client’s thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?
Percussion
A nurse is palpating the position of the client’s trachea. At which anatomic site would the nurse first position a finger for palpation?
Sternal notch
When preparing to assess a client’s thyroid gland, the nurse should ensure that which piece of equipment is readily available?
Cup of water
Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities?
Nodularity
A nurse is assessing an adult client’s neck. Which of the following would be most appropriate when auscultating the client’s thyroid gland for bruits?
Have the client hold his or her breath.
A nurse is preparing to palpate a client’s submental lymph nodes. At what anatomic location should the nurse position his or her hands?
Behind the tip of the client’s mandible
The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?
Sternomastoid
A nurse has completed an assessment of a client’s lymph nodes. Which of the following data would the nurse document as an abnormal finding?
C) Tender
The nurse is assessing the face of a client with a diagnosis of Parkinson’s disease. Which of the following would the nurse most likely assess?
Masklike expression
During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches
Pain radiating from eye to temporal region
A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client’s other vertebrae?
C7
A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client’s thyroid gland, the nurse should be aware of which of the following principles?
Many clients have an additional (third) thyroid lobe.
A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?
Referral for further assessment of thyroid function
A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants’ risks of head and neck cancers?
A smoking cessation program
Assessment of an adult female client’s face reveals a moon shape, increased hair distribution, and a reddened tone to the client’s cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?
RC: Cushing’s syndrome
A nurse is working with a client who has a history of headaches. When preparing to assess the client’s temporomandibular joint (TMJ), the nurse should provide what instruction?
ìI’m going to put my fingers in front of your ears and ask you to open your mouth
wide.î
A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client’s thyroid gland, what landmarks should the nurse first identify? Select all that apply.
Hyoid bone
Cricoid cartilage
The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client’s thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform?
Auscultate the client’s thyroid.
A client’s recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client’s thyroid gland, what assessment finding is most consistent with this diagnosis?
A sound of turbulent blood flow in the thyroid
A nurse has completed the assessment of an older adult client’s head and neck and is now analyzing the assessment findings. Which of the following findings should the nurse attribute to age-related physiological changes?
Decreased strength of temporal artery pulsations
The nurse is reviewing a client’s electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow-up?
Leukoplakia
In the course of the nurse’s health interview, a client reports an occasional blockage in the upper portion of his nasal passage. What is the most pronounced effect that this will have on the client?
Impaired sense of smell
A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?
History of allergies
The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. Which of the following would be most appropriate for the nurse to include?
Thoroughly chew small amounts of food with each mouthful.
When examining the mouth of an adult client with recent cognitive changes, the nurse notes a distinct bluish-black line along the client’s gum line. Which action should be the nurse’s priority?
Referring the client for further evaluation
While examining a client’s mouth, the nurse notes the presence of fasciculations (fine tremors) of the client’s tongue. How should the nurse best respond to this assessment finding?
Assess the client’s cranial nerve function.
A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. Which of the following assessment findings should the nurse anticipate along
with this condition?
Crepitus over the maxillary sinuses
The nurse is inspecting a client’s tonsils and notes that they make contact with the client’s uvula. The nurse would document this finding as which of the following?
3+
A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?
XII
When examining a child who complains of a sore throat, the nurse notes swelling on either side of the child’s oropharynx. The nurse would include which of the following when documenting this finding?
Enlarged palatine tonsils
The nurse is assessing an older adult client whose health problems include receding gums. The nurse notes gum ischemia and worn tooth surfaces. Which question would be most important for the nurse to ask?
ìHave you lost any teeth recently?î
During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. Which of the following would be most important for the nurse to assess?
Checking for a deviated nasal septum
While performing an elderly client’s admission assessment, the nurse notes the presence of deep tongue fissures. Which of the following responses should take priority?
Intravenous fluid replacement
The nurse assesses thick, white plaques on a client’s tongue and hard palate. Which of the following nursing actions should the nurse do next?
Refer the client to a primary care provider for medication.
The nurse inspects a client’s mouth and notes the presence of a bifid uvula. The nurse understands that this finding is most common in which ethnic group?
Native Americans
On inspection, the nurse observes a line across the tip of an 8-year-old client’s nose. The nurse should consequently focus on which area of assessment?
Chronic allergies
A client has presented for care because of frequent sinus headaches. During transillumination of the frontal sinuses, a red glow is noted. The nurse should anticipate which of the following?
The headaches are most likely not from a sinus infection.
A group of students is reviewing information about the salivary glands and their secretions. The students demonstrate understanding of the information when they identify which of the following as components of saliva? Select all that apply.
Salts
Mucus
Amylase
The nurse has completed a focused assessment of a client’s mouth, nose, and throat. Which of the following findings would a nurse interpret as being normal?
Pinkish, spongy soft palate
When assessing a client for possible oral cancer, the nurse should most closely inspect which area?
Area under the tongue
A nurse is integrating health promotion education into the assessment of a client’s mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer?
C) ìDo you use tobacco, whether smoking or chewing?î
The nurse is assessing a client who enjoys good health overall but who has brought a complaint of chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize?
ìHow often do you use over-the-counter nasal sprays?î
The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his history of environmental allergies, the client states, ìI’m pretty sure that I’m allergic to something, but I’m not exactly sure what triggers my allergies.î How can the nurse begin to identify the specific allergens that cause the man’s symptoms?
Ask the client about the timing of his allergy symptoms.
n experienced nurse is aware that receding gums are an expected finding in some clients whereas in other clients this finding is abnormal. In which of the following clients would the nurse identify receding gums as an expected assessment finding?
A 77-year-old man who describes himself as being healthy
Assessment of a client’s mouth reveals a lesion on the client’s buccal membrane that is approximately 0.5 cm in diameter. On further questioning, the client states that the lesion has been present for 3 months and that it bleeds intermittently. How should the nurse follow up this assessment finding?
Refer the client to her primary care provider promptly.
A client has presented with ìa terrible head cold,î and the nurse is assessing for signs and symptoms of sinusitis. The nurse should utilize what assessment techniques? Select all that apply.
Palpation
Percussion
Transillumination
The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client’s sinuses, what assessment finding would most strongly suggest sinusitis?
Pain on percussion
The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem?
Risk for aspiration related to decreased swallowing ability
A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection (thrush). On inspection of the patient’s tongue, the nurse should anticipate what appearance?
A) Thick, white plaques on the tongue surface
The nurse is assessing the characteristics and positioning of the client’s uvula, which deviates asymmetrically when the nurse has the client say ìaaah.î This finding should prompt the nurse to focus on which of the following during subsequent assessment?
The client’s neurological status
While auscultating the client’s heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse should document which of the following?
Pericardial friction rub
During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client’s chest. The nurse interprets this as which grade?
2
A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying this layer as which of the following?
Myocardium
A nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. The nurse should be aware that the electrical signal originates in which of the following locations?
Sinoatrial node
The nurse is analyzing the data from the assessment of a client’s heart and neck vessels. The client’s first heart sound corresponds with what event in the cardiac cycle?
Closure of the atrioventricular valves
The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate?
Increased jugular venous pressure
The nurse is assessing a client with a cardiac condition who complains of not sleeping
well and of having to get up frequently at night to urinate. The nurse should recognize what implication of this statement?
The client may be experiencing symptoms of heart failure.
The nurse is assessing a client’s heart and neck vessels. Which technique would be most appropriate to use when examining the client’s jugular venous pulse?
Inspect the suprasternal notch or around the clavicles.
The nurse is preparing to assess a client’s apical impulse. The nurse should palpate at which location?
Fifth intercostal space, left midclavicular line
A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, which information would the nurse include?
Hypertension is more prevalent in African Americans than among Caucasians.
- The nurse is assessing a client with mitral insufficiency. Which characteristic of the first heart sound should the nurse expect to hear?
Diminished
The nurse is assessing a client who has a complex cardiac history. The nurse has asked the client to lean forward while in a sitting position. This position will allow the nurse to
do which of the following?
Identify heart sounds that may be inaudible in other positions.
A nurse is auscultating a client’s heart sounds. What action should the nurse perform during this assessment?
Systematically listen to the entire precordium.
After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which of the following as Erb’s point?
Third to fifth intercostal space at the left sternal border
A nurse is reviewing a client’s electrocardiogram (ECG). The nurse should identify which component as indicating ventricular repolarization?
T wave
The nurse is preparing to assess a client’s carotid arteries. Which of the following actions would be most appropriate?
Palpate each artery individually to compare.
A nurse auscultates a client’s heart rate and rhythm and finds the rhythm to be irregular. Which of the following should the nurse do next?
Auscultate for pulse rate deficit.
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+
A nurse is having difficulty identifying a client’s heart sounds, specifically S1 and S2. Which of the following would be most appropriate for the nurse to do?
Palpate the carotid pulse while auscultating the heart.
A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations should the nurse include as appropriate for reducing a person’s risk? Select all that apply.
- Eat foods low in sodium.
- Walk for at least 30 minutes/day.
- Use relaxation techniques to manage stress.
A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse’s assessment confirms the presence of bilateral edema. The nurse’s subsequent assessments should focus on the signs and symptoms of what health problem?
Heart failure
The nurse is using the COLDSPA mnemonic to assess a client’s history of chest pain. What interview question addresses the ìAî in this assessment model?
ìDo you have any other symptoms together with your chest pain, such as nausea,
sweating?î
The nurse has begun the objective assessment of a client’s heart and neck vessels and is assessing the client’s jugular veins. What finding would the nurse consider to be normal in a healthy client?
The jugular venous pulse is not visible when the client is sitting upright.
The nurse is assessing the carotid arteries of a client with a history of heart disease.
Palpate the client’s carotid arteries gently if an occlusion is audible.
The nurse’s auscultation of a 22-year-old client’s apical heart rate reveals the presence of S3. When the client stands upright, the S3 is no longer audible. How should the nurse respond to this assessment finding?
Recognize this as a normal assessment finding in this client.
The nurse is auscultating a client’s heart sounds and hears what she believes to be a murmur. How should the nurse proceed with gathering further assessment data related to the suspected murmur?
Auscultate with the client in a variety of different positions.
The nurse is assessing an older adult client’s heart and neck vessels. When attempting to palpate the client’s apical impulse, what principle should guide the nurse’s actions?
The apical impulse may be more difficult to palpate than in a younger client.
The nurse’s auscultation of the client’s heart sounds reveals the presence of a split S1. What conclusion should the nurse draw from this assessment finding?
A) The client’s ventricles are not contracting simultaneously.
The nurse is integrating health promotion education into the assessment of a client’s heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease?
ìYour risk for heart disease will drop greatly if you’re able to stop smoking.î
The nurse has assessed a client’s neck vessels and is now preparing to auscultate the client’s heart sounds. What action should the nurse perform during this phase of assessment?
Elevate the head of the client’s bed to 30 degrees.
During a client’s vascular assessment, the nurse is palpating the pulse just under the client’s inguinal ligament. The nurse is assessing which pulse?
Femoral
During a health visit, a client says, ìI know that arteries and veins are both blood vessels, but what’s the difference?î Which of the following would the nurse include in the response?
Arteries have thicker walls than veins.
A nurse is palpating a client’s epitrochlear nodes. The nurse is palpating which area?
Upper arm
An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. Which of the following would the nurse suspect?
Arterial insufficiency
The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral?
Venous insufficiency
Which question would be most important to ask when obtaining the nursing health history of a male client with extensive peripheral vascular disease?
ìHave you experienced a change in your usual sexual activity?î
When analyzing the nursing history recently taken on a client, which factor would most strongly alert the nurse to a significantly increased risk for chronic arterial insufficiency?
14-year history of smoking a pack a day
The clinic nurse is reviewing the medication history of a 39-year-old woman. Which medication would the nurse identify as a potential risk factor for thrombophlebitis?
C) An oral contraceptive
The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. Which of the following would be most appropriate for the nurse to do next?
Use Doppler ultrasonography to locate the pulse.
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?
Document this finding as normal.
A nurse is unable to palpate a client’s radial and ulnar pulses. What is the nurse’s most appropriate action?
Palpate the brachial pulse.
A nurse assesses a client’s epitrochlear nodes and finds them to be enlarged and tender. Which of the following would the nurse do next?
Examine the lower arm and hand for infection si
Assessment of a client’s lower extremities reveals unilateral edema of the right foot and ankle. Which of the following would be most appropriate for the nurse to do next?
Compare measurements of both extremities.
When assessing a client for possible varicose veins, the nurse should do which of the following actions?
Have the client stand for the exam.
A group of nursing students is reviewing information about the lymph nodes of the lower extremity and the areas drained by them. The students demonstrate the need for additional teaching when they identify which area as being drained by the superficial inguinal nodes?
Upper abdomen
A nurse instructor is observing a nursing student assess a client’s capillary refill. Which action by the student indicates the proper technique?
Student compresses the client’s nail bed until it blanches.
A nurse is determining a client’s ankle-brachial index. Which result would indicate to the nurse that the client’s circulation is normal and free of arterial occlusion?
1.1
Assessment of a client’s radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following?
3+
A nurse obtains the following information: right arm brachial pressure, 160 mm Hg; left arm brachial pressure, 150 mm Hg; right ankle pressure, 80 mm Hg; left ankle pressure, 94 mm Hg. The nurse determines that the right ankle-brachial index would be which of the following?
0.50
While inspecting the lower extremities of a client, the nurse observes an ulcer. Which of the following would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply.
Deep
Circular in shape
Client report of severe pain
The nurse is assessing a client who has been referred to the clinic because of possible arterial insufficiency. What assessment finding should the nurse identify as most consistent with this diagnosis?
Dry, shiny, hairless shins and feet
The nurse is assessing an 81-year-old client’s peripheral vascular function. What principle should guide the nurse’s analysis of assessment data?
Hair loss on the legs may be an age-related change rather than a sign of arterial
insufficiency.
The nurse’s inspection of a client’s extremities reveals a deep, circular, painful wound on the client’s great toe. What should the nurse suspect as the etiology of the client’s wound?
The client’s toe is receiving an inadequate supply of blood.
The nurse has attempted to palpate the client’s popliteal pulses but is unable to feel them, despite confirming appropriate landmarking and client positioning. What is the nurse’s best response?
Document the finding and proceed with the assessment.
The nurse is using Doppler ultrasound to auscultate the peripheral pulses of a client with peripheral vascular disease. What action should the nurse perform during this assessment?
Hold the probe at a 60- to 90-degree angle to the client’s skin.
The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client’s peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients?
Ulnar
The nurse is performing the Allen test on a client who has a diagnosis of peripheral vascular disease. What action should the nurse take after a positive Allen test?
Document the lack of patency in the ulnar and/or radial arteries.
The nurse reads in a client’s electronic health record that her most recent ankle-brachial index (ABI) was 0.42. How should this assessment finding inform the nurse’s care?
the nurse should implement interventions to address severe arterial insufficiency.
The nurse’s inspection of a Caucasian client’s lower extremities reveals a brownish coloration to the client’s ankles and shins. The nurse should perform further assessments that address what health problem?
Venous insufficiency
The presence of faint pedal pulses in a client has prompted the nurse to perform a position change test for arterial insufficiency. What finding would suggest that the client
may have arterial insufficiency?
The client’s legs are visibly pale when elevated above the examination table.
