EXAMS 1

Question 1

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?

Answer 1

Establishing a trusting relationship

Question 2

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?

Answer 2

Working

Question 3

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?

Answer 3

“You must quit smoking because it affects others, not only you.”

Question 4

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?

Answer 4

Using a moderate amount of eye contact

Question 5

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?

Answer 5

“Are you allergic to any medications?”

Question 6

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?

Answer 6

Provide a laundry list of descriptive words.

Question 7

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?

Answer 7

romise to find out the information for the client.

Question 8

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?

Answer 8

The client’s sensory abilities

Question 9

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?

Answer 9

By interpreting the client’s language and culture

Question 10

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?

Answer 10

“You’re certainly justified in being upset, but I am ready to begin your exam now.”

Question 11

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?

Answer 11

“This helps us have an appropriate focus for the physical examination.”

Question 12

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?

Answer 12

C) “What is your major health concern at this time?”

Question 13

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”?

Answer 13

“What makes it worse?”

Question 14

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?

Answer 14

“Menarche at age 13”

Question 15

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?

Answer 15

Obtain a 24-hour diet recall.

Question 16

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?

Answer 16

“I go to a step class for an hour three times a week.”

Question 17

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?

Answer 17

Ask the client to bring all the medications and supplements to an interview.

Question 18

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?

Answer 18

“Could you describe how you perform self-breast exams?”

Question 19

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?

Answer 19

Circle

Question 20

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?

Answer 20

Explain the purpose of the interview.

Question 21

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?

Answer 21

“How does that make you feel right now?”

Question 22

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?

Answer 22

Severity

Question 23

The nurse is obtaining information about a client’s past health history. Which client statement would best reflect this component of assessment?

Answer 23

“I had surgery 5 years ago to repair an inguinal hernia.”

Question 24

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?

Answer 24

Providing a laundry list of descriptors when needed

Question 25

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.

Answer 25

• Biographic data
• Reason for seeking care
• History of present concern
• Past health history
• Family health history
• Review of body systems

Question 26

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?

Answer 26

• Joint stiffness
• Muscle strength
• Knee swelling

Question 27

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?

Answer 27

“Client denies recent constipation, diarrhea, bowel incontinence, or abdominal
pain.”

Question 28

. 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?

Answer 28

“We want to make sure your nursing care matches your needs as closely as possible.”

Question 29

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?

Answer 29

Briefly describe some of the potential benefits of regular exercise.

Question 30

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?

Answer 30

The client’s stress management and coping strategies

Question 31

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?

Answer 31

Collect necessary equipment essential to the exam.

Question 32

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?

Answer 32

Ensuring client’s privacy by providing an examination gown

Question 33

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?

Answer 33

C) Wearing gloves to palpate the tongue and buccal membranes

Question 34

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?

Answer 34

Fungal infection

Question 35

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?

Answer 35

Skin lesion size

Question 36

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?

Answer 36

Newspaper

Question 37

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?

Answer 37

Blood

Question 38

The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing?

Answer 38

Joint flexion/extension

Question 39

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?

Answer 39

Explain the importance of the pelvic exam and Pap smear, but respect the client’s
wishes and omit the exam.

Question 40

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?

Answer 40

Vital signs

Question 41

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?

Answer 41

Face shield

Question 42

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?

Answer 42

Try to minimize position changes.

Question 43

The nurse is preparing to assess the peripheral pulses of a client. The nurse should place the client in which position?

Answer 43

Supine

Question 44

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?

Answer 44

Dorsal hand surface

Question 45

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?

Answer 45

Use both hands to depress the skin 1 to 2 inches.

Question 46

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?

Answer 46

Blunt percussion

Question 47

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?

Answer 47

Heart sounds

Question 48

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?

Answer 48

ìWhen using the bell, push on it lightly.î

Question 49

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?

Answer 49

The diaphragm should be held firmly against the body part.

Question 50

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?

Answer 50

Feeling the surface structures using a circular motion

Question 51

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?

Answer 51

Speak clearly and slowly when explaining a procedure.

Question 52

The nurse assists a client into the dorsal recumbent position. Assessment of which area is contraindicated when the client is in this position?

Answer 52

Abdomen

Question 53

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?

Answer 53

Tuning fork

Question 54

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.

Answer 54

Adequate lighting
Quiet surroundings
Table for equipment
Door or curtain

Question 55

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?

Answer 55

Pulses

Question 56

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?

Answer 56

Inspection

Question 57

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?

Answer 57

Resonance

Question 58

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?

Answer 58

ìOf course. There’s a chair in the exam room where she can sit.î

Question 59

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?

Answer 59

compare the appearance of the client’s other hand

Question 60

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?

Answer 60

Direct percussion

Question 61

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.

Answer 61

• 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

Question 62

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?

Answer 62

Early morning

Question 63

The nurse is preparing to assess a client’s vital signs. Which vital sign should the nurse assess first?

Answer 63

Temperature

Question 64

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?

Answer 64

The client’s radial pulse occluded with moderate pressure.

Question 65

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?

Answer 65

Calculate the difference between the diastolic and systolic pressures.

Question 66

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?

Answer 66

The client’s blood pressure will be slightly lower than standing readings.

Question 67

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?

Answer 67

It indicates the client’s involvement in his health care.

Question 68

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?

Answer 68

The cuff is placed about 1 inch above the antecubital area.

Question 69

Which of the following would be most important for the nurse to do when assessing a client’s blood pressure?

Answer 69

Inflate the cuff 30 mm Hg above where the radial pulse disappears.

Question 70

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?

Answer 70

Auscultatory gap

Question 71

When assessing an older adult client with osteoporotic thinning and vertebral collapse, which of the following findings would the nurse expect to identify?

Answer 71

Kyphosis

Question 72

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?

Answer 72

Chronic obstructive pulmonary disease

Question 73

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?

Answer 73

Heart rate greater than 100 bpm

Question 74

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?

Answer 74

Evaluating for orthostatic hypotension

Question 75

A nurse is obtaining a client’s radial pulse. Which of the following actions demonstrates correct technique for this assessment?

Answer 75

Use of two middle fingers lightly applied to wrist area along the thumb side

Question 76

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?

Answer 76

Ashen gray skin color

Question 77

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?

Answer 77

Deep in the posterior sublingual pocket

Question 78

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?

Answer 78

Observe the client’s chest expansion bilaterally.

Question 79

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?

Answer 79

97.4∫F

Question 80

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?

Answer 80

Perform a focused assessment of the client’s musculoskeletal system

Question 81

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?

Answer 81

ìAre you having any pain right now?î

Question 82

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?

Answer 82

The client’s normothermic temperature does not rule out the presence of an
infection.

Question 83

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?

Answer 83

Radial artery

Question 84

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?

Answer 84

44 mm Hg

Question 85

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?

Answer 85

ìPlease have a seat on the edge of the exam table.î

Question 86

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?

Answer 86

Arthritis

Question 87

27. 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?

Answer 87

Tympanic temperature is slightly higher than oral temperature.

Question 88

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?

Answer 88

Assess the client’s pulse at the carotid site.

Question 89

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?

Answer 89

Auscultate the client’s apical pulse.

Question 90

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

Answer 90

Physiologic

Psychosocial

Question 91

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?

Answer 91

Sharp

Question 92

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?

Answer 92

It is likely that the client’s pain rating will be influences by his emotional state.

Question 93

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?

Answer 93

6

Question 94

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?

Answer 94

It is typically caused by compressed peripheral nerves.

Question 95

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?

Answer 95

The client’s report of her pain

Question 96

The nurse is using the Verbal Descriptor Scale to assess a client’s pain. The nurse will prioritize which of the following data?

Answer 96

The client’s explanation of how her pain feels

Question 97

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?

Answer 97

Heart rate of 110 beats per minute

Question 98

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?

Answer 98

Readiness for enhanced spiritual well-being related to coping with prolonged
physical pain

Question 99

A nurse is preparing to document a collaborative problem for a client with pain. Which of the following would be most appropriate?

Answer 99

ìRC: peripheral nerve compressionî

Question 100

The nurse is assessing a client whose chronic pain is poorly controlled. Which assessment finding should the nurse expect under these circumstances?

Answer 100

Decreased gastric motility

Question 101

A client rates his pain as 9 on a scale of 1 to 10. The nurse would expect to assess which of the following?

Answer 101

Increased serum glucose

Question 102

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?

Answer 102

What were you doing when the pain first stated?î

Question 103

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?

Answer 103

ìIt helps me to determine how the family understands and perceives pain.î

Question 104

When assessing pain in an older adult client who is alert and oriented, which assessment tool would be most appropriate to use?

Answer 104

Numerical rating scale

Question 105

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?

Answer 105

Slumped posture

Question 106

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?

Answer 106

Nociceptors

Question 107

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?

Answer 107

Deep somatic

Question 108

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?

Answer 108

Sensory

Question 109

When attempting to assess a client’s pain, which of the following actions should the nurse perform first?

Answer 109

Obtain a client self-report.

Question 110

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?

Answer 110

Identifying pain as the fifth vital sign and assessing clients accordingly

Question 111

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?

Answer 111

ìCan you describe to me how your pain feels?î

Question 112

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?

Answer 112

Faces Pain Scale-Revised (FPS-R)

Question 113

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?

Answer 113

Closely monitor the effects of the client’s pain on her emotions.

Question 114

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?

Answer 114

The client may be reluctant to accept opioids.

Question 115

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?

Answer 115

Search for potential causes of pain.

Question 116

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?

Answer 116

Assess the client’s pain according to COLDSPA.

Question 117

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?

Answer 117

Validate the assessment data with the client.

Question 118

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?

Answer 118

ìWhat were you doing immediately before your last migraine?î

Question 119

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?

Answer 119

Activity intolerance related to knee pain

Question 120

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?

Answer 120

Risks of sun exposure

Question 121

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?

Answer 121

Oral mucosa

Question 122

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?

Answer 122

Perform a random blood sugar test.

Question 123

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?

Answer 123

Sebum production

Question 124

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?

Answer 124

Endocrine

Question 125

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?

Answer 125

Iron deficiency anemia

Question 126

In which health condition would the nurse most likely expect to assess a capillary refill
time that is longer than 2 seconds?

Answer 126

Peripheral vascular disease

Question 127

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?

Answer 127

Stage II

Question 128

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?

Answer 128

Papule

Question 129

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?

Answer 129

Petechiae

Question 130

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?

Answer 130

Asymmetric, irregular borders

Question 131

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?

Answer 131

Vesicle

Question 132

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?

Answer 132

ìAre you allergic to foods, medications, or other substances?î

Question 133

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?

Answer 133

Increased thinness

Question 134

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?

Answer 134

Circulatory

Question 135

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?

Answer 135

Bacterial infection

Question 136

The nurse is preparing to examine a client’s skin. Which of the following actions would
be most important for the nurse to do?

Answer 136

Expose only the body part that is being examined.

Question 137

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?

Answer 137

Monthly

Question 138

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?

Answer 138

Discrete

Question 139

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?

Answer 139

Acute illness

Question 140

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?

Answer 140

The client’s ability to change position

Question 141

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?

Answer 141

ìHaving bad sunburns when you’re a child puts you at risk for skin cancer later in
life.î

Question 142

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?

Answer 142

When palpating lesions on the client’s skin

Question 143

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?

Answer 143

Vasoconstriction

Question 144

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?

Answer 144

There is a nonblanching reddened area on the client’s coccyx region.

Question 145

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?

Answer 145

Illuminate the area using a Wood’s light.

Question 146

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?

Answer 146

ìDo you take steroid medications on a regular basis?î

Question 147

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?

Answer 147

Vitiligo

Question 148

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?

Answer 148

The client is consistently incontinent of urine.

Question 149

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?

Answer 149

The lesions will not be palpable.

Question 150

The nurse is preparing to palpate a client’s temporal artery. The nurse would place the hands at which location?

Answer 150

On each side between the top of the ear and the eye

Question 151

A nurse is preparing to assess an adult client’s carotid pulses. Which of the following actions would be contraindicated?

Answer 151

Compressing the arteries bilaterally

Question 152

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?

Answer 152

Accessory (XI)

Question 153

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?

Answer 153

Trigeminal neuralgia

Question 154

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?

Answer 154

ìDo you have any visual changes before the headache?î

Question 155

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?

Answer 155

Smokeless tobacco use

Question 156

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?

Answer 156

Falls prevention

Question 157

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?

Answer 157

Acromegaly

Question 158

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?

Answer 158

Hearing acuity

Question 159

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?

Answer 159

Vision

Question 160

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?

Answer 160

Percussion

Question 161

A nurse is palpating the position of the client’s trachea. At which anatomic site would the nurse first position a finger for palpation?

Answer 161

Sternal notch

Question 162

When preparing to assess a client’s thyroid gland, the nurse should ensure that which piece of equipment is readily available?

Answer 162

Cup of water

Question 163

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities?

Answer 163

Nodularity

Question 164

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?

Answer 164

Have the client hold his or her breath.

Question 165

A nurse is preparing to palpate a client’s submental lymph nodes. At what anatomic location should the nurse position his or her hands?

Answer 165

Behind the tip of the client’s mandible

Question 166

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?

Answer 166

Sternomastoid

Question 167

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?

Answer 167

C) Tender

Question 168

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?

Answer 168

Masklike expression

Question 169

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

Answer 169

Pain radiating from eye to temporal region

Question 170

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?

Answer 170

C7

Question 171

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?

Answer 171

Many clients have an additional (third) thyroid lobe.

Question 172

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?

Answer 172

Referral for further assessment of thyroid function

Question 173

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?

Answer 173

A smoking cessation program

Question 174

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?

Answer 174

RC: Cushing’s syndrome

Question 175

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?

Answer 175

ìI’m going to put my fingers in front of your ears and ask you to open your mouth
wide.î

Question 176

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.

Answer 176

Hyoid bone

Cricoid cartilage

Question 177

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?

Answer 177

Auscultate the client’s thyroid.

Question 178

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?

Answer 178

A sound of turbulent blood flow in the thyroid

Question 179

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?

Answer 179

Decreased strength of temporal artery pulsations

Question 180

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?

Answer 180

Leukoplakia

Question 181

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?

Answer 181

Impaired sense of smell

Question 182

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?

Answer 182

History of allergies

Question 183

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?

Answer 183

Thoroughly chew small amounts of food with each mouthful.

Question 184

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?

Answer 184

Referring the client for further evaluation

Question 185

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?

Answer 185

Assess the client’s cranial nerve function.

Question 186

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?

Answer 186

Crepitus over the maxillary sinuses

Question 187

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?

Answer 187

3+

Question 188

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

Answer 188

XII

Question 189

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?

Answer 189

Enlarged palatine tonsils

Question 190

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?

Answer 190

ìHave you lost any teeth recently?î

Question 191

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?

Answer 191

Checking for a deviated nasal septum

Question 192

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?

Answer 192

Intravenous fluid replacement

Question 193

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?

Answer 193

Refer the client to a primary care provider for medication.

Question 194

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?

Answer 194

Native Americans

Question 195

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?

Answer 195

Chronic allergies

Question 196

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?

Answer 196

The headaches are most likely not from a sinus infection.

Question 197

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.

Answer 197

Salts
Mucus
Amylase

Question 198

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?

Answer 198

Pinkish, spongy soft palate

Question 199

When assessing a client for possible oral cancer, the nurse should most closely inspect which area?

Answer 199

Area under the tongue

Question 200

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?

Answer 200

C) ìDo you use tobacco, whether smoking or chewing?î

Question 201

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?

Answer 201

ìHow often do you use over-the-counter nasal sprays?î

Question 202

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?

Answer 202

Ask the client about the timing of his allergy symptoms.

Question 203

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?

Answer 203

A 77-year-old man who describes himself as being healthy

Question 204

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?

Answer 204

Refer the client to her primary care provider promptly.

Question 205

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.

Answer 205

Palpation
Percussion
Transillumination

Question 206

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?

Answer 206

Pain on percussion

Question 207

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?

Answer 207

Risk for aspiration related to decreased swallowing ability

Question 208

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?

Answer 208

A) Thick, white plaques on the tongue surface

Question 209

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?

Answer 209

The client’s neurological status

Question 210

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?

Answer 210

Pericardial friction rub

Question 211

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?

Answer 211

2

Question 212

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?

Answer 212

Myocardium

Question 213

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?

Answer 213

Sinoatrial node

Question 214

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?

Answer 214

Closure of the atrioventricular valves

Question 215

The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate?

Answer 215

Increased jugular venous pressure

Question 216

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?

Answer 216

The client may be experiencing symptoms of heart failure.

Question 217

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?

Answer 217

Inspect the suprasternal notch or around the clavicles.

Question 218

The nurse is preparing to assess a client’s apical impulse. The nurse should palpate at which location?

Answer 218

Fifth intercostal space, left midclavicular line

Question 219

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?

Answer 219

Hypertension is more prevalent in African Americans than among Caucasians.

Question 220

11. The nurse is assessing a client with mitral insufficiency. Which characteristic of the first heart sound should the nurse expect to hear?

Answer 220

Diminished

Question 221

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?

Answer 221

Identify heart sounds that may be inaudible in other positions.

Question 222

A nurse is auscultating a client’s heart sounds. What action should the nurse perform during this assessment?

Answer 222

Systematically listen to the entire precordium.

Question 223

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?

Answer 223

Third to fifth intercostal space at the left sternal border

Question 224

A nurse is reviewing a client’s electrocardiogram (ECG). The nurse should identify which component as indicating ventricular repolarization?

Answer 224

T wave

Question 225

The nurse is preparing to assess a client’s carotid arteries. Which of the following actions would be most appropriate?

Answer 225

Palpate each artery individually to compare.

Question 226

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?

Answer 226

Auscultate for pulse rate deficit.

Question 227

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?

Answer 227

2+

Question 228

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?

Answer 228

Palpate the carotid pulse while auscultating the heart.

Question 229

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.

Answer 229

• Eat foods low in sodium.
• Walk for at least 30 minutes/day.
• Use relaxation techniques to manage stress.

Question 230

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?

Answer 230

Heart failure

Question 231

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?

Answer 231

ìDo you have any other symptoms together with your chest pain, such as nausea,
sweating?î

Question 232

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?

Answer 232

The jugular venous pulse is not visible when the client is sitting upright.

Question 233

The nurse is assessing the carotid arteries of a client with a history of heart disease.

Answer 233

Palpate the client’s carotid arteries gently if an occlusion is audible.

Question 234

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?

Answer 234

Recognize this as a normal assessment finding in this client.

Question 235

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?

Answer 235

Auscultate with the client in a variety of different positions.

Question 236

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?

Answer 236

The apical impulse may be more difficult to palpate than in a younger client.

Question 237

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?

Answer 237

A) The client’s ventricles are not contracting simultaneously.

Question 238

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?

Answer 238

ìYour risk for heart disease will drop greatly if you’re able to stop smoking.î

Question 239

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?

Answer 239

Elevate the head of the client’s bed to 30 degrees.

Question 240

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?

Answer 240

Femoral

Question 241

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?

Answer 241

Arteries have thicker walls than veins.

Question 242

A nurse is palpating a client’s epitrochlear nodes. The nurse is palpating which area?

Answer 242

Upper arm

Question 243

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?

Answer 243

Arterial insufficiency

Question 244

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?

Answer 244

Venous insufficiency

Question 245

Which question would be most important to ask when obtaining the nursing health history of a male client with extensive peripheral vascular disease?

Answer 245

ìHave you experienced a change in your usual sexual activity?î

Question 246

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?

Answer 246

14-year history of smoking a pack a day

Question 247

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?

Answer 247

C) An oral contraceptive

Question 248

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?

Answer 248

Use Doppler ultrasonography to locate the pulse.

Question 249

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?

Answer 249

Document this finding as normal.

Question 250

A nurse is unable to palpate a client’s radial and ulnar pulses. What is the nurse’s most appropriate action?

Answer 250

Palpate the brachial pulse.

Question 251

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?

Answer 251

Examine the lower arm and hand for infection si

Question 252

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?

Answer 252

Compare measurements of both extremities.

Question 253

When assessing a client for possible varicose veins, the nurse should do which of the following actions?

Answer 253

Have the client stand for the exam.

Question 254

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?

Answer 254

Upper abdomen

Question 255

A nurse instructor is observing a nursing student assess a client’s capillary refill. Which action by the student indicates the proper technique?

Answer 255

Student compresses the client’s nail bed until it blanches.

Question 256

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?

Answer 256

1.1

Question 257

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?

Answer 257

3+

Question 258

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?

Answer 258

0.50

Question 259

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.

Answer 259

Deep
Circular in shape
Client report of severe pain

Question 260

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?

Answer 260

Dry, shiny, hairless shins and feet

Question 261

The nurse is assessing an 81-year-old client’s peripheral vascular function. What principle should guide the nurse’s analysis of assessment data?

Answer 261

Hair loss on the legs may be an age-related change rather than a sign of arterial
insufficiency.

Question 262

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?

Answer 262

The client’s toe is receiving an inadequate supply of blood.

Question 263

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?

Answer 263

Document the finding and proceed with the assessment.

Question 264

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?

Answer 264

Hold the probe at a 60- to 90-degree angle to the client’s skin.

Question 265

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?

Answer 265

Ulnar

Question 266

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?

Answer 266

Document the lack of patency in the ulnar and/or radial arteries.

Question 267

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?

Answer 267

the nurse should implement interventions to address severe arterial insufficiency.

Question 268

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?

Answer 268

Venous insufficiency

Question 269

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?

Answer 269

The client’s legs are visibly pale when elevated above the examination table.