Practice Question ch 13

Question 1

1. When preparing to perform an assessment , which elements need to be included to ensure the integrity of the nurse-patient relationship ?
2. Introduction of the nurse to the patient, which includes title (LPN / L * VN) and purpose of visit
3. Explanation of what the nurse will need to accomplish (i.e., vital signs , body system review) during the time with the patient
4. An estimated time frame to complete the assessment
5. Standing at the foot of the bed to get the best look at the patient and his and her responses
6. Preparation of the room for the least amount of distractions so that the patient can remain focused to questions offered by the nurse

Answer 1

1,2,3,5

Question 2

A patient has been admitted with acute bronchitis When performing a lung assessment, the nurse is best able to auscultate the lower lobes by listening to what location on the body?

1. Posterior 2. Anterior 3. Lateral 4. Superior

Answer 2

1

Question 3

A 90-year-old patient is having difficulty answering the nurse’s questions while completing the patient history What should the nurse keep in mind about caring for older adults?

1. All older adults age at the same rate.
2. The nurse should write down all of the questions and have the patient’s family complete the information
3. The nurse should sit down at eye level with the patient and allow a longer period to answer each question
4. The nurse should talk more loudly and raise the pitch of the voice.

Answer 3

3

Question 4

The nurse documents which finding while assessing a patient with heart failure where it is noted that the lower extremities have deep indentations that remain for 30 seconds when pressed ?

1. Nonpitting edema
2. 2+ pitting edema
3. 3+ pitting edema
4. 4+ pitting edema

Answer 4

3

Question 5

The patient reports severe abdominal pain. What type of assessment should the nurse perform?

1. Head-to-toe assessment
2. Focused assessment
3. System -by-system assessment
4. Complete assessment

Answer 5

2

Question 6

An elderly male patient is admitted for chest pain. How does the nurse best document the information the patient gives about his symptoms ?

1. Use the patient’s own words in quotation marks
2. Briefly summarize what the patient says
3. Interpret the patient’s comments using medical terminology .
4. Use the information for the chief complaint from the admission sheet.

Answer 6

1

Question 7

The nurse asks the patient about which signs and symptoms experienced when reviewing the elderly patient’s gastrointestinal system ? ( Select all that apply)

1. Changes in bowel habits
2. Pyrosis ( heartburn)
3. Firmness of the abdomen
4. Dyspnea
5. Anorexia

Answer 7

1,2,3,5

Question 8

What is the first area to be assessed after taking vital signs when performing a nursing assessment ?

1. Assess for level of consciousness and orientation
2. Assess the skin.
3. Listen to lung sounds
4. Check for pitting edema .

Answer 8

1

Question 9

A patient has been admitted for dehydration after a prolonged period of diarrhea . Which finding does the nurse expect to observe in this patient ?

1. Skin warm , moist , pink with good skin turgor
2. Skin warm , dry , pale with decreased skin turgor
3. Skin cool , dry, pink with increased skin turgor
4. Skin cool , moist , pale with decreased skin turgor

Answer 9

2

Question 10

The nurse assesses a vibration felt along the patient’s carotid artery with palpation. How should the nurse describe this assessment finding ?

1. Palpation 2. Thrill 3. Bruit 4. Aneurysm

Answer 10

2

Question 11

The nurse is preparing a female patient for a gynecologic examination . Which patient position best assists the health care provider in this examination ?

1. High Fowler’s
2. Dorsal recumbent
3. Lithotomy
4. Sims

Answer 11

3

Question 12

Which risk factor for cardiovascular disease can be modified ? (Select all that apply .)

1. Age
2. Race
3. Diet
4. Family history
5. Smoking

Answer 12

3,5

Question 13

What is the term used to describe a patient’s respiratory rate that exceeds 36 breaths per minute ?

1. Sonorous
2. Bradypnea
3. Tachypnea
4. Apnea

Answer 13

3

Question 14

The nurse is auscultating breath sounds on a patient and detects adventitious breath sounds . The nurse describes them as a loud , bubbly noise heard during inspiration . The nurse is correct when using which term for documenting this finding ?

1. Coarse crackles
2. Sonorous wheezes
3. Pleural friction rub
4. Sibilant wheezes

Answer 14

1

Question 15

The nurse is documenting a patient assessment . The nurse correctly identifies which information as being objective data ? (Select all that apply .)

1. have a headache and feel like the room is
2. “When I eat I have horrible pain in my stomach .
   “3. burns when I use the bathroom ; what do youthink is wrong with me ?
   “ 4. is noted that the blood pressure (B /P) is high at 156/96
   5.Abdomen is distended and hypoactive bowel sounds are noted “

Answer 15

4,5

Question 16

The nurse is performing a cardiovascular system assessment on a patient. Which is included in an assessment of the peripheral vascular system? (Select all that apply .)

1. Assessment of the apical pulse rate by counting the pulsations for 60 seconds
2. Assessment of the brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial pulses
3. Assessment of capillary refill in the nail beds of the fingers and toes
4. Determination of the rate, rhythm, and strength of the dorsalis pedis pulse
5. Assessment of the patient’s skin turgor by counting the amount of time the skin remains tented

Answer 16

1,2,3,4

Question 17

The patient has been admitted to the medical unit with a wound to the left lower extremity from a mowing accident 2 days ago. The inflammatory response present at this stage includes which signs and symptoms? (Select all that apply. )

1. Swelling
2. Pain
3. Coolness
4. Purulent drainage
5. Pale skin at injury site

Answer 17

1,2

Question 18

The patient asks the nurse why all of the nurses always listen to his abdomen with the stethoscope before pressing on it. Which response is correct?

1. This prevents distortion of vascular sounds .
2. This prevents distortion of bowel sounds.
3. This determines any areas of tenderness or pain.
4. This allows the patient to relax and be comfortable .

Answer 18

2

Question 19

Online question 1-10

Answer 19

online
Look pic iPad

Question 20

A nurse in a provider’s office is preparing to test a client’s cranial nerve functionWhich of the following directions should the nurse include when testing cranial nerve V? ( Select all that apply)

A. “Close your eyes.”
B. “Tell me what you can taste .”
C. “Clench your teeth.”
D. “Raise your eyebrows.”
E. “Tell me when you feel a touch.”

Answer 20

Ati book ch 28

c,e

Question 21

A nurse is assessing a client’s thyroid gland as part of a comprehensive physical examination Which of the following findings should the nurse expect ? ( Select all that apply )

A. Palpating the thyroid in the lower half of the neck
B. Visualizing the thyroid on inspection of the neck
C. Hearing a bruit when auscultating the thyroid
D. Feeling the thyroid ascend as the client swallows
E. Finding symmetric extension off the trachea on both sides of the midline

Answer 21

Ati book ch 28

a,d,e

Question 22

A nurse is assessing an adult client’s internal ear canals with an otoscope as part of a head and neck examination . Which of the following actions should the nurse take ? (Select all that apply .)

A. Pull the auricle down and back
B. Insert the speculum slightly down and forward .
C. Insert the speculum 2 to 2.5 cm ( 0.8 to 1 in ).
D. Make sure the speculum does not touch the ear canal .
E. Use the light to visualize the tympanic membrane in a cone shape .

Answer 22

Ati book ch 28

b,d,e

Question 23

A nurse is caring for a client who asks what their Snellen eye test results mean. The client’s visual acuity is 20/30 . Which of the following responses should the nurse make ?

A. “Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet .
B. “Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet.”
C. Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet.
D. “Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet.”

Answer 23

Ati book ch 28

A

Question 24

A nurse is performing a head and neck examination for an older adult client. Which of the following age -related findings should the nurse expect? (Select all that apply.)

A. Reddened gums
B. Lowered vocal pitch
C. Tooth loss
D. Glare intolerance
E. Thickened eardrums

Answer 24

Ati book ch 28

c,d,e

Question 25

A nurse in a provider’s office is preparing to perform a breast examination for an older adult client who is postmenopausalWhich of the following findings should the nurse expect? (Select all that apply.)

A. Smaller nipples
B. Less adipose tissue
C. Nipple discharge
D. More pendulous
E. Nipple inversion

Answer 25

Ati-book chapter 29

a,d,e

Question 26

A nurse in a provider’s office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.)

A. Rhonchi
B. Crackles
C. Resonance
D. Tactile fremitus
E. Bronchovesicular sounds

Answer 26

Ati-book chapter 29

c,e

Question 27

During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks . Which of the following possible causes of distention should the nurse suspect ?

A. Fat
B. Fluid
C. Flatus
D. Hernias

Answer 27

Ati-book chapter 29

c

Question 28

During a cardiovascular examination , a nurse in a provider’s office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space . Which of the following data is the nurse attempting to auscultate ? (Select all that apply. )

A. Ventricular gallop
B. Closure of the mitral valve
C. Closure of the pulmonic valve
D. Apical heart rate E. Murmur

Answer 28

Ati-book chapter 29

b,d

Question 29

A nurse in a provider’s office is preparing to auscultate and percuss a client’s abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply .)

A. Tympany
B. High-pitched clicks
C. Borborygmi
D. Friction rubs
E. Bruits

Answer 29

Ati-book chapter 29

A,B

Question 30

A nurse is performing a physical examination of the spine for an olderadult client. The nurse should identify that which of the following findings is common with aging?
A. Lordosis
B. Kyphosis
C. Ankylosis
D. Scoliosis

Answer 30

B

Question 31

A nurse is preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics?
A. Gait
B. Hearing
C. Vision
D. Balance

Answer 31

D

Question 32

A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first?
A. Auscultation
B. Inspection
C. Percussion
D. Palpation

Answer 32

B

Question 33

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect?

A. A continuous sensation of vibration felt over the second and third left intercostal spaces.
B. A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum.
C. A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line.
D. A whooshing or swishing sound over the second intercostal space along the left sternal border.

Answer 33

C

Question 34

A nurse is performing a general client survey & finds that the client has a BMI of 23. Which of the following should the nurse document?

A. The client has no nutritional issues or deficits.
B. The client is at high risk for obesity-related health problems.
C. The client will need a referral to a dietitian.
D. The client has a BMI within the expected reference range.

Answer 34

D
18.5-24.9 BMI range

Question 35

A nurse is assessing a client’s peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the client’s foot, between the tendons of the great toe & those of the toe next to it, in order to palpate which of the following pulses?

A. Posterior tibial
B. Popliteal
C. Dorsalis pedis
D. Femoral

Answer 35

C

Question 36

A nurse is palpating a tender area of a client’s abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document?

A. Borborygmi
B. Rebound tenderness
C. Tympany
D. Abdominal guarding

Answer 36

B

Question 37

A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first?

A. Document accurate data
B. Develop a plan of care
C. Validate previous data
D. Evaluate outcomes of care

Answer 37

B

Question 38

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include?

A. “Insert the earpieces at a downward angle toward your nose.”
B. “Use the diaphragm to listen to low-pitched sounds.”
C. “Drape the stethoscope over your neck when not in use.”
D. “Clean the stethoscope by immersing it in soapy water.”

Answer 38

A

Question 39

A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client’s breathing. The nurse should identify this observation as which of the following findings?

A. Crackles
B. Stridor
C. Wheezes
D. Friction rub

Answer 39

A

Question 40

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client’s abdomen should the nurse attempt to auscultate active bowel sounds first?

A. Right upper quadrant
B. Left upper quadrant
C. Right lower quadrant
D. Left lower quadrant

Answer 40

C

Question 41

A nurse is assessing a client’s cranial nerves. Which of the following client actions is an indication that cranial nerve I is intact?

A. The client can stick their tongue out.
B. The client can smile symmetrically.
C. The client can hear whispered words.
D. The client can identify a minty scent.

Answer 41

D