A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

Place a tongue blade lightly on the posterior aspect of the pharynx.

Place a tongue blade on the front of the tongue and ask the client to say "ah."

Place a tongue blade on the middle of the tongue and ask the client to cough.

Place a tongue blade on the uvula.

A nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?

A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.

A rub occurs only during expiration and produces a light, popping, musical noise.

A rub occurs only during inspiration and the nurse may hear it anywhere.

A rub occurs only during inspiration and clears with coughing.

A nurse is taking a client's blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure?

Inflate the cuff at least another 30 mm Hg after she can't palpate the radial pulse.

Have the client lie down while she takes his blood pressure.

Inflate the cuff to at least 200 mm Hg.

Take blood pressure readings in both of the client's arms.

When palpating the bladder of an adult client, a nurse should identify which finding as normal?

A palpable bladder located 3″ to 5″ (7.5 to 12.7 cm) above the symphysis pubis

When obtaining a client's history, a nurse develops a genogram. What is the purpose of developing a genogram?

To identify genetic and familial health problems

To identify previously undetected diseases and disorders

To identify the client's reason for seeking care

To identify the client's chronic health problems

A nurse conducts a test for Romberg's sign. What is the correct procedure for this test?

Have the client stand with feet together and arms at his sides and try to balance. Have the client first do this with his eyes open and then with his eyes closed.

Instruct the client to walk across the room on his heels and to return walking on his toes.

Ask the client to touch the thumb of one hand to each finger on that hand and then do the same thing using the other hand.

Instruct the client to lie on his back and slowly slide his heel down the shin of the opposite leg, from the knee to the ankle.

A nurse is conducting a physical assessment on an obese 17-year-old who has asked for information about gastric bypass surgery. Which statement best describes informed consent as it applies to this situation?

The nurse should inform the adolescent that, in most states, only parents may give consent for a minor's medical care.

Providing the adolescent with information about the procedure implies informed consent.

The nurse should inform the adolescent that he may sign a consent form for the surgical procedure if a parent cosigns the form.

The nurse may provide the adolescent's legal guardian with information regarding the procedure.

A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

sunken eyeballs and poor skin turgor.

increased heart rate with hypotension.

A nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain more information about the client's rash? Select all that apply.

Are you allergic to any medications, foods, or pollen?

What have you been using to treat the rash?

Have you recently traveled outside the country?

Do you smoke cigarettes or drink alcohol?

A nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?

The diaphragm detects high-pitched sounds best.

The bell detects high-pitched sounds best.

The diaphragm detects low-pitched sounds best.

A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by:

allowing extra time for the assessment.

addressing the client by his first name.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

Assess the client's level of pain and administer prescribed analgesics.

Assess the client's level of anxiety and provide emotional support.

Prepare the client for pulmonary artery catheterization.

Ensure that the client's family is kept informed of his status.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:

left calf circumference 1" (2.5 cm) larger than the right.

pallor and coolness of the left foot.

a decrease in the left pedal pulse.

loss of hair on the lower portion of the left leg.

A mother comes to the clinic with her 5-year-old son who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This rating means they're:

barely visible outside the tonsillar pillar.

midway between the tonsillar pillar and the uvula.

Basic Physical Assessment

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Quizzes Created: 12 | Total Attempts: 15,212

Questions: 108 | Attempts: 1,723 | Updated: Mar 22, 2023

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Physical assessment is an important step in the nursing process it is considered the foundation of the nursing process. With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans, therefore, creating wrong interventions and evaluation. Take the quiz below to see how much you know about basic physical assessment.

Questions and Answers

1.

A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel.The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing.Based on these findings, the nurse suspects injury to which lobe of thebrain?
- A.
  
  Frontal
- B.
  
  Occipital
- C.
  
  Parietal
- D.
  
  Temporal
Correct Answer
D. Temporal

Explanation
RATIONALE: The temporal lobe controls hearing, language comprehension, and storage and recall memory. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The occipital lobe functions primarily in interpreting visual stimuli. The parietal lobe interprets and integrates sensations, including pain, temperature, and touch.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 595.

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2.

A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?
- A.
  
  Pustules
- B.
  
  Papules
- C.
  
  Plaque
- D.
  
  Vesicles
Correct Answer
D. Vesicles

Explanation
RATIONALE: Vesicles are raised, round, serous-filled lesions that are usually less than 1 cm in diameter. Examples of vesicles include chickenpox (varicella) and shingles (herpes zoster). A pustule is a raised, circumscribed lesion that's usually less than 3/8″ in diameter and contains purulent material that gives it a yellow-white color — for example, acne pustule and impetigo. A plaque is a circumscribed, solid, elevated lesion that's more than 3/8″, in diameter — for example, psoriasis. A papule is a firm, inflammatory, raised lesion that's as long as 1/4″ in diameter and that may be pigmented or the same color as the client's skin — for example, acne papule and lichen planus.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 178.

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3.

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?
- A.
  
  Place a tongue blade on the front of the tongue and ask the client to say "ah."
- B.
  
  Place a tongue blade lightly on the posterior aspect of the pharynx.
- C.
  
  Place a tongue blade on the middle of the tongue and ask the client to cough.
- D.
  
  Place a tongue blade on the uvula.
Correct Answer
B. Place a tongue blade lightly on the posterior aspect of the pharynx.

Explanation
RATIONALE: To assess a client's gag reflex, the nurse should gently touch the posterior aspect of the pharynx with a tongue blade, which should elicit gagging. Having the client say "ah" allows the nurse to evaluate cranial nerves IX and X. However, the nurse needn't use a tongue blade to hold down the tongue; the client need only stick out his tongue. Placing a tongue blade on the middle of the tongue and asking the client to cough has no value. Placing a tongue blade on the uvula may traumatize the area and harm the client.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 619.

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4.

A nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?
- A.
  
  A rub occurs only during expiration and produces a light, popping, musical noise.
- B.
  
  A rub occurs only during inspiration and the nurse may hear it anywhere.
- C.
  
  A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.
- D.
  
  A rub occurs only during inspiration and clears with coughing.
Correct Answer
C. A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.

Explanation
RATIONALE: A pleural friction rub, heard in the lateral portion of the lungs during both inspiration and expiration, produces a squeaking or grating sound. Other abnormal sounds may clear with coughing, but pleural friction rubs don't.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 317.

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5.

During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides which type of data?
- A.
  
  Subjective
- B.
  
  Objective
- C.
  
  Secondary source
- D.
  
  Medical
Correct Answer
B. Objective

Explanation
RATIONALE: Physical examination techniques such as auscultation provide objective data, which reflect findings without interpretation. The client and his family report subjective data to the nurse. The family and members of the health care team provide secondary source information. The nurse obtains medical data from the physician and medical record.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 7.

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6.

A nurse is taking a client's blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure?
- A.
  
  Have the client lie down while she takes his blood pressure.
- B.
  
  Inflate the cuff to at least 200 mm Hg.
- C.
  
  Take blood pressure readings in both of the client's arms.
- D.
  
  Inflate the cuff at least another 30 mm Hg after she can't palpate the radial pulse.
Correct Answer
D. Inflate the cuff at least another 30 mm Hg after she can't palpate the radial pulse.

Explanation
RATIONALE: The nurse should wrap an appropriate-size cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can't palpate or auscultate the pulse, then continue inflating until the pressure rises another 30 mm Hg. Having the client lie down, inflating the cuff to at least 200 mg, and taking blood pressure readings in both of the client's arms aren't appropriate measures.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 99.

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7.

When palpating the bladder of an adult client, a nurse should identify which finding as normal?
- A.
  
  A soft, smooth bladder
- B.
  
  A hard, rough bladder
- C.
  
  A nonpalpable bladder
- D.
  
  A palpable bladder located 3″ to 5″ (7.5 to 12.7 cm) above the symphysis pubis
Correct Answer
C. A nonpalpable bladder

Explanation
RATIONALE: An adult's bladder may not be palpable. An adult's bladder that is palpable is usually firm, smooth, and located 1″ to 2″ (2.5 to 5 cm) above the symphysis pubis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 453.

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8.

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?
- A.
  
  Confusion
- B.
  
  Pale, warm, dry skin
- C.
  
  Heart rate of 110 beats/minute
- D.
  
  Urine output of 30 ml/hour
Correct Answer
A. Confusion

Explanation
RATIONALE: Early in shock, inadequate perfusion leads to anaerobic metabolism, which causes metabolic acidosis. As the respiratory rate increases to compensate, the client's carbon dioxide level decreases, causing alkalosis and subsequent confusion and combativeness. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2526.

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9.

A nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity?
- A.
  
  Collects data
- B.
  
  Formulates nursing diagnoses
- C.
  
  Develops a care plan
- D.
  
  Writes client outcomes
Correct Answer
A. Collects data

Explanation
RATIONALE: During the assessment step of the nursing process, the nurse collects relevant data from various sources. She formulates nursing diagnoses during the nursing diagnosis step and develops a care plan and writes appropriate client outcomes during the planning step.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 4.

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10.

A nurse correctly identifies which items as belonging to the dorsal cavity?
- A.
  
  Mediastinum
- B.
  
  Mouth
- C.
  
  Vertebral canal
- D.
  
  Reproductive organs
Correct Answer
C. Vertebral canal

Explanation
RATIONALE: The dorsal cavity consists of the cranial (skull) and vertebral canal (spinal cavity). The mediastinum and reproductive organs are located in the ventral cavity. The mouth is located in the oral cavity.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Rosdahl, C. Textbook of Basic Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 1999, p. 155.

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11.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3–, 24 mEq/L. What do these values indicate?
- A.
  
  Metabolic acidosis
- B.
  
  Metabolic alkalosis
- C.
  
  Respiratory acidosis
- D.
  
  Respiratory alkalosis
Correct Answer
D. Respiratory alkalosis

Explanation
RATIONALE: A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3–) response is delayed, so the client's HCO3– level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3– level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 335.

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12.

When obtaining a client's history, a nurse develops a genogram. What is the purpose of developing a genogram?
- A.
  
  To identify genetic and familial health problems
- B.
  
  To identify previously undetected diseases and disorders
- C.
  
  To identify the client's reason for seeking care
- D.
  
  To identify the client's chronic health problems
Correct Answer
A. To identify genetic and familial health problems

Explanation
RATIONALE: A genogram organizes a family's history into a diagram or flow chart. A nurse uses a genogram to identify genetic and familial health problems. A genogram doesn't identify previously undetected diseases and disorders, the client's reason for seeking care, or chronic health problems.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 40.

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13.

A nurse conducts a test for Romberg's sign. What is the correct procedure for this test?
- A.
  
  Have the client stand with feet together and arms at his sides and try to balance. Have the client first do this with his eyes open and then with his eyes closed.
- B.
  
  Instruct the client to walk across the room on his heels and to return walking on his toes.
- C.
  
  Ask the client to touch the thumb of one hand to each finger on that hand and then do the same thing using the other hand.
- D.
  
  Instruct the client to lie on his back and slowly slide his heel down the shin of the opposite leg, from the knee to the ankle.
Correct Answer
A. Have the client stand with feet together and arms at his sides and try to balance. Have the client first do this with his eyes open and then with his eyes closed.

Explanation
RATIONALE: To test for Romberg's sign, which assesses balance, the nurse instructs the client to stand with feet together and arms at his sides. The nurse observes the client's ability to maintain his balance — first with his eyes open and then with eyes closed. Instructing the client to walk across the room on his heels and to return walking on his toes describes heel-and-toe walking, another test that evaluates balance. Asking the client to touch the thumb of one hand to each finger on that hand describes a test nurses use to evaluate motor function and range of motion. Instructing the client to lie on his back and slowly slide his heel down the shin of the opposite leg describes a test nurses use to assess coordination.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE:Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 264.

Rate this question:
14.

The ear canal of an infant or young child:
- A.
  
  Slants upward.
- B.
  
  Slants downward.
- C.
  
  Is horizontal.
- D.
  
  Slants backward.
Correct Answer
A. Slants upward.

Explanation
RATIONALE: The ear canal slants up in a younger child and down in an older child or adult.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 733.

Rate this question:
15.

A nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?
- A.
  
  38.9° C
- B.
  
  39° C
- C.
  
  40.1° C
- D.
  
  47° C
Correct Answer
A. 38.9° C

Explanation
RATIONALE: To convert Fahrenheit degrees to Centigrade, use this formula:
°C = (°F – 32) ÷ 1.8
°C = (102 – 32) ÷ 1.8
°C = 70 ÷ 1.8
°C = 38.9.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 489.

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16.

A nurse is conducting a physical assessment on an obese 17-year-old who has asked for information about gastric bypass surgery. Which statement best describes informed consent as it applies to this situation?
- A.
  
  Providing the adolescent with information about the procedure implies informed consent.
- B.
  
  The nurse should inform the adolescent that he may sign a consent form for the surgical procedure if a parent cosigns the form.
- C.
  
  The nurse should inform the adolescent that, in most states, only parents may give consent for a minor's medical care.
- D.
  
  The nurse may provide the adolescent's legal guardian with information regarding the procedure.
Correct Answer
C. The nurse should inform the adolescent that, in most states, only parents may give consent for a minor's medical care.

Explanation
RATIONALE: Nurses may provide information to adolescents about medical decisions, but a parent must consent to medical care of an adolescent who hasn't reached adulthood or isn't an emancipated minor. Providing the adolescent with information isn't synonymous with obtaining informed consent. Providing the adolescent's parent or legal guardian with information about the procedure without the adolescent's permission violates the adolescent's right of confidentiality.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1108.

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17.

A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
- A.
  
  Coma or seizures.
- B.
  
  Sunken eyeballs and poor skin turgor.
- C.
  
  Increased heart rate with hypotension.
- D.
  
  Thirst or irritability.
Correct Answer
D. Thirst or irritability.

Explanation
RATIONALE: Early signs and symptoms of dehydration include thirst, irritability, dry mucous membranes, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2503.

Rate this question:
18.

A nurse is palpating a client's pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing?
- A.
  
  Brachial
- B.
  
  Femoral
- C.
  
  Posterior tibial
- D.
  
  Dorsalis pedis
Correct Answer
C. Posterior tibial

Explanation
RATIONALE: To evaluate the posterior tibial pulse, the nurse palpates the inner aspect of the ankle, below the medial malleolus. The nurse palpates medially in the antecubital space to evaluate the brachial pulse; midway between the superior iliac spine and symphysis pubis to assess the femoral pulse; and along the top of the foot, over the instep, to evaluate the dorsalis pedis pulse.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 411.

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19.

A nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain more information about the client's rash? Select all that apply.
- A.
  
  When did the rash start?
- B.
  
  Are you allergic to any medications, foods, or pollen?
- C.
  
  How old are you?
- D.
  
  What have you been using to treat the rash?
- E.
  
  Have you recently traveled outside the country?
- F.
  
  Do you smoke cigarettes or drink alcohol?
Correct Answer(s)
A. When did the rash start?
B. Are you allergic to any medications, foods, or pollen?
D. What have you been using to treat the rash?
E. Have you recently traveled outside the country?

Explanation
RATIONALE: When assessing a client who has a rash, the nurse should first find out when the rash began; this information can identify where the rash is in the disease process and assists with the correct diagnosis. The nurse should also ask about allergies because rashes related to allergies can occur when a person changes medications, eats new foods, or comes into contact with agents in the air, such as pollen. The nurse needs to find out how the client has been treating the rash because treating the rash with topical ointments or taking oral medications may make the rash worse. The nurse should ask about recent travel because travel outside the country exposes the client to foreign foods and environments, which can contribute to the onset of a rash. Although the client's age and smoking and drinking habits can be important to know, this information won't provide further insight to the rash or its cause.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1934.

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20.

A nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?
- A.
  
  The bell detects high-pitched sounds best.
- B.
  
  The diaphragm detects high-pitched sounds best.
- C.
  
  The bell detects thrills best.
- D.
  
  The diaphragm detects low-pitched sounds best.
Correct Answer
B. The diaphragm detects high-pitched sounds best.

Explanation
RATIONALE: The diaphragm of a stethoscope detects high-pitched sounds best; the bell detects low-pitched sounds best. Palpation detects thrills best.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 60.

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21.

A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by:
- A.
  
  Shortening it.
- B.
  
  Speaking in a loud voice.
- C.
  
  Addressing the client by his first name.
- D.
  
  Allowing extra time for the assessment.
Correct Answer
D. Allowing extra time for the assessment.

Explanation
RATIONALE: When assessing an elderly client, the nurse should allow extra time to compensate for aging-related physiologic changes, address the client respectfully rather than by his first name, and give simple instructions. Speaking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 818.

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22.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?
- A.
  
  Assess the client's level of pain and administer prescribed analgesics.
- B.
  
  Assess the client's level of anxiety and provide emotional support.
- C.
  
  Prepare the client for pulmonary artery catheterization.
- D.
  
  Ensure that the client's family is kept informed of his status.
Correct Answer
A. Assess the client's level of pain and administer prescribed analgesics.

Explanation
RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and his family should be kept informed at every step of the recovery process, this action isn't the priority when treating a client with a suspected MI.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 876.

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23.

A nurse is teaching a client who will soon be discharged how to change a sterile dressing on his right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?
- A.
  
  Infection
- B.
  
  Dehiscence
- C.
  
  Hemorrhage
- D.
  
  Evisceration
Correct Answer
A. Infection

Explanation
RATIONALE: Infection produces such signs as redness, swelling, induration, warmth, and possibly drainage. Dehiscence may cause unexplained fever and tachycardia, unusual wound pain, prolonged paralytic ileus, and separation of the surgical incision. Hemorrhage can result in increased pulse and respiratory rate, decreased blood pressure, restlessness, thirst, and cold, clammy skin. Evisceration produces visible organ protrusion, usually through an incision.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1057.

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24.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:
- A.
  
  Pallor and coolness of the left foot.
- B.
  
  A decrease in the left pedal pulse.
- C.
  
  Loss of hair on the lower portion of the left leg.
- D.
  
  Left calf circumference 1" (2.5 cm) larger than the right.
Correct Answer
D. Left calf circumference 1" (2.5 cm) larger than the right.

Explanation
RATIONALE: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 10th ed., Philadelphia: Lippincott Williams & Wilkins, 2004, p. 1005.

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25.

A mother comes to the clinic with her 5-year-old son who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This rating means they're:
- A.
  
  Barely visible outside the tonsillar pillar.
- B.
  
  Midway between the tonsillar pillar and the uvula.
- C.
  
  Touching the uvula.
- D.
  
  Touching each other.
Correct Answer
C. Touching the uvula.

Explanation
RATIONALE: Tonsils that touch the uvula are rated 3+. Tonsils barely visible outside the tonsillar pillar are rated 1+. Tonsils between the tonsillar pillar and the uvula are rated 2+. Tonsils that touch each other are rated 4+.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 785.

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26.

When a nurse enters a client's room, the client complains that she's spitting up blood when she coughs. The nurse takes a quick health history that includes:
- A.
  
  The history of the present problem, medications, review of systems, and recent major operations.
- B.
  
  The history of the present problem, allergies, medications, and recent major operations.
- C.
  
  The history of the present problem, medications, family history, psychosocial history, and review of systems.
- D.
  
  The history of the present problem, allergies, medications, review of systems, and recent major operations.
Correct Answer
B. The history of the present problem, allergies, medications, and recent major operations.

Explanation
RATIONALE: After assessing the client's chief complaint, the nurse should review the client's pertinent medical history; a description of any allergies or allergic reactions; any illness requiring treatment; major surgeries performed, including why and when; and current medications (both prescription and over-the-counter) and their purposes. This information allows the nurse to establish a baseline and determine the cause and urgency of the client's problem.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 252.

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27.

A nurse is conducting a physical assessment on an adolescent who doesn't want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse can implement in this situation?
- A.
  
  Respect the adolescent's wishes and maintain her confidentiality.
- B.
  
  Because the adolescent is a minor, inform her parents about her medical history.
- C.
  
  Discussing the adolescent's medical history with her parents and thoroughly document it in the medical record.
- D.
  
  Before agreeing to maintain confidentiality, determine whether the adolescent is an emancipated minor.
Correct Answer
A. Respect the adolescent's wishes and maintain her confidentiality.

Explanation
RATIONALE: The nurse should respect the rights of minors who don't want parents informed of medical problems; she shouldn't tell parents about an adolescent's past procedures. Many states have laws that emancipate minors for health care visits involving pregnancy, abortion, or sexually transmitted diseases.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 129.

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28.

When testing a client's pupils for accommodation, a nurse should interpret which findings as normal?
- A.
  
  Constriction and divergence
- B.
  
  Dilation and convergence
- C.
  
  Constriction and convergence
- D.
  
  Dilation and divergence
Correct Answer
C. Constriction and convergence

Explanation
RATIONALE: During accommodation, the pupils should constrict and converge equally on an object. Pupils normally dilate in darkness and when a person stares at an object across a room. Divergence is never a normal response.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 231.

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29.

At 8 a.m., a nurse assesses a client who's scheduled for surgery at 10 a.m. During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?
- A.
  
  Check to see that the client had a chest X-ray the previous day as ordered.
- B.
  
  Check the client's serum electrolyte levels and complete blood count (CBC).
- C.
  
  Immediately notify the physician of these findings.
- D.
  
  Sign the preoperative checklist for this client.
Correct Answer
C. Immediately notify the physician of these findings.

Explanation
RATIONALE: The nurse should notify the physician immediately because dyspnea, a nonproductive cough, and back pain may signal a change in the client's respiratory status. The nurse should then check the results of any ordered tests (such as a chest X-ray, serum electrolyte levels, and CBC) because this information may help explain the change in the client's condition. The nurse should sign the preoperative checklist after notifying the physician of the client's condition and learning whether the physician will proceed with the scheduled surgery.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 648.

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30.

A client is admitted to the hospital with pneumonia. He has a history of Parkinson's disease, which his family says is worsening. Which assessment should the nurse expect?
- A.
  
  Impaired speech
- B.
  
  Muscle flaccidity
- C.
  
  Pleasant and smiling demeanor
- D.
  
  Tremors in the fingers that increase with purposeful movement
Correct Answer
A. Impaired speech

Explanation
RATIONALE: In Parkinson's disease, dysarthria, or impaired speech, results from a disturbance in muscle control. Muscle rigidity, not flaccidity, causes resistance to passive muscle stretching. The client may exhibit a masklike appearance rather than a pleasant and smiling demeanor. Tremors should decrease, not increase, with purposeful movement and sleep.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2313.

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31.

A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle?
- A.
  
  Intradermal injection is less painful.
- B.
  
  Intradermal drugs are easier to administer.
- C.
  
  Intradermal drugs diffuse more rapidly.
- D.
  
  Intradermal drugs diffuse more slowly.
Correct Answer
D. Intradermal drugs diffuse more slowly.

Explanation
RATIONALE: Drugs administered intradermally (injected between the skin layers just below the surface stratum corneum) diffuse slowly into the local microcapillary system. Slow diffusion is necessary during diagnostic allergy testing because rapidly introducing an allergen could cause a life-threatening allergic reaction in a sensitive client. The ease of administration and client comfort aren't principles taken into account when using intradermal injections for allergy testing.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 795.

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32.

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?
- A.
  
  Lower back pain
- B.
  
  Burning sensation on urination
- C.
  
  Frequency of urination
- D.
  
  Fever and change in urine clarity
Correct Answer
D. Fever and change in urine clarity

Explanation
RATIONALE: Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2263.

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33.

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?
- A.
  
  Macule
- B.
  
  Papule
- C.
  
  Vesicle
- D.
  
  Pustule
Correct Answer
C. Vesicle

Explanation
RATIONALE: A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 178.

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34.

A nurse prepares to palpate a client's maxillary sinuses. For this procedure, where should the nurse place her hands?
- A.
  
  On the bridge of the client's nose
- B.
  
  Below the client's eyebrows
- C.
  
  Below the client's cheekbones
- D.
  
  Over the client's temporal area
Correct Answer
C. Below the client's cheekbones

Explanation
RATIONALE: To palpate the maxillary sinuses, the nurse should place her hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places her thumb just above the client's eye, under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 288.

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35.

A nurse can auscultate for heart sounds more easily if the client is:
- A.
  
  Supine.
- B.
  
  On his right side.
- C.
  
  Holding his breath.
- D.
  
  Leaning forward.
Correct Answer
D. Leaning forward.

Explanation
RATIONALE: The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This position enables the nurse to listen for heart sounds without the sound of expiration interfering. Using the supine position to visually inspect the precordium allows the nurse to observe the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole. Placing the client in a left lateral decubitus position may make it easier for the nurse to hear low-pitched sounds related to atrioventricular valve problems.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Bickley, L. Bates' Guide to Physical Examination and History Taking, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 315.

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36.

A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's slightly concave. Additional assessment should proceed in which order?
- A.
  
  Auscultation, percussion, and palpation
- B.
  
  Palpation, percussion, and auscultation
- C.
  
  Percussion, palpation, and auscultation
- D.
  
  Palpation, auscultation, and percussion
Correct Answer
A. Auscultation, percussion, and palpation

Explanation
RATIONALE: The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the nurse should perform the less-intrusive techniques before the more-intrusive techniques. Percussion and palpation can alter natural findings during auscultation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 436.

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37.

A nurse is performing a preoperative assessment. Which client statement should alert her to the presence of risk factors for postoperative complications?
- A.
  
  I haven't been able to eat anything solid for the past 2 days.
- B.
  
  I've never had surgery before.
- C.
  
  I had an operation 2 years ago, and I don't want to have another one.
- D.
  
  I've cut my smoking down from two packs to one pack per day.
Correct Answer
D. I've cut my smoking down from two packs to one pack per day.

Explanation
RATIONALE: Smoking one pack of cigarettes per day reduces the activity of the cilia lining the respiratory tract, increasing the client's risk of ineffective airway clearance after surgery. Lack of solid foods for 2 days before surgery, no history of previous surgery, or anxiety about surgery wouldn't increase the risk of postoperative complications.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 827.

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38.

A nurse is obtaining the health history of a client whose background differs from her own. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor?
- A.
  
  Marital status
- B.
  
  Cultural influences
- C.
  
  Financial resources
- D.
  
  Community involvement
Correct Answer
B. Cultural influences

Explanation
RATIONALE: Assessing the client's cultural influences helps the nurse identify behaviors she should take into account when planning his care. Although the nurse also must consider the client's marital status, financial resources, and community involvement when planning care and rehabilitation, these factors have little relevance when she is formulating culturally acceptable strategies for nursing care.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 18.

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39.

To evaluate a client's reason for seeking care, a nurse performs deep palpation. What is the nurse assessing?
- A.
  
  Skin turgor
- B.
  
  Hydration
- C.
  
  Organs
- D.
  
  Temperature
Correct Answer
C. Organs

Explanation
RATIONALE: The purpose of deep palpation, in which the nurse indents the client's skin approximately 1½" (3.8 cm), is to assess underlying organs and structures, such as the kidneys and spleen. The nurse can assess skin turgor, hydration, and temperature by using light touch or light palpation.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 449.

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40.

A 10-year-old child with rheumatic fever must have his heart rate measured while he's awake and while he's sleeping. Why are two readings necessary?
- A.
  
  To obtain a heart rate that isn't affected by medication
- B.
  
  To eliminate interference from the jerky movements of chorea
- C.
  
  To ensure that the child can't consciously raise or lower his heart rate
- D.
  
  To compensate for activity's effects on the child's heart rate
Correct Answer
D. To compensate for activity's effects on the child's heart rate

Explanation
RATIONALE: Tachycardia may be a sign of heart failure. The nurse can detect mild tachycardia more easily when the child is asleep than when he's awake because activity can increase his heart rate. Medications given for rheumatic fever and rheumatic heart disease, such as digoxin (Lanoxin), exert their influence both day and night. Chorea, a symptom of rheumatic fever, is the loss of voluntary muscle control. It doesn't affect pulse because the child would be sitting quietly while the nurse measured his heart rate and wouldn't be involved in purposeful movement. A 10-year-old child probably doesn't know how to consciously raise or lower his heart rate.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Hatfield, N. Broadribb's Introductory Pediatric Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 380.

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41.

A nurse is caring for a client with herpes zoster. Place the pathophysiologic changes associated with the client's disorder in the proper sequence.1. Fever, malaise, and red nodules develop.2. Pain, itching, and paresthesia develop3. Vesicles crust and scab.4. Residual antibodies mobilize but are effective.5. Vesicles with clear fluid or pus appear.6. Varicella-zoster virus is reactivated.

Correct Answer
641253

Explanation
RATIONALE: Herpes zoster is an acute inflammation caused by the herpesvirus varicella-zoster (chickenpox) virus. It develops when the varicella-zoster virus is reactivated. Residual antibodies to the initial infection attempt to mobilize, but they're ineffective. Fever, malaise, and red nodules develop in the dermatomes. The virus then multiplies in the ganglia, causing deep pain, itching, and paresthesia or hyperesthesia. Vesicles with clear fluid or pus appear. Vesicles ultimately crust and scab and no longer shed the virus.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1958.

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4
42.

When percussing a client's chest, the nurse should expect to hear:
- A.
  
  Hyperresonance.
- B.
  
  Tympany.
- C.
  
  Resonance.
- D.
  
  Dullness.
Correct Answer
C. Resonance.

Explanation
RATIONALE: Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in a client with emphysema. When percussing over the abdomen, the nurse may assess tympany, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 313.

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43.

What is a common source of airway obstruction in an unconscious client?
- A.
  
  A foreign object
- B.
  
  Saliva or mucus
- C.
  
  The tongue
- D.
  
  Edema
Correct Answer
C. The tongue

Explanation
RATIONALE: In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 10th ed., Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2522.

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44.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control?
- A.
  
  The client exhibits signs of adequate GI perfusion.
- B.
  
  The client expresses positive feelings about himself.
- C.
  
  The client verbalizes a manageable level of discomfort.
- D.
  
  The client maintains skin integrity.
Correct Answer
A. The client exhibits signs of adequate GI perfusion.

Explanation
RATIONALE: Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1247.

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45.

A nurse is assessing a postoperative client. Which information should the nurse document as subjective data?
- A.
  
  Vital signs
- B.
  
  Laboratory test results
- C.
  
  Client's descriptions of pain
- D.
  
  Electrocardiograms (ECGs)
Correct Answer
C. Client's descriptions of pain

Explanation
RATIONALE: Subjective data come directly from the client and are usually recorded as direct quotations that reflect his opinions or feelings about a situation. Vital signs, laboratory test results, and ECGs are examples of objective data.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 7.

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46.

A nurse measures a client's apical pulse rate and compares it with his radial pulse rate. The differential between these two pulses is called:
- A.
  
  The pulse pressure.
- B.
  
  The pulse deficit.
- C.
  
  The pulse rhythm.
- D.
  
  Pulsus regularis.
Correct Answer
B. The pulse deficit.

Explanation
RATIONALE: The differential between the apical and radial pulse rates is the pulse deficit. Pulse pressure refers to the differential between systolic and diastolic blood pressures. Pulse rhythm is the interval pattern between heartbeats. Pulsus regularis is the normal pulse pattern, in which the interval between beats is consistent.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 498.

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47.

A nurse determines that a client has 20/40 vision. Which statement about this client's vision is true?
- A.
  
  The client can read the entire vision chart at a distance of 40′ (12 m).
- B.
  
  The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′.
- C.
  
  The client can read the vision chart from a distance of 20′ with the right eye and from 40′ with the left eye.
- D.
  
  The client can read at a distance of 30′ (9 m) what a person with normal vision can read at a distance of 40′.
Correct Answer
B. The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′.

Explanation
RATIONALE: The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance a person with normal vision can read the chart.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 223.

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48.

A nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal?
- A.
  
  Dullness over the liver
- B.
  
  Bowel sounds occurring every 10 seconds
- C.
  
  Shifting dullness over the abdomen
- D.
  
  Vascular sound over the renal arteries
Correct Answer
C. Shifting dullness over the abdomen

Explanation
RATIONALE: Shifting dullness over the abdomen indicates ascites, an abnormal finding. Dullness over the liver, bowel sounds occurring every 10 seconds, and vasular sounds over the renal arteries are normal abdominal findings.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 453.

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49.

To help assess a client's cerebral function, a nurse should ask:
- A.
  
  Have you noticed a change in your memory?
- B.
  
  Have you noticed a change in your muscle strength?
- C.
  
  Have you had any problems with coordination?
- D.
  
  Have you had any problems with your eyes?
Correct Answer
A. Have you noticed a change in your memory?

Explanation
RATIONALE: To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status. Questions about muscle strength help evaluate the client's motor system. Questions about coordination help her assess cerebellar function. Questions about eyesight help the nurse evaluate the cranial nerves associated with vision.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2145.

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50.

Which assessment finding indicates an increased risk of skin cancer?
- A.
  
  A deep sunburn
- B.
  
  A dark mole on the client's back
- C.
  
  An irregular scar on the client's abdomen
- D.
  
  White irregular patches on the client's arm
Correct Answer
A. A deep sunburn

Explanation
RATIONALE: A deep sunburn is a risk factor for skin cancer. A dark mole or an irregular scar is a benign finding. White irregular patches are abnormal but aren't a risk for skin cancer.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1978.

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Basic Physical Assessment

A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

A nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?

During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides which type of data?

A nurse is taking a client's blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure?

When palpating the bladder of an adult client, a nurse should identify which finding as normal?

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?

A nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity?

A nurse correctly identifies which items as belonging to the dorsal cavity?

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3–, 24 mEq/L. What do these values indicate?

When obtaining a client's history, a nurse develops a genogram. What is the purpose of developing a genogram?

A nurse conducts a test for Romberg's sign. What is the correct procedure for this test?

The ear canal of an infant or young child:

A nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?

A nurse is conducting a physical assessment on an obese 17-year-old who has asked for information about gastric bypass surgery. Which statement best describes informed consent as it applies to this situation?

A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

A nurse is palpating a client's pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing?

A nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain more information about the client's rash? Select all that apply.

A nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?

A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by:

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

A nurse is teaching a client who will soon be discharged how to change a sterile dressing on his right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:

A mother comes to the clinic with her 5-year-old son who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This rating means they're:

When a nurse enters a client's room, the client complains that she's spitting up blood when she coughs. The nurse takes a quick health history that includes:

A nurse is conducting a physical assessment on an adolescent who doesn't want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse can implement in this situation?

When testing a client's pupils for accommodation, a nurse should interpret which findings as normal?

At 8 a.m., a nurse assesses a client who's scheduled for surgery at 10 a.m. During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?

A client is admitted to the hospital with pneumonia. He has a history of Parkinson's disease, which his family says is worsening. Which assessment should the nurse expect?

A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle?

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?

A nurse prepares to palpate a client's maxillary sinuses. For this procedure, where should the nurse place her hands?

A nurse can auscultate for heart sounds more easily if the client is:

A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's slightly concave. Additional assessment should proceed in which order?

A nurse is performing a preoperative assessment. Which client statement should alert her to the presence of risk factors for postoperative complications?

A nurse is obtaining the health history of a client whose background differs from her own. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor?

To evaluate a client's reason for seeking care, a nurse performs deep palpation. What is the nurse assessing?

A 10-year-old child with rheumatic fever must have his heart rate measured while he's awake and while he's sleeping. Why are two readings necessary?

When percussing a client's chest, the nurse should expect to hear:

What is a common source of airway obstruction in an unconscious client?

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control?

A nurse is assessing a postoperative client. Which information should the nurse document as subjective data?

A nurse measures a client's apical pulse rate and compares it with his radial pulse rate. The differential between these two pulses is called:

A nurse determines that a client has 20/40 vision. Which statement about this client's vision is true?

A nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal?

To help assess a client's cerebral function, a nurse should ask:

Which assessment finding indicates an increased risk of skin cancer?