Basic Physical Assessment

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  • 1/108 Questions

    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?

    • Infection
    • Dehiscence
    • Hemorrhage
    • Evisceration
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About This Quiz

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.

Basic Physical Assessment - Quiz

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  • 2. 

    A nurse is assessing a client's abdomen. Which examination technique should the nurse use first?

    • Auscultation

    • Inspection

    • Percussion

    • Palpation

    Correct Answer
    A. Inspection
    Explanation
    RATIONALE: Inspection always comes first when performing a physical examination. Inspection is followed by auscultation. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.

    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. 436.

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  • 3. 

    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?

    • Marital status

    • Cultural influences

    • Financial resources

    • Community involvement

    Correct Answer
    A. 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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  • 4. 

    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?

    • Auscultation, percussion, and palpation

    • Palpation, percussion, and auscultation

    • Percussion, palpation, and auscultation

    • 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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  • 5. 

    When examining a client who has abdominal pain, a nurse should assess:

    • Any quadrant first.

    • The symptomatic quadrant first.

    • The symptomatic quadrant last.

    • The symptomatic quadrant either second or third.

    Correct Answer
    A. The symptomatic quadrant last.
    Explanation
    RATIONALE: The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.

    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. 449.

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  • 6. 

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

    • Subjective

    • Objective

    • Secondary source

    • Medical

    Correct Answer
    A. 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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  • 7. 

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

    • Collects data

    • Formulates nursing diagnoses

    • Develops a care plan

    • 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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  • 8. 

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

    • Vital signs

    • Laboratory test results

    • Client's descriptions of pain

    • Electrocardiograms (ECGs)

    Correct Answer
    A. 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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  • 9. 

    A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?

    • Level of consciousness (LOC)

    • Memory

    • Personality changes

    • Intellectual ability

    Correct Answer
    A. Level of consciousness (LOC)
    Explanation
    RATIONALE: Following bronchoscopy, LOC is the most important assessment because changes in the client's LOC may alert the nurse to serious neurologic problems. Memory, personality changes, and intellectual ability are important but don't take precedence at this time.

    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. 581.

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  • 10. 

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

    • Skin turgor

    • Hydration

    • Organs

    • Temperature

    Correct Answer
    A. 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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  • 11. 

    Which component of a client's medical record is the major source of subjective data about the client's health status?

    • Health history

    • Physical findings

    • Laboratory test results

    • Radiologic findings

    Correct Answer
    A. Health history
    Explanation
    RATIONALE: Only the health history provides subjective data. Physical findings, laboratory test results, and radiologic findings are examples of objective data.

    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. 7.

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  • 12. 

    When performing an abdominal assessment, a nurse should follow which examination sequence?

    • Inspection, auscultation, percussion, and palpation

    • Inspection, auscultation, palpation, and percussion

    • Inspection, percussion, palpation, and auscultation

    • Inspection, palpation, percussion, and auscultation

    Correct Answer
    A. Inspection, auscultation, percussion, and palpation
    Explanation
    RATIONALE: The correct sequence for abdominal assessment is inspection, auscultation, percussion, and palpation because this sequence prevents altering bowel sounds by performing palpation before auscultation. The correct sequence for all other assessments is inspection, palpation, percussion, and 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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  • 13. 

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

    • The client can read the entire vision chart at a distance of 40′ (12 m).

    • The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′.

    • The client can read the vision chart from a distance of 20′ with the right eye and from 40′ with the left eye.

    • 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
    A. 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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  • 14. 

    To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site?

    • Radial

    • Apical

    • Carotid

    • Brachial

    Correct Answer
    A. Carotid
    Explanation
    RATIONALE: During CPR, the carotid artery pulse is the most accessible and may persist when the peripheral pulses (radial and brachial) are no longer palpable because of decreases in cardiac output and peripheral perfusion. Chest compressions performed during CPR preclude accurate assessment of the apical pulse.

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

    REFERENCE: ECC Committee, Subcommittees and Task Forces of the American Heart Association. "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 4: Adult Basic Life Support," Circulation 112(24 suppl):IV19-IV34, December 13, 2005.

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  • 15. 

    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

    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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  • 16. 

    After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

    • A respiratory rate of 28 breaths/minute with accessory muscle use

    • Effective breathing at a rate of 16 breaths/minute through the established airway

    • Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds

    • Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds

    Correct Answer
    A. Effective breathing at a rate of 16 breaths/minute through the established airway
    Explanation
    RATIONALE: Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.

    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. 741.

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  • 17. 

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

    • Hyperresonance.

    • Tympany.

    • Resonance.

    • Dullness.

    Correct Answer
    A. 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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  • 18. 

    A nurse plans to obtain client information from a primary source. Which option is a primary information source?

    • A family member

    • The physician

    • The client

    • Previous medical records

    Correct Answer
    A. The client
    Explanation
    RATIONALE: The client is the only primary information source. Family members, the physician, and previous medical records are examples of secondary information sources.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    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. 438.

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  • 19. 

    When palpating a client's body to detect warmth, the nurse should use which part of her hand?

    • Fingertips

    • Finger pads

    • Back (dorsal surface)

    • Ulnar surface

    Correct Answer
    A. Back (dorsal surface)
    Explanation
    RATIONALE: To palpate for warmth, the nurse should use the back, or dorsal surface, of her hand. The fingertips are best for distinguishing texture and shape; the finger pads, for assessing hair texture, grasping tissues, and feeling lymph node enlargement; and the ulnar surface, for feeling thrills and fremitus.

    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. 57.

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  • 20. 

    Which pulse should the nurse palpate during rapid assessment of an unconscious adult?

    • Radial

    • Brachial

    • Femoral

    • Carotid

    Correct Answer
    A. Carotid
    Explanation
    RATIONALE: During a rapid assessment, the nurse's first priority is to check the client's vital functions by assessing his airway, breathing, and circulation. To check circulation, the nurse must assess a client's heart and vascular network function. She does this by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a client's circulation. In a client with a circulatory problem or a history of compromised circulation, the nurse may not be able to palpate the radial pulse. The nurse palpates the brachial pulse during rapid assessment of an infant.

    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. 970.

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  • 21. 

    Which factors are major components of a client's general background history?

    • Allergies and socioeconomic status

    • Urine output and allergies

    • Gastric reflex and the client's age

    • Bowel habits and allergies

    Correct Answer
    A. Allergies and socioeconomic status
    Explanation
    RATIONALE: General background data consist of such components as age, allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    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. 601.

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  • 22. 

    A client complains of abdominal pain. Which question should the nurse ask the client?

    • Are you having pain?

    • Is the pain constant?

    • Is the pain sharp?

    • What does the pain feel like?

    Correct Answer
    A. What does the pain feel like?
    Explanation
    RATIONALE: An open-ended question (one that can't be answered with a simple "yes" or "no") provides more information than a closed-ended question, which limits the client's response. The other options are closed-ended questions.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    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. 491.

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  • 23. 

    When should a nurse check for rebound tenderness in a client who complains of abdominal pain?

    • Near the beginning of the examination

    • Before doing anything else

    • Anytime during the examination

    • At the end of the examination

    Correct Answer
    A. At the end of the examination
    Explanation
    RATIONALE: If a client complains of abdominal pain, the nurse should check for rebound tenderness. Because this maneuver can be painful, the nurse should perform it at the end of the abdominal assessment.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    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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  • 24. 

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

    • 38.9° C

    • 39° C

    • 40.1° C

    • 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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  • 25. 

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

    • Shortening it.

    • Speaking in a loud voice.

    • Addressing the client by his first name.

    • Allowing extra time for the assessment.

    Correct Answer
    A. 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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  • 26. 

    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.

    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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  • 27. 

    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?

    • Check to see that the client had a chest X-ray the previous day as ordered.

    • Check the client's serum electrolyte levels and complete blood count (CBC).

    • Immediately notify the physician of these findings.

    • Sign the preoperative checklist for this client.

    Correct Answer
    A. 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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  • 28. 

    Which statement regarding heart sounds is correct?

    • S1 and S2 sound equally loud over the entire cardiac area.

    • S1 and S2 sound fainter at the apex than at the base.

    • S1 and S2 sound fainter at the base than at the apex.

    • S1 is loudest at the apex, and S2 is loudest at the base.

    Correct Answer
    A. S1 is loudest at the apex, and S2 is loudest at the base.
    Explanation
    RATIONALE: The S1 sound — the "lub" sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2. The S2 — the "dub" sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.

    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. 355.

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  • 29. 

    A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should:

    • Have the client inhale during auscultation.

    • Palpate the radial artery during auscultation.

    • Use the bell of the stethoscope.

    • Use the diaphragm of the stethoscope.

    Correct Answer
    A. Use the bell of the stethoscope.
    Explanation
    RATIONALE: With the client holding his breath, the nurse uses the bell of the stethoscope to auscultate the carotid arteries for bruits. Having the client inhale would interfere with the nurse's ability to detect sound. Palpating the radial artery wouldn't yield significant information and could interfere with the nurse's ability to listen without interruptions or distractions. The nurse uses the diaphragm of the stethoscope to detect high-pitched sounds, such as breath and bowel sounds.

    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. 369.

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  • 30. 

    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?

    • 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.

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

    Correct Answer
    A. 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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  • 31. 

    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.

    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.

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  • 32. 

    A nurse must assess skin turgor in an elderly client. When evaluating skin turgor, the nurse should remember that:

    • Overhydration causes the skin to tent.

    • Dehydration causes the skin to appear edematous and spongy.

    • Inelastic skin turgor is a normal part of aging.

    • Normal skin turgor is moist and boggy.

    Correct Answer
    A. Inelastic skin turgor is a normal part of aging.
    Explanation
    RATIONALE: Inelastic skin turgor is a normal part of aging. Dehydration — not overhydration — causes inelastic skin with tenting. Overhydration — not dehydration — causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm.

    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. 846.

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  • 33. 

    To evaluate a client's cerebellar function, a nurse should ask:

    • Do you have any problems with balance?

    • Do you have any difficulty speaking?

    • Do you have any trouble swallowing food or fluids?

    • Have you noticed any changes in your muscle strength?

    Correct Answer
    A. Do you have any problems with balance?
    Explanation
    RATIONALE: To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help her evaluate the client's motor system.

    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. 2142.

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  • 34. 

    Which description about crackles are true?

    • They're grating sounds.

    • They're high-pitched, musical squeaks.

    • They're low-pitched noises that sound like snoring.

    • They may be fine or coarse.

    Correct Answer
    A. They may be fine or coarse.
    Explanation
    RATIONALE: Crackles result from air moving through airways that contain fluid. Audible during both inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. They're classified as fine or coarse. Pleural friction rubs have a distinctive grating sound. As the name indicates, these breath sounds result when inflamed visceral and parietal pleurae rub together. Wheezes occur on expiration and sometimes on inspiration. Wheezes are continuous, high-pitched, musical squeaks that result when air moves rapidly through airways narrowed by asthma or infection — or when a tumor or foreign body partially obstructs an airway. Gurgles develop when thick secretions partially obstruct airflow through the large upper airways. Loud, coarse, and low-pitched, they sound like snoring.

    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. 317.

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  • 35. 

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

    • Mediastinum

    • Mouth

    • Vertebral canal

    • Reproductive organs

    Correct Answer
    A. 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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  • 36. 

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

    • The bell detects high-pitched sounds best.

    • The diaphragm detects high-pitched sounds best.

    • The bell detects thrills best.

    • The diaphragm detects low-pitched sounds best.

    Correct Answer
    A. 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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  • 37. 

    A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?

    • The client agrees to attend supportive counseling.

    • The client agrees to involve his family in psychotherapy.

    • The client agrees to ongoing participation in one or more support groups.

    • The client agrees to detoxification, rehabilitation, and participation in an aftercare program.

    Correct Answer
    A. The client agrees to detoxification, rehabilitation, and participation in an aftercare program.
    Explanation
    RATIONALE: Detoxification, rehabilitation, and participation in an aftercare program are the only options that address the client's long-term treatment needs. Supportive counseling, family involvement, and support-group participation are important aspects of the treatment process, but they don't address the client's need for long-term treatment.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    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. 2549.

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  • 38. 

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

    • I haven't been able to eat anything solid for the past 2 days.

    • I've never had surgery before.

    • I had an operation 2 years ago, and I don't want to have another one.

    • I've cut my smoking down from two packs to one pack per day.

    Correct Answer
    A. 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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  • 39. 

    A client reports abdominal pain. Which action allows the nurse to investigate this complaint?

    • Using deep palpation

    • Assessing the painful area last

    • Assessing the painful area first

    • Checking for warmth in the painful area

    Correct Answer
    A. Assessing the painful area last
    Explanation
    RATIONALE: Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. The nurse should always let the client know when she will be assessing the painful area. Pressure resulting from deep palpation may cause an underlying mass to rupture. Checking for warmth in the painful area offers no real information about the client's pain.

    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. 449.

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  • 40. 

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

    • A foreign object

    • Saliva or mucus

    • The tongue

    • Edema

    Correct Answer
    A. 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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  • 41. 

    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:

    • The pulse pressure.

    • The pulse deficit.

    • The pulse rhythm.

    • Pulsus regularis.

    Correct Answer
    A. 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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  • 42. 

    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?

    • Pustules

    • Papules

    • Plaque

    • Vesicles

    Correct Answer
    A. 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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  • 43. 

    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?

    • Confusion

    • Pale, warm, dry skin

    • Heart rate of 110 beats/minute

    • 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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  • 44. 

    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?

    • Respect the adolescent's wishes and maintain her confidentiality.

    • Because the adolescent is a minor, inform her parents about her medical history.

    • Discussing the adolescent's medical history with her parents and thoroughly document it in the medical record.

    • 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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  • 45. 

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

    • On the bridge of the client's nose

    • Below the client's eyebrows

    • Below the client's cheekbones

    • Over the client's temporal area

    Correct Answer
    A. 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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  • 46. 

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

    • Coma or seizures.

    • Sunken eyeballs and poor skin turgor.

    • Increased heart rate with hypotension.

    • Thirst or irritability.

    Correct Answer
    A. 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.

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  • 47. 

    Tachycardia can result from:

    • Vagal stimulation.

    • Vomiting, anger, or suctioning.

    • Fear, pain, or anger.

    • Stress, pain, or vomiting.

    Correct Answer
    A. Fear, pain, or anger.
    Explanation
    RATIONALE: Fear, anger, stress, or pain can increase heart rate (tachycardia). Decreases in heart rate (bradycardia) can stem from vomiting, suctioning (causing vagal nerve stimulation), or certain medications.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    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. 566.

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  • 48. 

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

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

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

    • Place a tongue blade on the uvula.

    Correct Answer
    A. 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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  • 49. 

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

    • A rub occurs only during inspiration and clears with coughing.

    Correct Answer
    A. 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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