Basic Physical Assessment

1. 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

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.

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.

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

Auscultation

Inspection

Percussion

Palpation

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.

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.

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

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.

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.

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

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.

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.

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.

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.

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.

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

Subjective

Objective

Secondary source

Medical

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.

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.

7. 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)

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.

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.

8. 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

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.

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.

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

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.

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.

10. 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

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.

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.

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

Skin turgor

Hydration

Organs

Temperature

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.

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.

12. 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

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.

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.

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).

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.

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.

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

Radial

Apical

Carotid

Brachial

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.

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.

15. 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

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.

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.

16. 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

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.

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.

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

Hyperresonance.

Tympany.

Resonance.

Dullness.

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.

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.

18. 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

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.

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.

19. 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

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.

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.

20. 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

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.

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.

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

Radial

Brachial

Femoral

Carotid

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.

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.

22. 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

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.

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.

23. 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?

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

27. 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.

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.

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.

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.

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.

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.

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?

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.

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.

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.

30. 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.

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.

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.

31. 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.

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.

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.

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

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

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.

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.

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?

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.

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.

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.

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.

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.

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

Mediastinum

Mouth

Vertebral canal

Reproductive organs

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.

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.

36. 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.

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.

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.

37. 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.

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.

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.

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.

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.

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.

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

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.

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.

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

A foreign object

Saliva or mucus

The tongue

Edema

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.

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.

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.

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.

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.

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

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.

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.

43. 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

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.

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.

44. 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

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.

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.

45. 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.

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.

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.

46. Tachycardia can result from:

Vagal stimulation.

Vomiting, anger, or suctioning.

Fear, pain, or anger.

Stress, pain, or vomiting.

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.

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.

47. 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.

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.

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.

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.

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.

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.

49. During the physical examination, a nurse uses various techniques to assess structures, organs, and body systems. Which technique allows the nurse to feel for vibration and locate body structures?

Auscultation

Inspection

Palpation

Percussion

RATIONALE: During palpation, a nurse touches a client's body to feel for vibrations and pulsations, to locate body structures, and to assess such characteristics as size, texture, temperature, tenderness, and mobility. During auscultation, the nurse uses a stethoscope to listen for sounds. During inspection, the nurse uses her critical observation skills. During percussion, she taps the client's body sharply with her fingers or hands to elicit sounds.

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. 57.

Explanation

RATIONALE: During palpation, a nurse touches a client's body to feel for vibrations and pulsations, to locate body structures, and to assess such characteristics as size, texture, temperature, tenderness, and mobility. During auscultation, the nurse uses a stethoscope to listen for sounds. During inspection, the nurse uses her critical observation skills. During percussion, she taps the client's body sharply with her fingers or hands to elicit sounds.

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. 57.

50. A nurse prepares to perform an otoscopic examination on an adult. For proper visualization, the nurse should position the client's ear by pulling the:

Lobule down and forward.

Auricle up and back.

Auricle up and forward.

Lobule down and back.

RATIONALE: To perform an otoscopic examination on an adult, the nurse grasps the auricle of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the auricle and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization.

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. 259.

Explanation

RATIONALE: To perform an otoscopic examination on an adult, the nurse grasps the auricle of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the auricle and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization.

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. 259.

51. 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.

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.

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.

52. A nurse is conducting a physical assessment on a 17-year-old female. The adolescent's mother asks to see her chart in order to confirm her suspicions that her daughter is sexually active. Which statement best describes how the nurse should protect the adolescent's rights in this situation?

Inform the adolescent's mother that she must discuss the matter with the physician.

Allow the adolescent's mother access to the chart based on the Family Educational Rights and Privacy Act (FERPA).

Talk with the mother about the concept of protected health information under the Health Insurance Portability and Accountability Act (HIPAA).

Determine whether the adolescent is an emancipated minor before releasing information.

RATIONALE: The Center for Adolescent Health Policy and the Law has determined that it's appropriate for a minor to exercise privacy rights under the HIPAA regulation, whether or not the minor is emancipated. Therefore, it isn't appropriate for the nurse to show the adolescent's chart to the mother without the adolescent's permission. The physician is held to the same constraints as the nurse, so telling the mother to speak with the physician is inappropriate. FERPA is a federal law that protects the privacy of student education records, not health records. Parents have the right to review these records and have some control over disclosure of the information contained in them.

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.

Explanation

RATIONALE: The Center for Adolescent Health Policy and the Law has determined that it's appropriate for a minor to exercise privacy rights under the HIPAA regulation, whether or not the minor is emancipated. Therefore, it isn't appropriate for the nurse to show the adolescent's chart to the mother without the adolescent's permission. The physician is held to the same constraints as the nurse, so telling the mother to speak with the physician is inappropriate. FERPA is a federal law that protects the privacy of student education records, not health records. Parents have the right to review these records and have some control over disclosure of the information contained in them.

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.

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

Constriction and divergence

Dilation and convergence

Constriction and convergence

Dilation and divergence

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.

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.

54. A nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?

Prolonged half-life

Poor absorption

Potential for drug dependence

Potential for hepatotoxicity

RATIONALE: Clients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and don't cause hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic damage does require cautious use of these drugs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Abrams, A.C., et al. Clinical Drug Therapy: Rationales for Nursing Practice, 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 241.

Explanation

RATIONALE: Clients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and don't cause hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic damage does require cautious use of these drugs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Abrams, A.C., et al. Clinical Drug Therapy: Rationales for Nursing Practice, 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 241.

55. A nurse is assessing a client using light palpation. How does a nurse perform light palpation?

By indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm)

By indenting the client's skin 1″ to 2″ (2.5 to 5 cm)

By indenting the client's skin 1″, using both hands

By indenting the client's skin 1″ and then releasing the pressure quickly

RATIONALE: To perform light palpation, the nurse indents the client's skin ½″ to ¾″, using the tips and pads of her fingers. She indents the skin approximately 1½″ (3.8 cm) when performing deep palpation. She indents the skin 1″ and then releases the pressure quickly when eliciting rebound tenderness.

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. 448.

Explanation

RATIONALE: To perform light palpation, the nurse indents the client's skin ½″ to ¾″, using the tips and pads of her fingers. She indents the skin approximately 1½″ (3.8 cm) when performing deep palpation. She indents the skin 1″ and then releases the pressure quickly when eliciting rebound tenderness.

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. 448.

56. A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?

The stoma should appear dark and have a bluish hue.

At first, the stoma may bleed slightly when touched.

The stoma should remain swollen distal to the abdomen.

A burning sensation under the stoma faceplate is normal.

RATIONALE: The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

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. 1256.

Explanation

RATIONALE: The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

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. 1256.

57. A nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test?

Whispered voice test

Weber's test

Watch tick test

Rinne test

RATIONALE: The Rinne test compares air conduction to bone conduction in both ears. The whispered voice test evaluates low-pitched sounds, and the watch tick test assesses high-pitched sounds. Both tests assess gross hearing. Weber's test evaluates bone conduction.

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. 264.

Explanation

RATIONALE: The Rinne test compares air conduction to bone conduction in both ears. The whispered voice test evaluates low-pitched sounds, and the watch tick test assesses high-pitched sounds. Both tests assess gross hearing. Weber's test evaluates bone conduction.

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. 264.

58. 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?

The client exhibits signs of adequate GI perfusion.

The client expresses positive feelings about himself.

The client verbalizes a manageable level of discomfort.

The client maintains skin integrity.

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.

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.

59. Which client best fits into the middle-old elderly population?

A 68-year old with coronary artery disease

A 76-year old with hypertension

An 80-year old with end-stage renal disease

An 88-year old with osteoarthritis

RATIONALE: A 76-year-old client with hypertension belongs to the middle-old elderly population. The young-old elderly population ranges in age from 65 to 74; the middle-old from 75 to 84; and the old-old from 85 and older. Within each of these three subgroups is the frail elderly. This group includes all individuals older than age 65 who have one or more debilitating conditions, such as end-stage renal disease. Hypertension isn't considered a debilitating condition.

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

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

Explanation

RATIONALE: A 76-year-old client with hypertension belongs to the middle-old elderly population. The young-old elderly population ranges in age from 65 to 74; the middle-old from 75 to 84; and the old-old from 85 and older. Within each of these three subgroups is the frail elderly. This group includes all individuals older than age 65 who have one or more debilitating conditions, such as end-stage renal disease. Hypertension isn't considered a debilitating condition.

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

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

60. A nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release

Using light palpation, noting any tenderness over an area

Using deep ballottement, noting any tenderness over an area

Pressing firmly with one hand, releasing pressure while maintaining fingertip contact with the skin, and noting tenderness on release

RATIONALE: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. She doesn't use light palpation or deep ballottment or maintain fingertip contact with skin to elicit rebound tenderness.

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. 455.

Explanation

RATIONALE: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. She doesn't use light palpation or deep ballottment or maintain fingertip contact with skin to elicit rebound tenderness.

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. 455.

61. Which plane divides the body longitudinally into anterior and posterior regions?

Frontal plane

Sagittal plane

Midsagittal plane

Transverse plane

RATIONALE: A frontal or coronal plane, which runs longitudinally at a right angle to a sagittal plane, divides the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.

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. 152.

Explanation

RATIONALE: A frontal or coronal plane, which runs longitudinally at a right angle to a sagittal plane, divides the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.

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. 152.

62. 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?

To obtain a heart rate that isn't affected by medication

To eliminate interference from the jerky movements of chorea

To ensure that the child can't consciously raise or lower his heart rate

To compensate for activity's effects on the child's heart rate

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.

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.

63. 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.

Touching the uvula.

Touching each other.

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.

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.

64. 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?

Macule

Papule

Vesicle

Pustule

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.

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.

65. A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:

Progressively deeper breaths followed by shallower breaths with apneic periods.

Rapid, deep breaths with abrupt pauses between each breath.

Rapid, deep breaths and irregular breathing without pauses.

Shallow breaths with an increased respiratory rate.

RATIONALE: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

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

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 319.

Explanation

RATIONALE: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

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

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 319.

66. A nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal aging-related change is:

Cloudy vision.

Incontinence.

Diminished reflexes.

Tremors.

RATIONALE: Degenerative changes can lead to decreased reflexes, which are a normal result of aging. Cloudy vision, incontinence, and tremors may be signs and symptoms of underlying pathology.

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. 627.

Explanation

RATIONALE: Degenerative changes can lead to decreased reflexes, which are a normal result of aging. Cloudy vision, incontinence, and tremors may be signs and symptoms of underlying pathology.

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. 627.

67. When performing a pediatric assessment, why should a nurse inspect first and then auscultate?

Because the nurse's touch may calm the child

Because the child may cry as the assessment proceeds, making auscultation difficult

Because the nurse's touch may frighten the child

Because the nurse's hand or stethoscope may feel cold, making the child recoil

RATIONALE: Because other assessment procedures may make the child cry, the nurse should auscultate the child's lungs right after inspection. Crying increases the respiratory rate and creates noise that interferes with clear auscultation.

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. 771.

Explanation

RATIONALE: Because other assessment procedures may make the child cry, the nurse should auscultate the child's lungs right after inspection. Crying increases the respiratory rate and creates noise that interferes with clear auscultation.

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. 771.

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

Dullness over the liver

Bowel sounds occurring every 10 seconds

Shifting dullness over the abdomen

Vascular sound over the renal arteries

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.

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.

69. A nurse must assess a client's splinted extremity for neurovascular damage. What should she do?

Assess the client's extremities, ensuring that the extremity with the splint feels cooler than the unsplinted extremities

Move the client's fingers or toes to test movement

Evaluate each extremity's capillary refill, making sure it's the same bilaterally

Be aware that edema and pulse checks aren't part of the neurovascular assessment

RATIONALE: During the complete neurovascular assessment, the nurse should compare the client's extremities, for example, compare the capillary refill of each extremity, which should be the same bilaterally. Extremities should be equally warm. The nurse should assess movement by having the client move his own fingers and toes. Edema and pulse checks are part of a neurovascular assessment.

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

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 404.

Explanation

RATIONALE: During the complete neurovascular assessment, the nurse should compare the client's extremities, for example, compare the capillary refill of each extremity, which should be the same bilaterally. Extremities should be equally warm. The nurse should assess movement by having the client move his own fingers and toes. Edema and pulse checks are part of a neurovascular assessment.

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

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 404.

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

Supine.

On his right side.

Holding his breath.

Leaning forward.

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.

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.

71. When routinely evaluating an elderly client for atypical signs or symptoms, the nurse should remember that:

Aging can reduce an individual's ability to regulate body temperature.

Aging can increase pain perception.

Anesthesia usually causes postoperative psychotic behavior in a geriatric client.

The risk of developing emphysema is highest in elderly people.

RATIONALE: In an assessment, the nurse should remember that aging can reduce ability to regulate body temperature. This not only increases the elderly client's susceptibility to hyperthermia and heat stroke but also decreases his ability to produce a fever in response to his infection. An elderly client may exhibit decreased (not increased) pain perception. Many medications, such as anesthetic agents and analgesics, can cause confusion or depression (not psychotic behavior) in an elderly client. The risk of developing emphysema is highest in smokers, regardless of age.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
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. 559.

Explanation

RATIONALE: In an assessment, the nurse should remember that aging can reduce ability to regulate body temperature. This not only increases the elderly client's susceptibility to hyperthermia and heat stroke but also decreases his ability to produce a fever in response to his infection. An elderly client may exhibit decreased (not increased) pain perception. Many medications, such as anesthetic agents and analgesics, can cause confusion or depression (not psychotic behavior) in an elderly client. The risk of developing emphysema is highest in smokers, regardless of age.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
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. 559.

72. 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?

Intradermal injection is less painful.

Intradermal drugs are easier to administer.

Intradermal drugs diffuse more rapidly.

Intradermal drugs diffuse more slowly.

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.

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.

73. When auscultating a client's abdomen, a nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nurse suspects:

Decreased bowel motility.

Increased bowel motility.

Nothing abnormal.

Abdominal cramping.

RATIONALE: High-pitched gurgles are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds. Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction.

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. 442.

Explanation

RATIONALE: High-pitched gurgles are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds. Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction.

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. 442.

74. Why should an infant be quiet and seated in an upright position when the nurse assesses his fontanels?

A mother will have less trouble holding a quiet, upright infant.

The fontanels may recede, making assessment more difficult.

The infant can breathe more easily when he's sitting up.

Lying down and crying can cause the fontanels to bulge.

RATIONALE: Lying down and crying can cause the fontanels to bulge, making the nurse's assessment inaccurate. The nurse should sit the child upright and try to keep him calm and quiet. The fontanels should look almost flush with the scalp, and the nurse should observe slight pulsation. The fontanels should feel soft and either flat or slightly indented.

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

REFERENCE: Hatfield, N. Broadribb's Introductory Pediatric Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 71.

Explanation

RATIONALE: Lying down and crying can cause the fontanels to bulge, making the nurse's assessment inaccurate. The nurse should sit the child upright and try to keep him calm and quiet. The fontanels should look almost flush with the scalp, and the nurse should observe slight pulsation. The fontanels should feel soft and either flat or slightly indented.

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

REFERENCE: Hatfield, N. Broadribb's Introductory Pediatric Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 71.

75. Which assessment finding indicates an increased risk of skin cancer?

A deep sunburn

A dark mole on the client's back

An irregular scar on the client's abdomen

White irregular patches on the client's arm

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.

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.

76. The ear canal of an infant or young child:

Slants upward.

Slants downward.

Is horizontal.

Slants backward.

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.

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.

77. A nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure?

Wrapping the cuff around the limb, with the uninflated bladder covering about one-fourth of the limb circumference

Measuring the arm about 2″ (5 cm) above the antecubital space

Wrapping the cuff around the limb, with the uninflated bladder covering about three-quarters of the limb circumference

Using a bladder that is 6″ (15 cm) long.

RATIONALE: When measuring blood pressure, the nurse should wrap the cuff around the client's arm or leg with the bladder uninflated; the bladder should cover approximately three-quarters (not one-fourth) of the limb circumference. The nurse chooses bladder size according to the size of the extremity.

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. 99.

Explanation

RATIONALE: When measuring blood pressure, the nurse should wrap the cuff around the client's arm or leg with the bladder uninflated; the bladder should cover approximately three-quarters (not one-fourth) of the limb circumference. The nurse chooses bladder size according to the size of the extremity.

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. 99.

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

Have you noticed a change in your memory?

Have you noticed a change in your muscle strength?

Have you had any problems with coordination?

Have you had any problems with your eyes?

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.

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.

79. 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?

Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis

Respiratory alkalosis

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.

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.

80. Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that he has no active gag reflex. In response, the nurse should:

Insert an oral airway.

Withhold food and fluids.

Position the client on his side.

Introduce a nasogastric (NG) tube.

RATIONALE: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.

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. 811.

Explanation

RATIONALE: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.

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. 811.

81. A nurse is assessing a 47-year-old client who has come to the physician's office for his annual physical. One of the first physical signs of aging is:

Having more frequent aches and pains.

Failing eyesight, especially close vision.

Increasing loss of muscle tone.

Accepting limitations while developing assets.

RATIONALE: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Loss of muscle tone increases in later years (ages 80 and older). Accepting limitations while developing assets is socialization development that occurs during adulthood (ages 31 to 45).

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. 850.

Explanation

RATIONALE: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Loss of muscle tone increases in later years (ages 80 and older). Accepting limitations while developing assets is socialization development that occurs during adulthood (ages 31 to 45).

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. 850.

82. 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?

Brachial

Femoral

Posterior tibial

Dorsalis pedis

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.

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.

83. A nurse is assessing tactile fremitus in a client with pneumonia. For this examination, the nurse should use the:

Fingertips.

Ulnar surface of her hand.

Dorsal surface of her hand.

Finger pads.

RATIONALE: The nurse uses the ulnar surface, or ball, of her hand to assess tactile fremitus, thrills, and vocal vibrations through the chest wall. The fingertips and finger pads best distinguish texture and shape. The dorsal surface is most sensitive to warmth.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
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. 1614.

Explanation

RATIONALE: The nurse uses the ulnar surface, or ball, of her hand to assess tactile fremitus, thrills, and vocal vibrations through the chest wall. The fingertips and finger pads best distinguish texture and shape. The dorsal surface is most sensitive to warmth.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
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. 1614.

84. 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:

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.

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

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.

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.

85. 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.

When did the rash start?

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

How old are you?

What have you been using to treat the rash?

Have you recently traveled outside the country?

Do you smoke cigarettes or drink alcohol?

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.

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.

Submit

86. 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?

Frontal

Occipital

Parietal

Temporal

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.

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.

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

A soft, smooth bladder

A hard, rough bladder

A nonpalpable bladder

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

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.

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.

88. A nurse expects to find hypoactive bowel sounds when assessing which client?

A client complaining of hunger.

A client admitted with paralytic ileus.

A client admitted with intestinal obstruction.

A client with diarrhea.

RATIONALE: Hypoactive bowel sounds indicate paralytic ileus or peritonitis. Hyperactive bowel sounds can indicate hunger, diarrhea, or early intestinal obstruction.

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. 443.

Explanation

RATIONALE: Hypoactive bowel sounds indicate paralytic ileus or peritonitis. Hyperactive bowel sounds can indicate hunger, diarrhea, or early intestinal obstruction.

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. 443.

89. During a physical examination, a nurse asks a client to hold his breath briefly, and then uses a stethoscope to auscultate over his carotid arteries. Which finding is normal when auscultating over these arteries?

No sounds over either carotid artery

Faint swishing sounds over both carotid arteries

Throbbing pulsations bilaterally

Louder sounds over the right carotid artery than over the left carotid artery

RATIONALE: Absence of sounds over either carotid artery indicates unobstructed blood flow. Auscultation of any sounds (bruits) is abnormal and the nurse should report this finding to the physician.

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. 369.

Explanation

RATIONALE: Absence of sounds over either carotid artery indicates unobstructed blood flow. Auscultation of any sounds (bruits) is abnormal and the nurse should report this finding to the physician.

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. 369.

90. When auscultating a client's chest, a nurse assesses a second heart sound (S2). This sound results from:

Opening of the mitral and tricuspid valves.

Closing of the mitral and tricuspid valves.

Opening of the aortic and pulmonic valves.

Closing of the aortic and pulmonic valves.

RATIONALE: The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.

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.

Explanation

RATIONALE: The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.

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.

91. When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include:

Increased coronary artery blood flow.

Decreased posterior thoracic curve.

Decreased peripheral resistance.

Delayed gastric emptying.

RATIONALE: Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

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

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 776.

Explanation

RATIONALE: Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

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

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 776.

92. When determining appropriate nursing interventions for a client with a medical diagnosis, the nurse uses:

Developmental anatomy.

Applied anatomy.

Regional anatomy.

Descriptive anatomy.

RATIONALE: Applied anatomy enables the nurse to base nursing interventions on her knowledge of anatomic findings for nursing care and diagnosis and treatment of medical disorders. She uses developmental anatomy to study structural changes occurring from conception through old age. Regional anatomy refers to the study of limited portions of the body. Descriptive anatomy describes individual body parts in an orderly fashion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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. 208.

Explanation

RATIONALE: Applied anatomy enables the nurse to base nursing interventions on her knowledge of anatomic findings for nursing care and diagnosis and treatment of medical disorders. She uses developmental anatomy to study structural changes occurring from conception through old age. Regional anatomy refers to the study of limited portions of the body. Descriptive anatomy describes individual body parts in an orderly fashion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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. 208.

93. An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking properly. When assessing the client for dehydration, the nurse would expect to find:

Distended jugular veins.

Hypothermia.

Hypertension.

Tachycardia.

RATIONALE: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. Distended jugular veins and hypertension may be signs of fluid volume overload. Body temperature may be elevated with dehydration. Blood pressure, in particular systolic blood pressure, falls with dehydration, and orthostatic hypotension may occur.

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

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

Explanation

RATIONALE: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. Distended jugular veins and hypertension may be signs of fluid volume overload. Body temperature may be elevated with dehydration. Blood pressure, in particular systolic blood pressure, falls with dehydration, and orthostatic hypotension may occur.

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

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

94. A nurse is assessing a client's pulse. Which pulse feature should the nurse document?

Timing in the cycle

Amplitude

Pitch

Intensity

RATIONALE: The nurse should document the rate, rhythm, and amplitude of a client's pulse. Pitch, timing, and intensity aren't associated with pulse assessment.

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. 86.

Explanation

RATIONALE: The nurse should document the rate, rhythm, and amplitude of a client's pulse. Pitch, timing, and intensity aren't associated with pulse assessment.

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. 86.

95. Why should the nurse avoid palpating both carotid arteries at one time?

The nurse can't assess the pulse accurately unless she palpates the arteries one at a time.

Palpating both arteries at one time may cause transient hypertension.

Palpating both arteries at one time may cause severe bradycardia.

Palpating both arteries at one time may cause severe tachycardia.

RATIONALE: The nurse must palpate the carotid arteries one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia could lead to cardiac arrest.

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. 370.

Explanation

RATIONALE: The nurse must palpate the carotid arteries one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia could lead to cardiac arrest.

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. 370.

96. A nurse is conducting a physical assessment on a client who has been diagnosed with syphilis. The client verbalizes concern about his ability to keep his diagnosis confidential. Which statement best explains the information security measures the nurse must implement?

The nurse must report all syphilis cases to the Public Health Department.

The client must inform his sexual partners about the need for them to be tested and, perhaps, treated for syphilis.

The nurse must add the client's name to the hospital's database of clients who have contracted sexually transmitted diseases (STDs).

RATIONALE: State laws require health care providers to report all syphilis cases to the appropriate Public Health Department. The nurse should encourage the client to provide his sexual partners with information about HIV, but she may not supply the information herself without breaching confidentiality. Although the nurse should urge the client to inform his sexual partners of their need to be tested, she can't force him to do so. The nurse doesn't have to help maintain a database of clients with STDs unless she is the facility's infection control nurse.

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. 1057.

Explanation

RATIONALE: State laws require health care providers to report all syphilis cases to the appropriate Public Health Department. The nurse should encourage the client to provide his sexual partners with information about HIV, but she may not supply the information herself without breaching confidentiality. Although the nurse should urge the client to inform his sexual partners of their need to be tested, she can't force him to do so. The nurse doesn't have to help maintain a database of clients with STDs unless she is the facility's infection control nurse.

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. 1057.

97. Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:

Keep the client warm.

Maintain room temperature at 78° F (25.6° C).

Keep the client uncovered.

Match the room temperature to the client's body temperature.

RATIONALE: The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.

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. 987.

Explanation

RATIONALE: The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.

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. 987.

98. A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

The client took small steps at a rate of 40 to 50 per minute.

The client reported feeling dizzy and weak and perspired profusely.

The client's head was down, gaze was cast down, and toes were pointed outward.

The client's pulse and respiratory rates increased moderately during ambulation.

RATIONALE: Pulse and respiratory rates normally increase during and for a short time after ambulation, especially if it's the first ambulation after 3 days of bed rest. A normal walking pace is 70 to 100 steps/minute; a much slower pace may indicate distress. Dizziness, weakness, and profuse perspiration are definite signs of activity intolerance. A client who tolerates ambulation well holds his head erect, gazes straight ahead, and keeps his toes pointed forward. A client who ambulates with his head down, gaze cast down, and toes pointed outward is exhibiting activity intolerance.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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. 1310.

Explanation

RATIONALE: Pulse and respiratory rates normally increase during and for a short time after ambulation, especially if it's the first ambulation after 3 days of bed rest. A normal walking pace is 70 to 100 steps/minute; a much slower pace may indicate distress. Dizziness, weakness, and profuse perspiration are definite signs of activity intolerance. A client who tolerates ambulation well holds his head erect, gazes straight ahead, and keeps his toes pointed forward. A client who ambulates with his head down, gaze cast down, and toes pointed outward is exhibiting activity intolerance.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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. 1310.

99. A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4″ (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate?

The X-ray is inconclusive.

A disease process is present.

The ET tube must be advanced.

The ET tube must be pulled back.

RATIONALE: This X-ray suggests tuberculosis. An ET tube that's 3/4″ above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
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. 644.

Explanation

RATIONALE: This X-ray suggests tuberculosis. An ET tube that's 3/4″ above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
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. 644.

100. When assessing the facial lacerations of a middle-aged client admitted to the facility 1 week earlier, a nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing?

Contraction

Fibrinoplastic

Lag

Inflammation

RATIONALE: At the end of the lag phase, the fibrin network dries out and forms a scab. The fibrinoplastic phase concludes with a scar, and sloughing and shrinking of the scar indicate the contraction phase. Inflammation, which is the first stage of wound healing, includes hemostasis, edema, and drawing of leukocytes to the wound area.

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

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 538.

Explanation

RATIONALE: At the end of the lag phase, the fibrin network dries out and forms a scab. The fibrinoplastic phase concludes with a scar, and sloughing and shrinking of the scar indicate the contraction phase. Inflammation, which is the first stage of wound healing, includes hemostasis, edema, and drawing of leukocytes to the wound area.

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

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 538.

101. A 2-year-old child is being examined in the emergency department for epiglottiditis. Which assessment finding supports this diagnosis?

Mild fever

Clear speech

Tripod position

Gradual onset of symptoms

RATIONALE: The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottiditis because this position facilitates breathing. Epiglottiditis presents with a sudden onset of signs and symptoms, such as high fever, muffled speech, inspiratory stridor, and drooling.

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. 263.

Explanation

RATIONALE: The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottiditis because this position facilitates breathing. Epiglottiditis presents with a sudden onset of signs and symptoms, such as high fever, muffled speech, inspiratory stridor, and drooling.

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. 263.

102. 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?

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

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

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

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.

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.

103. A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the client's baseline arm blood pressure, the nurse should expect the thigh to have a:

Higher systolic blood pressure reading.

Higher diastolic blood pressure reading.

Lower systolic blood pressure reading.

Lower diastolic blood pressure reading.

RATIONALE: Systolic readings in the thigh may be 10 to 40 mm Hg higher than in the arm. Diastolic readings are the same in the arm and thigh.

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

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 578.

Explanation

RATIONALE: Systolic readings in the thigh may be 10 to 40 mm Hg higher than in the arm. Diastolic readings are the same in the arm and thigh.

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

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 578.

104. 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?

Impaired speech

Muscle flaccidity

Pleasant and smiling demeanor

Tremors in the fingers that increase with purposeful movement

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.

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.

105. 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?

Lower back pain

Burning sensation on urination

Frequency of urination

Fever and change in urine clarity

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.

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.

106. 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:

The history of the present problem, medications, review of systems, and recent major operations.

The history of the present problem, allergies, medications, and recent major operations.

The history of the present problem, medications, family history, psychosocial history, and review of systems.

The history of the present problem, allergies, medications, review of systems, and recent major operations.

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.

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.

107. A student nurse working with a registered nurse is assessing a child with epiglottiditis. The student nurse tells the child that she must look into his throat. Which intervention by the registered nurse is most appropriate?

Hand the student nurse a flashlight and tongue blade.

Give the student nurse a sterile tongue blade and culturette swab.

Tell the student nurse that the registered nurse will visually examine the child's throat.

Tell the student nurse that the anesthesiologist will visually examine the child's throat.

RATIONALE: Direct visualization of the epiglottis can trigger complete airway obstruction. Only an anesthesiologist or a physician skilled in pediatric intubation may perform this procedure.

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

REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1252.

Explanation

RATIONALE: Direct visualization of the epiglottis can trigger complete airway obstruction. Only an anesthesiologist or a physician skilled in pediatric intubation may perform this procedure.

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

REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1252.

108. 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 develop

3. 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.

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.

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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