Basic Physical Assessment

  • NCLEX
Reviewed by Editorial Team
The ProProfs editorial team is comprised of experienced subject matter experts. They've collectively created over 10,000 quizzes and lessons, serving over 100 million users. Our team includes in-house content moderators and subject matter experts, as well as a global network of rigorously trained contributors. All adhere to our comprehensive editorial guidelines, ensuring the delivery of high-quality content.
Learn about Our Editorial Process
| By Suarezenriquec1
S
Suarezenriquec1
Community Contributor
Quizzes Created: 12 | Total Attempts: 17,290
| Attempts: 1,807 | Questions: 108 | Updated: Mar 22, 2025
Quiz
Mind Map
Study Guide
Please wait...
Question 1 / 109
🏆 Rank #-- ▾
0 %
0/100
Score 0/100

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?

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.

Submit
Please wait...
About This Quiz
Basic Physical Assessment - Quiz

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

2.

What first name or nickname would you like us to use?

You may optionally provide this to label your report, leaderboard, or certificate.

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

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.

Submit

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?

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.

Submit

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?

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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?

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.

Submit

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

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.

Submit

28. Which statement regarding heart sounds is correct?

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

34. Which description about crackles are true?

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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:

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.

Submit

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?

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

47. Tachycardia can result from:

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

51. 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?

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.

Submit

52. 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:

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.

Submit

53. 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?

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.

Submit

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

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.

Submit

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

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.

Submit

56. 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?

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.

Submit

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

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.

Submit

58. 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?

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.

Submit

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

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.

Submit

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

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.

Submit

61. 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:

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.

Submit

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?

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.

Submit

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

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.

Submit

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?

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.

Submit

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:

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

69. 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?

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

77. 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?

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.

Submit

78. 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?

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.

Submit

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

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.

Submit

80. 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:

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.

Submit

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

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.

Submit

82. 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:

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.

Submit

83. 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:

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.

Submit

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

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.

Submit

85. 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?

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.

Submit

86. 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.

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

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

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.

Submit

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

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.

Submit

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?

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.

Submit

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

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.

Submit

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

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.

Submit

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

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.

Submit

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:

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.

Submit

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

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.

Submit

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

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.

Submit

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?

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.

Submit

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:

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.

Submit

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?

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.

Submit

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?

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.

Submit

100. 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?

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.

Submit

101. 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?

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.

Submit

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

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.

Submit

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:

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.

Submit

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?

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.

Submit

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?

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.

Submit

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:

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.

Submit

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?

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.

Submit

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.

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.

Submit
×
Saved
Thank you for your feedback!
View My Results
Cancel
  • All
    All (108)
  • Unanswered
    Unanswered ()
  • Answered
    Answered ()
A nurse is teaching a client who will soon be discharged how to change...
A nurse is assessing a client's abdomen. Which examination...
A nurse is obtaining the health history of a client whose background...
A client with fever, weight loss, and watery diarrhea is being...
When examining a client who has abdominal pain, a nurse should assess:
During assessment, a nurse auscultates for a client's breath...
A nurse prepares to assess a client who has just been admitted to the...
A nurse is assessing a postoperative client. Which information should...
A client has just undergone bronchoscopy. Which nursing assessment is...
To evaluate a client's reason for seeking care, a nurse performs...
Which component of a client's medical record is the major source...
When performing an abdominal assessment, a nurse should follow which...
A nurse determines that a client has 20/40 vision. Which statement...
To assess the effectiveness of cardiac compressions during adult...
When obtaining a client's history, a nurse develops a genogram....
After suctioning a tracheostomy tube, the nurse assesses the client to...
When percussing a client's chest, the nurse should expect to hear:
A nurse plans to obtain client information from a primary source....
When palpating a client's body to detect warmth, the nurse should...
Which pulse should the nurse palpate during rapid assessment of an...
Which factors are major components of a client's general...
A client complains of abdominal pain. Which question should the nurse...
When should a nurse check for rebound tenderness in a client who...
A nurse measures a client's temperature at 102° F. What is the...
A client, age 75, is admitted to the facility. Because of the...
A nurse is caring for a client who is exhibiting signs and symptoms...
At 8 a.m., a nurse assesses a client who's scheduled for surgery...
Which statement regarding heart sounds is correct?
A nurse prepares to auscultate a client's carotid arteries for...
A nurse is taking a client's blood pressure and fails to recognize...
A nurse conducts a test for Romberg's sign. What is the correct...
A nurse must assess skin turgor in an elderly client. When evaluating...
To evaluate a client's cerebellar function, a nurse should ask:
Which description about crackles are true?
A nurse correctly identifies which items as belonging to the dorsal...
A nurse uses a stethoscope to auscultate a client's chest. Which...
A nurse is caring for a client who is experiencing alcohol withdrawal....
A nurse is performing a preoperative assessment. Which client...
A client reports abdominal pain. Which action allows the nurse to...
What is a common source of airway obstruction in an unconscious...
A nurse measures a client's apical pulse rate and compares it with...
A client tells a nurse that he has a rash on his back and right flank....
A client undergoes a total abdominal hysterectomy. When assessing the...
A nurse is conducting a physical assessment on an adolescent who...
A nurse prepares to palpate a client's maxillary sinuses. For this...
A nurse is assessing a client who may be in the early stages of...
Tachycardia can result from:
A client comes to the clinic for a routine checkup. To assess the...
A nurse is auscultating a client's chest. How can the nurse...
When testing a client's pupils for accommodation, a nurse should...
During the physical examination, a nurse uses various techniques to...
A nurse prepares to perform an otoscopic examination on an adult. For...
A nurse is conducting a physical assessment on a 17-year-old female....
A nurse is assessing a client using light palpation. How does a nurse...
A nurse is monitoring a client for adverse reactions during...
A nurse is caring for a client who has experienced an acute...
A nurse is examining a client with suspected peritonitis. How does the...
A nurse is helping to plan a teaching session for a client who will be...
A nurse is evaluating a client's auditory function. To compare air...
Which client best fits into the middle-old elderly population?
A mother comes to the clinic with her 5-year-old son who is...
A 10-year-old child with rheumatic fever must have his heart rate...
Which plane divides the body longitudinally into anterior and...
When inspecting a client's skin, a nurse finds a circumscribed...
A nurse is caring for a client who has suffered a severe stroke....
A nurse is assessing an elderly client. When performing the...
A nurse is assessing a client's abdomen. Which finding should the...
When performing a pediatric assessment, why should a nurse inspect...
A client comes to the clinic for diagnostic allergy testing. The nurse...
A nurse can auscultate for heart sounds more easily if the client is:
When routinely evaluating an elderly client for atypical signs or...
A nurse must assess a client's splinted extremity for...
The ear canal of an infant or young child:
Which assessment finding indicates an increased risk of skin cancer?
Why should an infant be quiet and seated in an upright position when...
When auscultating a client's abdomen, a nurse detects high-pitched...
A nurse reviews the arterial blood gas (ABG) values of a client...
A nurse is palpating a client's pulse on the inner aspect of his...
To help assess a client's cerebral function, a nurse should ask:
A nurse is assessing a 47-year-old client who has come to the...
A nurse prepares to measure a client's blood pressure. What is the...
Before a transesophageal echocardiogram, a nurse gives a client an...
Two days after undergoing a total abdominal hysterectomy, a client...
A nurse is assessing tactile fremitus in a client with pneumonia. For...
A client involved in a motor vehicle accident is admitted to the...
A nurse is assessing a client who has a rash on his chest and upper...
When palpating the bladder of an adult client, a nurse should identify...
A nurse expects to find hypoactive bowel sounds when assessing which...
During a physical examination, a nurse asks a client to hold his...
When auscultating a client's chest, a nurse assesses a second...
When assessing an elderly client, the nurse expects to find various...
When determining appropriate nursing interventions for a client with a...
An 82-year-old client is admitted to the hospital with a diagnosis of...
A nurse is assessing a client's pulse. Which pulse feature should...
Why should the nurse avoid palpating both carotid arteries at one...
A nurse is conducting a physical assessment on a client who has been...
Vasodilation or vasoconstriction produced by an external cause will...
A nurse is helping a client ambulate for the first time after 3 days...
A nurse is reviewing a client's X-ray. The X-ray shows an...
A nurse is conducting a physical assessment on an obese 17-year-old...
When assessing the facial lacerations of a middle-aged client admitted...
A 2-year-old child is being examined in the emergency department for...
A client has lymphedema in both arms and the nurse must measure blood...
A client is admitted to the hospital with pneumonia. He has a history...
A client with a spinal cord injury says he has difficulty recognizing...
When a nurse enters a client's room, the client complains that...
A student nurse working with a registered nurse is assessing a child...
A nurse is caring for a client with herpes zoster. Place the...
play-Mute sad happy unanswered_answer up-hover down-hover success oval cancel Check box square blue
Alert!