1A nurse assesses the skin of an older adult's forearms and observes purpura. The nurse interprets this finding as indicative of which issue?
A. Elder abuse
B. Vascular fragility
C. Poor circulation
D. Herpes zoster
Answer: B
Rationale: The fragility of the thin skin and the capillary fragility of the older person lead to dark red-purple areas known as "senile purpura," caused often by minor trauma. Bruising, especially large bruises, may suggest elder abuse. Pallor may suggest poor circulation. Vesicles draining clear fluid or pustules atop an erythematous base following a clear linear pattern and accompanied by pain suggest herpes zoster.
2When examining the eyes of an elderly client, the nurse observes a brownish discoloration of the lens. The nurse interprets this finding as suggestive of which of the following?
A. Conjunctivitis
B. Presbyopia
C. Glaucoma
D. Cataracts
D. Cataracts result in a yellowish or brownish discoloration of the lens. Conjunctivitis would most likely result in a reddened conjunctiva. The nurse would not observe any changes in the eye with presbyopia or glaucoma.
3A nurse is preparing a class for a group of older adult clients at a local senior center. The nurse is focusing on health promotion and disease prevention. Which condition would the nurse most likely include as a common cause of infection- related deaths in the elderly?
A. Pyelonephritis B. Wounds
C. Pneumonia D. Tuberculosis
Answer: C
Rationale: Pneumonia is the most common cause of infection-related deaths in the elderly. The pneumovax is recommended once a lifetime for those over age 65 and every 6 years for high-risk clients. Pyelonephritis, wounds, and tuberculosis are not common causes.
4Which question would provide the nurse the best information when assessing an elderly client who presents to the emergency department complaining of dyspnea and shortness of breath?
A. How does your difficulty breathing affect your daily function?
B. When did you have your last chest x-ray?
C. Have you had the influenza immunization this year? D. Have you ever been exposed to tuberculosis?
Answer: A
Rationale: The question about how the client's symptoms affect his or her function is broad and allows the nurse to obtain information about a variety of areas, including severity, frequency, and duration, as well as possible underlying problems. Dyspnea is a frequently reported symptom associated with common illnesses among elderly clients. Questions related to the last chest x-ray, influenza immunization, and exposure to tuberculosis are highly specific and would be appropriate if the client's response to the first question reveals a problem.
5After teaching a group of students about geriatric syndromes, the instructor determines that the teaching was successful when the students identify what as an example?
A. Confusion B. Pneumonia C. Heart failure D. Renal failure
A. Adverse events (AE) or adverse drug effects (ADE) in this population often include falls, confusion, incontinence, generalized weakness, and lethargy. These complications are also referred to as geriatric syndromes, and are more common signs and symptoms of illness in the very old than are the more common manifestations of illness in younger adults such as fever, pain, and abnormal lab values.
6When assessing the thorax and lungs of an elderly client, which of the following would be of concern to the nurse? Select all that apply.
A. Respiratory rate over 25 breaths per minute B. Decreased vital capacity C. Increased residual volume D. Dyspnea with exertion
E. Slight barrel chest
F. Decreased aerobic capacity
A,D,F Findings that would be of concern include a respiratory rate over 25 breaths per minute, which may signal a pulmonary infection along with increased sputum production, confusion, loss of appetite, and hypotension.
Significant loss of aerobic capacity and dyspnea with exertion are usually due to disease, exposure over a lifetime to pollutants or smoke, or severe or prolonged lack of exercise. Normal findings include decreased vital capacity, increased residual volume, and a slight barrel chest.
7When examining the skin of an elderly client, the presence of which skin lesions should indicate a need for referral?
A. Cherry angioma
B. Actinic keratosis
C. Seborrheic keratosis D. Acrochordons
Answer: B
Rationale: Actinic keratoses are round or irregularly shaped tan, scaly lesions that may bleed or be inflamed and suggest a premalignancy. Cherry angioma, seborrheic keratosis, and acrochordons are considered normal, age-related findings.
8During an assessment of an elderly client, the nurse notes a decrease in pupil size and a slowed reaction of the pupil to light. Accommodation and convergence are normal. Based on these findings, what should the nurse emphasize with client education?
A. Use drops to prevent dryness
B. Wear sunglasses outdoors C. Avoid driving at night
D. Obtain an eye examination
Answer: C
Rationale: Overall decrease in size of pupil and ability to dilate in dark and constrict in light may occur with advanced age; this results in poorer night vision and decreased tolerance to glare. Although using drops, wearing sunglasses, and obtaining an eye exam may be appropriate client teaching, they are unrelated to the specific assessment findings.
9 A client's medical assessment reveals no heart disease. An electrocardiogram is performed and a dysrhythmia is noted. The nurse interprets this finding as most likely reflecting which age-related change?
A. Decreased ventricular compliance
B. Peripheral vascular disease
C. Widening pulse pressure
D. Collagen deposits around pacemaker cells
Answer: D
Rationale: In the absence of heart disease, the accumulation of lipofuscin, amyloid, collagen, and fats in the pacemaker cells of the heart and loss of pacemaker cells in the sinus node predispose the older adult to dysrhythmias. Decreased ventricular compliance, PVD, and a widened pulse pressure would not result in these findings.
10The family members of an elderly client tell the nurse, "He has lost his appetite. He eats very small amounts, and only twice a day." Which suggestion would be most appropriate?
A. Inform them that he will eat when he is hungry.
B. Counsel them to weigh him daily. C. Recommend nutrient-dense foods. D. Advise them to restrict fluid intake.
Answer: C
Rationale: Older adults need nutrient-dense foods to ingest enough essential nutrients. Telling them that he will eat when he is hungry is inappropriate. Loss of appetite is a nearly universal cofactor of both physical and mental disease in the elderly. Weighing the client periodically, rather than daily, would be more appropriate. Restricting fluid intake may predispose the client to possible dehydration.
11The nurse is assessing an elderly client who is receiving tube feedings via a nasogastric tube. The nurse would assess the client for which complication?
A. Gingivitis
B. Sinusitis
C. Epiglottitis D. Cellulitis
Answer: B
Rationale: Elderly clients with nasogastric tubes are at increased risk for sinusitis related to the obstruction in the nasal cavity. Gingivitis, epiglottitis and cellulitis are unrelated to nasogastric tube feedings.
12When assessing an older client's hip joint after a fall, which finding should lead the nurse to suspect that the client has a hip fracture?
A. Internal rotation of the affected leg
B. Abduction of the affected leg
C. Partial weight bearing D. Severe pain in groin
Answer: D
Rationale: Complaints of severe pain in the groin, external rotation and adduction of the affected leg, and an inability to bear weight are the most common signs of a hip fracture. Much less common signs may be mild discomfort and a minimal shortening of the leg.
13An elderly client with a history of sinusitis has been taking antibiotics. The nurse should assess for what potential adverse effect of treatment?
A. Exacerbation of cardiac dysrhythmias
B. Candidal infection
C. Over drying of nasal passages D. Exacerbation of hypertension
Answer: B
Rationale: Because antibiotics also may kill normal bacteria, watch for signs of candidal or Clostridium difficile infection in the GI tract, mouth, or vagina.
Decongestants and antihistamines may aggravate hypertension (in clients taking antihypertensive drugs), exacerbate cardiac dysrhythmias, and further dry the nasal passages and prevent normal sinus drainage.
14An older adult client has been admitted to the intensive care unit after experiencing a serious decline in health due to influenza. The client's family is surprised that influenza could have such serious health consequences. When educating the family about this phenomenon, what should the nurse describe?
A. Older adults' immune systems cannot produce new antibodies. B. Older adults have a diminished physiologic reserve.
C. Older adults lack resistance to many common viruses.
D. Older adults cannot tolerate antibiotics used to treat influenza.
Answer: B
Rationale: Older adults' susceptibility to illness is largely attributable to declines in physiologic reserve. This susceptibility is not primarily due to changes in the function of the immune system, although this system becomes somewhat less effective with age. Influenza is not treated with antibiotics.
15The gerontologic nurse is using the SPICES screening tool to assess an older adult's health status. The nurse will assess for which of the following health problems? Select all that apply.
A. Sleep disturbances
B. Infection
C. Poor nutrition D. Falls
E. Pain
Answer: A, C, D
Rationale: Assessment parameters in the SPICES tool include evidence of falls, poor nutrition, and sleep disturbances. Infection and pain are not explicitly addressed in this screening tool. sleep problems, problems with eating and feeding, incontinence, confusion, evidence of falls, and skin breakdown.
16A nurse is using the Katz Activities of Daily Living tool to assess an older adult's functional status. What question will the nurse include in this assessment?
A. Who generally prepares your meals and snacks?
B. Do you require any assistance when showering or bathing?
C. Do you feel like you have enough support from your family? D. Are you able to shop for your own groceries?
Answer: B
Rationale: Bathing is considered to be an ADL, whereas shopping and cooking are categorized as instrumental ADLs. Family support is an important consideration, but it is not a central aspect of functional status.
17An older adult client who enjoys good overall health has sought care because of a recent onset of weakness and fatigue. The client is unaware of any precipitating events. How should the nurse proceed with assessment?
A. Perform a focused respiratory assessment.
B. Obtain the client's vaccination history.
C. Assess the client for signs and symptoms of anemia. D. Assess the client for evidence of chronic heart failure.
Answer: C
Rationale: When an older adult complains of weakness and fatigue, anemia must always be ruled out
18An older adult client has been admitted for assessment related to decreased cognition. What assessment finding is most suggestive of delirium as the cause of the client's cognitive changes?
A. The client has a family history of cognitive disorders.
B. The client recently began a new medication regimen.
C. The client has been under significant psychosocial stress. D. The client's cognition has declined over several months.
Answer: B
Rationale: Adverse medication effects are a common cause of delirium in older adults, and these effects are most pronounced when a new drug is introduced. Gradual onset and family history are more characteristic of dementia. Stress can exacerbate cognitive deficits but is rarely a direct cause of delirium.
19A nurse who is skilled in assessment is to obtain a comprehensive health assessment. The nurse would most likely be able to complete this assessment within which time frame?
A. 2 hours
B. 1 hour C. 1⁄2 hour D. 1⁄4 hour
C. novice nurse 2 hours skilled practitioner 30 min
20Before performing a complete assessment, which of the following would be most important for the nurse to do?
A. Check the state's Nurse Practice Act.
B. Review the client chart.
C. Gather personal protective equipment. D. Get necessary supplies ready.
Answer: A
Rationale: Although reviewing the chart, gathering personal protective equipment if needed, and getting the necessary supplies would be helpful, it would be most important for the nurse to check the state's Nurse Practice Act to find out what the nurse can legally assess and diagnose.
21The nurse is completing the general survey. In addition to observing the client's appearance, the nurse would assess which of the following?
A. mental status
B. cognitive abilities
C. vital signs
D. thought processes
Answer: C
Rationale: In addition to observing a client's appearance, the nurse would assess vital signs and take body measurements. The mental status examination, including cognitive abilities, mental status, and thought processes, would then be done.
22A novice nurse is practicing how to complete a comprehensive assessment to gain confidence and skill. What would be most important for the nurse to remember?
A. Gather health history information first.
B. Intersperse the physical exam with the history.
C. Establish a routine for the assessment.
D. Allow the client a break between the two parts of the history/exam.
Answer: C
Rationale: There is no one right way to integrate the entire health history and physical examination. However, it is important to stick to a routine to avoid omitting an important step that may delete significant data from the assessment. Short rest periods to help break up the assessment would be appropriate but not the most important.
23A nursing instructor is describing the use of a head-to-toe approach for a comprehensive health assessment and how body systems may be combined, using the legs as an example. Which of the following would the instructor describe as being included in this assessment? Select all that apply.
A. skin color and condition
B. gastrointestinal system
C. peripheral vascular system D. neurologic system
E. musculoskeletal system
A,C,D,E
24After teaching a group of students about areas to include when examining a client's mental status, the instructor determines that the teaching was successful when the students identify which of the following as important?
A. Ability to concentrate
B. Thought processes C. Level of orientation D. Recall ability
B
25 A nurse plans to assess the client's epitrochlear lymph nodes. The nurse should combine this with examination of which area?
A. Neck
B. Arms
C. Posterior chest D. Sinuses
B
26The nurse is performing an assessment of a client’s legs. Which finding(s) should the nurse document as part of the peripheral vascular assessment? Select all that apply.
A. pulses
B. color
C. edema
D. lesions
E. movement
F. strength
A. pulses
B. color
C. edema
D. lesions
27While performing a comprehensive assessment on a client, the nurse proceeds with the general survey. What data should the nurse collect duringthis portion of the assessment? Select all that apply.
A. overall physical and sexual development
B. overall skin coloring
C. level of consciousness
D. concentration, ability to focus and follow directions E. facial symmetry
A,b
28The nurse is preparing to perform a comprehensive assessment of a client who has a diagnosis of Alzheimer's disease. How should the nurse accommodate the client's cognitive deficit when obtaining the client's health history?
A. Get the client's history from the electronic health record, then do the physical assessment.
B. Focus the assessment on aspects of the client's history that he is able to accurately describe.
C. Perform the assessment as quickly as possible in order to minimize the client's stress.
D. Supplement the client's statements with data from the client's friends and family.
D
29The nurse is completing an abbreviated head-to-toe assessment of a client. What would the nurse perform when assessing the client's eyes?
A. Test the client's pupillary response to light.
B. Test the client's visual fields.
C. Perform the cover test. D. Test the client's vision.
A
30The nurse is planning the comprehensive head-to-toe assessment of a client. What assessment should the nurse usually conduct last?
A. assessment of the abdomen
B. assessment of the genitalia and rectum
C. assessment of the lower extremities D. assessment of the posterior thorax
B. less private to more private
31The nurse should ensure that a Doppler ultrasound is available when performing what assessment?
A. Respiratory assessment
B. Peripheral vascular assessment
C. Abdominal assessment
D. Musculoskeletal assessment
B
32When examining a client with a rotator cuff tear, which of the following would the nurse expect to find?
A. Limitation of all shoulder motion
B. Chronic pain
C. Limited abduction
D. Sharp catches of pain with movement
C. Painful and limited abduction accompanied by muscle weakness and atrophy are seen with a rotator cuff tear. Chronic pain and limitation of all shoulder motion is seen with calcified tendonitis. Sharp catches of pain are associated with rotator cuff tendonitis.
33A client is diagnosed with osteomalacia. Which of the following would a nurse include in the client's teaching plan?
A. Decreasing purine intake can reduce the risk of osteomalacia.
B. An increased amount of vitamin C intake is recommended.
C. At least 20 minutes of sunlight each day is recommended
D. Reduce the amount of protein intake.
C. Sunlight will stimulate the body's production of vitamin D. Vitamin D deficiency can increase the incidence of osteomalacia. A decreased purine intake is suggested for gout. Increased vitamin C intake would be appropriate to promote bone and tissue healing. Adequate protein intake is needed to promote muscle tone and bone growth Question Format: Multiple Choice
34What would the nurse expect to find when examining a client with a herniated lumbar disc?
A. Rounded thoracic convexity
B. Lumbar lordosis
C. Flattened lumbar curve
D. Lateral curvature of the spine
C. In a client with a herniated lumbar disc, flattening of the lumbar curve may be seen. A rounded thoracic convexity or kyphosis is commonly seen in older adults. Lumbar lordosis or an exaggerated lumbar curve is often seen in pregnancy and obesity. Lateral curvature of the spine is seen with scoliosis.
35The nurse is performing an assessment on an adolescent client and notes a 45-degree flexion of the cervical spine. What should the nurse do next?
A. Assess the thoracic and lumbar spine.
B. Palpate the spinous processes.
C. Perform the Lasegue test.
D. Continue the exam because this curve is normal.
D. Normal flexion of the cervical spine is 45 degrees. Because the finding is normal, assessing the thoracic and lumbar spine, palpating the spinous processes, and performing the Lasegue test would be unnecessary.
36When asked to touch the ear to the shoulder, a client reports pain. Which of the following would the nurse do next?
A. Perform muscle strength against resistance.
B. Refer the client for further evaluation.
C. Flex and then hyperextend the neck
D. Palpate the paravertebal muscles for pain.
Answer: B
Rationale: Pain when touching the ear to the shoulder indicates a problem with lateral bending so the client should be referred for further evaluation. Performing muscle strength against resistance, flexing and then hyperextending the next, and palpating the paravertebral muscles for pain would not be performed next by the nurse because the client has a medical problem that requires diagnosis by a primary care provider.
37The nurse is caring for a client who reports low back pain. Which test would be most appropriate for the nurse to perform?
A. Lasegue
B. muscle leg strength
C. lateral bending of cervical spine
D. internal rotation of the shoulders
Answer: A
Rationale: Lasegue test, or straight leg raising, will check for a herniated nucleus pulposus, which is a cause of low back pain. Testing muscle leg strength, lateral bending of the cervical spine, or internal rotation of the shoulders would not be indicated.
38The nurse is assessing a client's ability to shrug her shoulders against resistance. The nurse is assessing which cranial nerve?
A. III
B. V
C. VII
D. XI
Answer: D
Rationale: Inability to shrug shoulders against resistance suggests a lesion of cranial nerve XI (spinal accessory nerve). Cranial nerve III is involved with extraocular eye movements. Cranial nerve V is involved with facial sensation. Cranial nerve VII is associated with facial muscles.
39After assessing a client's musculoskeletal system, the nurse is preparing to document the data gathered. Which of the following would the nurse document as objective data?
A. Denies pain in hips or legs
B. Complains of burning in lower back
C. Neck rotation limited to 50 degrees
D. History of osteoporosis
Neck rotation limited to 50 degrees
40After assessing a client's musculoskeletal system, the nurse is preparing to document the data gathered. Which of the following would the nurse document as objective data?
A. Denies pain in hips or legs
B. Complains of burning in lower back
C. Neck rotation limited to 50 degrees
D. History of osteoporosis
C. Rationale: Neck rotation limitation would be objective data because it was measurable and obtained during the physical examination. Client reports such as denial of pain, complaints of burning, and a history of osteoporosis are subjective data
41The nurse notes limitation in active range of motion of a client's right shoulder. What would the nurse to do next?
A. Test muscle strength.
B. Perform passive range of motion test.
C. Measure range of motion with a goniometer.
D. Ask the client which is the dominant side.
C. When limited range of motion is noted, the nurse should measure range of motion with a goniometer to provide information about the joint motion in degrees. Testing muscle strength may be done later once the measurement is obtained. Asking the client about his or her dominant side would be important to know when testing muscle strength, not joint motion. If the client cannot move the part against resistance when testing muscle strength, then the nurse would ask the client to move the part against gravity, and if not possible, attempt to passively move the part through its full range of motion.
42The nurse is preparing to palpate the anatomic snuffbox. At whichlocation would the nurse palpate?
A. At the anterior area of the sternoclavicular joint
B. At the posterior temporomandibular joint
C. At the olecranon process of the elbow
D. At the back of the wrist and extended thumb
D
43Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. What test would the nurse perform to confirm the suspicion?
A. Phalen test
B. Tinel test
C. Ballottement test
D. Lasegue test
C
44When inspecting a client's feet, the nurse observes that the toes point inward. The nurse documents this finding as which of the following?
A. Hallus valgus
B. Pes varus
C. Verruca vulgaris
D. Pes cavus
Toes that point in are termed pes varus. Hallux valgus is noted as the great toe deviating laterally and possibly overlapping the second toe. Verruca vulgaris are painful warts that often occur under a callus. Pes cavus refers to feet with high arches.
45During the history, a young adult woman asks the nurse, "My mother has osteoporosis. What can I do to help reduce my risk?" Which response by the nurse would be most appropriate?
A. "Increase the amount of non-weight-bearing physical activity that you do."
B. "Keep your calcium intake at about 800 milligrams each day."
C. "Avoid being out in the sun for long periods of time."
D. "Avoid smoking and using alcohol."
D. Rationale: To reduce the risk of osteoporosis, the nurse should instruct the client to avoid smoking or alcohol consumption. The nurse should instruct the client to increase physical exercise or activity, especially weight-bearing activities; therefore, instructing the client to increase non-weight-bearing physical activity is not the nurse's most appropriate response. The nurse should instruct the client to consume approximately 1000 to 1500 mg of calcium daily; therefore, the recommendation of keeping the calcium intake at about 800 milligrams is too low. Avoiding long periods of sun exposure is not the most appropriate response, because the nurse should inform the client that sunlight can increase vitamin D levels to promote calcium absorption.
46A nursing student is preparing to demonstrate how to test the range of motion for the elbow. Which of the following would the student include? Select all that apply.
A. Flexion
B. Abduction
C. Extension
D. Rotation
E. Supination
F. Circumduction
A,C,E. When testing the range of motion of the elbow joint, the nurse would test flexion and extension, and supination and pronation of the forearm.
Abduction, rotation, and circumduction would be tested in the shoulder or the hip.
47The nurse is assessing a client’s range of motion of the lumbar spine. Which finding(s) require further follow-up by the nurse? Select all that apply.
A. Flexion of 60 degrees
B. Incremental movements while bending
C. Lumbar concavity flattening out
D. Spinal processes being in alignment
E. Unilateral exaggerated thoracic convexity
A,B,E. The findings of flexion of 60 degrees, incremental movement while bending, and unilateral exaggerated thoracic convexity are abnormal findings that require further follow- up by the nurse. The lumbar concavity flattening out and the spinal processes being in alignment are expected findings.
48A nurse is preparing a program on osteoporosis for a local women's group. What would the nurse cite as a risk factor?
A. Obesity
B. Multiparity (multiple births)
C. Smoking
D. African American ethnicity
(guessed)
C. Smoking is a risk factor for osteoporosis. Obesity, multiparity, and African American ethnicity are not noted risk factors for this disease.
49When testing muscle strength, a client has difficulty moving her right arm against resistance. What would the nurse to do next?
A. Move the part passively through its range of motion.
B. Ask the client to move the part against gravity.
C. Inspect by touch for a palpable contraction of the muscle.
D. Percuss the client's shoulder joint
B. If the client cannot move the part against resistance when testing muscle strength, then the nurse should ask the client to move the part against gravity and, if that is not possible, attempt to passively move the part through its full range of motion. Percussion is not indicated.
50Assessment reveals that a client has slight weakness with active range of motion against some resistance. How would the nurse document this finding?
A. 2/5
B. 3/5
C. 4/5
D. 5/5
C. Muscle strength is rated on a 5-point scale, with specific defining characteristics for each. Slight weakness with active motion against some resistance is 4 of 5 points. 2 of 5 points would indicate passive and poor range of motion. 3 of 5 points would indicate average weakness with active motion against gravity. 5 of 5 points would indicate normal findings, with active motion against full resistance.
51A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis?
A. Caucasian
B. African American
C. South Asian
D. Native American
D
52During the nursing history of a newly admitted client, the nurse is reviewing a client's current medication regimen. What medication category creates a risk for decreased bone density?
A. Beta-adrenergic blockers
B. Corticosteroids
C. Nonsteroidal anti-inflammatories (NSAIDs)
D. Calcium channel blockers
Answer: B
Rationale: Steroids can deplete bone mass, thereby contributing to osteoporosis. This is not true of beta blockers, calcium channel blockers, or NSAIDs.
53The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment?
A. The client takes medications to treat hypertension.
B. The client suffered a fractured humerus 1 year earlier.
C. The client has a diagnosis of type 1 diabetes.
D. The client had a total hip replacement 2 years ago
D. If the client has had a total hip replacement, do not test ROM unless the physician gives permission to do so, due to the risk of dislocating the hip prosthesis. A 1-year-old arm fracture is likely to have healed fully and would not normally affect the content of the assessment. Diabetes can affect various aspects of the musculoskeletal system, but it does not likely require the nurse to modify the assessment. Antihypertensives are unlikely to affect assessment.
54The nurse is performing the bulge test during the assessment of a client's knee. This test will allow the nurse to make what determination?
A. Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation
B. Whether the size of the client's knee changes throughout the joint's range of motion C. Whether swelling in the knee joint is a normal age-related change or a
pathological finding
D. Whether the client's knee joint is capable of adduction and abduction
A. The bulge test is used to determine if knee swelling is due to accumulation of fluid or soft tissue swelling. It does not address range of motion. Knee swelling is never considered to be an age-related change.
55Inspection of a client's foot reveals an enlarged, painful, inflamed bursa on the medial side of the foot. The nurse should make a referral for what health problem?
A. Osteomalacia
B. Hallux valgus
C. Pes planus
D. Gouty arthritis
B. Bunions are the characteristic sign of hallux valgus. They are not indicative of osteomalacia or gouty arthritis. Pes planus is flat feet.
56The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply.
A. Risk for injury related to osteoporosis
B. Risk for infection related to osteoporosis
C. Activity intolerance related to osteoporosis
D. Impaired physical mobility related to osteoporosis E. Disturbed sensory perception related to osteoporosis
A,C,D. Osteoporosis creates risks for injury, activity intolerance, and impaired mobility as consequences of musculoskeletal changes. The disease does not normally result in infection or impaired sensation.
57A nurse practitioner refers clients for osteoporosis screening according to the latest U.S. Preventive Services Task Force (USPSTF) recommendations. According to these recommendations, what client should be screen for osteoporosis?
A. A 71-year-old man who has type 2 diabetes
B. A 69-year-old woman with no major risk factors for osteoporosis
C. A 37-year-old woman who takes oral contraceptives
D. A 49-year-old African-American woman who is obese
B. USPSTF (2011) recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65- year-old white woman who has no additional risk factors. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. Oral contraceptive use is a risk factor for osteoporosis, but screening is not recommended for 37-year-old clients. A 49-year-old African-American woman would similarly not be a candidate for routine screening.
58A client presents to the health care clinic with reports of difficulty swallowing. Which cranial nerves will provide the nurse with information related to the problem? Select all that apply.
Vagus
Abducens
Trochlear
Hypoglossal
Spinal accessory
Glossopharyngeal
vagus, hypoglossal, glossopharyngeal
59The _____ area integrates understanding of spoken and written words
wernicke
60the ______ area regulates verbal expression and writing ability
Broca
61Upon assessment, the nurse suspects the client is having a stroke. What symptoms might the nurse have found? Select all that apply.
Slurred speech
Severe headache
Left arm weakness
Tremors
Unsteady gait
first 3
62Which of the following would the nurse expect to assess if a client has a lesion of the sympathetic nervous system?
A. Bilateral dilated pupils
B. Unilateral dilated pupil
C. Argyll Robertson pupils
D. Constricted pupil unresponsive to light
D. A constricted pupil unresponsive to light or accommodation suggests a lesion of the sympathetic nervous system. Sympathetic nervous system stimulation would lead to bilateral dilated pupils. A unilaterally dilated pupil unresponsive to light or accommodation would suggest damage to cranial nerve
63A client complains of headaches each morning that disappear after getting out of bed. Which of the following would be most appropriate for the nurse to do?
A. Assess if the headaches are accompanied by dizziness.
B. Perform a complete neurologic exam.
C. Refer the client for immediate follow-up.
D. Ask if the client has ever had a seizure.
C. Morning headaches that subside after arising may be an early sign of increased intracranial pressure and require immediate evaluation. Asking about dizziness or seizures, and completing a neurologic exam would most likely occur with the additional follow-up.
64Which of the following assessment findings would lead the nurse to suspect that a client has Bell palsy?
A. Inability to detect sharp and dull stimuli
B. Inability to wrinkle the forehead
C. Closure of the affected eye from swelling
D. Muscle spasm of the lower face on the affected side
B. Inability to close the eyes, wrinkle the forehead, or raise the forehead, along with paralysis of the lower part of the face on the affected side, is seen with Bell palsy. Inability to detect sharp and dull stimuli is associated with lesions of the trigeminal nerve (CN V). Closure of the affected eye from swelling would suggest trauma. Paralysis, not muscle spasm, occurs with Bell palsy.
65When explaining how the nurse would test graphesthesia, which of the following would the nurse include?
A. Client will close the eyes and identify what number the nurse writes inthe palm of the client's hand with a blunt-ended object
B. The client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time.
C. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred.
D. The nurse will briefly touch the client, and the client will need to identify where the touch occurred. (good guess)
A. Graphesthesia is the ability to identify what is being drawn on the client's body when the client's eyes are closed. Two-point discrimination is tested by having the client identify the number of points felts when touched with the ends of two applicators at the same time. Extinction is tested by simultaneously touching the client in the same area on both sides of the body at the same points and having the client identify the area touched. Point localization is tested by briefly touching the client and then asking the client to identify the points touched.
66The nurse is testing a client for Kernig sign. Which finding(s) should cause the nurse to suspect meningeal irritation? Select all that apply.
A. Pain when the knee is extended
B. Resistance to knee extension
C. Discomfort behind the knee with full extension D. Hips and knees remaining relaxed and motionless E. Able to easily bend head and neck forward
A,B. The nurse should suspect meningeal irritation if the client experiences pain when the knee is extended and resistance to knee extension when checking for Kernig sign. Discomfort behind the knee withfull extension during this assessment is normal for many clients. The hips and knees remaining motionless is considered a negative finding when checking for Brudzinski sign, not Kernig
sign. The client’s ability to easily bend the head and neck forward is an expected finding.
67During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?
A. Spastic hemiparesis
B. Parkinsonian gait C. Scissors gait
D. Cerebellar ataxia
D. A wide-based, staggering, unsteady gait and positive Romberg's test (client unable to stand with feet together) suggests cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gait is a short, stiff gait with the thighs overlapping each other with each step.
68When assessing a client's deep tendon reflexes, which technique would be most appropriate for the nurse to use?
A. Use the blunt end of the reflex hammer to strike a smaller area.
B. Strike the area slowly and methodically.
C. Hold the reflex hammer between the thumb and index finger. D. Percuss the area of the tendon to be struck for the reflex.
C. When eliciting deep tendon reflexes, the nurse should hold the reflex hammer between the thumb and index finger so that it swings freely. The nurse should use the pointed end to strike smaller areas and the blunt end to strike a wider area. The nurse should palpate the tendon to be used to elicit the reflex and use a rapid wrist movement to briskly strike the tendon.
69When preparing to test a client for meningeal irritation, what would the nurse to do first?
A. Check for evidence of fever and chills
B. Ensure no injury to the cervical spine
C. Position the client prone
D. Check for a Babinski reflex
B. Before testing a client for meningeal irritation, the nurse needs to ensure that there is no injury to cervical vertebrae or the cervical cord. Otherwise further injury could occur because testing involves flexing the neck. It is not necessary to check for fever or chills or a Babinski reflex. The client is positioned supine for these tests.
70During the health history a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?
A. CN I
B. CN II
C. CN VII D. CN IX
A. CN I (olfactory) would be evaluated to determine if the client was
experiencing a problem here related to his report of a decrease in smell.
Evaluation of CN II (optic) would be indicated if the client reported changes in vision. Evaluation of CN VII (facial) or IX (hypoglossal) would be indicated if the client reported a decrease in his ability to taste.
71When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?
A. 42-year-old Caucasian woman who smokes
B. 68-year-old African American male with hypertension
C. 55-year-old Caucasian male who has a two beers a week D. 35-year-old African American male who has sleep apnea
B. Risk factors include older adulthood (risk doubling each decade after age 55), male sex, African American race, hypertension, smoking, chronic alcohol intake (more than 3 drinks per day), and sleep apnea. In the clients listed, the 68-year-old African American male with hypertension has the greatest risk due to his age, race, and hypertension. The other clients would be at risk, but the risk would be less.
72The nurse is teaching a group of students about the brain and spinal cord and asks the students, “What does the brain stem control?” Which response by the students requires further follow-up by the nurse?
A. Respiratory function
B. Heart rate
C. Equilibrium D. Reflex actions
C. The brain stem is responsible for various reflex actions. The medulla has centers that control and regulate respiratory function, heart rate and force, and blood pressure. The brain stem does not control equilibrium.
73A nurse is testing a client's deep tendon reflex. The nurse taps the tendon above the olecranon process. The nurse is assessing which reflex?
A. Brachioradialis
B. Triceps
C. Biceps D. Achilles
B. The nurse tests the triceps reflex by tapping the tendon above the olecranon process. The nurse tests the brachioradialis reflex by tapping the tendon at the radius about 2 inches above the wrist. The nurse tests the biceps reflex by placing the thumb over the biceps tendon and striking the thumb with the reflex hammer. The nurse tests the Achilles reflex by tapping the Achilles tendon at the posterior aspect of the ankle above the heel.
74Which of the following would lead the nurse to suspect meningeal irritation? A. Hips and knees remain relaxed and motionless when neck is flexed
B. Reports of decreased pain with flexion of the hips and knees
C. Discomfort behind the knee with full extension of the leg
D. Pain and flexion of the hips and knees with neck flexion
D. Pain and flexion of the hips and knees with neck flexion are positive Brudzinski signs and suggest meningeal irritation. Pain and increased resistance to extending the knee when the client's leg is flexed at both the hip and knee and then straightened is a positive Kernig sign, suggesting meningeal irritation. Discomfort behind the knee during full extension when testing for Kernig sign occurs in many normal people.
75While the nurse is assessing a client’s coordination, the client exhibits uncoordinated, jerky movements and is unable to touch either finger to the nose. Which condition should the nurse suspect?
A. Cerebellar disease
B. Vestibular dysfunction
C. Lower motor neuron disease
D. Extrapyramidal tract abnormalities (correct but guessed)
A
Rationale: The nurse would suspect cerebellar disease for a patient exhibiting uncoordinated, jerky movements and the inability to touch a finger to the nose. Vestibular dysfunction is associated with swaying and moving the feet apart to prevent a fall. Lower motor neuron disease would be suspected if the patient exhibited fasciculation (rapid twitching of resting muscle). The nurse would suspect extrapyramidal tract abnormalities if the client exhibited rigid muscles that resist passive movement.
76What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?
A. Inability to hear high-pitched sounds
B. Loss of tactile sensation
C. Difficulty speaking
D. Blurred vision
The frontal lobe contains Broca's area, which is responsible for speech. Injury to this area may lead to difficulty speaking. Difficulty with sounds would be associated with the temporal lobe. Loss of tactile sensation would be associated with the parietal lobe. Blurred vision would be associated with the occipital lobe.
77During a routine follow-up visit, the nurse is assessing a client who reports a sudden severe headache and inability to see out of the left eye. What would be most appropriate for the nurse to do?
A. Assess the client's coordination.
B. Assess the client's visual acuity.
C. Refer the client for immediate medical follow-up. D. Suggest that the client take a daily aspirin.
(review)
C
Rationale: A sudden, severe headache and inability to see out of one or both eyes are symptoms of a stroke and require immediate medical follow-up.
Assessing the client’s coordination and visual acuity may be performed later, but these are not the most appropriate actions at this time. The nurse should not suggest that the client take a daily aspirin, because the client should speak with a doctor prior to doing so.
78A nurse is having difficulty eliciting a patellar reflex during a client's neurological assessment. What would be most appropriate for the nurse to have the client do?
A. Lock the fingers together and pull against each other.
B. Clench the jaw tightly.
C. Squeeze a thigh with the opposite hand. D. Stretch the arms over head.
A. Having the client interlock the hands is a reinforcement technique that aids in enhancing the reflex response in the legs. Clenching the jaw or having the client squeeze one thigh with the opposite hand would be a reinforcement technique for testing arm reflexes. Stretching arms overhead would be inappropriate.
79What would be most appropriate for the nurse to do when assessing motor function of a client's trigeminal nerve?
A. Ask client to differentiate sharp and dull sensations on the face.
B. Have the client smile, frown, and wrinkle the forehead.
C. Palpate temporal and masseter muscles while client clenches the teeth. D. Assess dilatation of the client's pupils with direct light.
C. To test the motor function of the trigeminal nerve (CN V), the nurse asks the client to clench the teeth and palpates the temporal and masseter muscles for contraction. Touching the client's face for dullness or sharp sensations tests the sensory function of the trigeminal nerve. Having the client frown, smile, and wrinkle the forehead tests the motor function of the facial nerve (CN VII). Assessing pupillary dilation tests the oculomotor (CN III) nerve.
80The nurse is assessing a client who has a history of recurrent Bell palsy. Which findings suggest to the nurse that the client is experiencing a recurrence of this condition? Select all that apply.
A. Inability to detect sharp and dull stimuli
B. Inability to wrinkle the forehead
C. Closure of the affected eye from swelling
D. Muscle spasm of the lower face on the affected side
E. Inability to close the eyes
B, E. Inability to wrinkle the forehead or raise the forehead, close the eyes, along with paralysis of the lower part of the face on the affected side, is seen with Bell palsy. Inability to detect sharp and dull stimuli is associated with lesions of the trigeminal nerve (CN V). Closure of the affected eye from swelling would suggest trauma. Paralysis, not muscle spasm, occurs with Bell palsy.
81When assessing cranial nerves IX and X, what would the nurse consider as a normal finding?
A. Stationary soft palate on phonation
B. Deviation of uvula when client says "ah"
C. Asymmetrical soft palate
D. Uvula and soft palate rising bilaterally on phonation
D. Normal findings associated with testing CN IX and CN X include a uvula and soft palate rising bilaterally and symmetrically on phonation. A stationary or asymmetrical soft palate or deviation of the uvula would be considered an abnormal finding.
82The nurse is performing a point localization test on a client during a
neurological assessment. How shoulld the nurse perform this test?
A. The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.
B. The client is asked to identify the number of points felt when the nurse touches
the client with the ends of two applicators at the same time.
C. The nurse will simultaneously touch the client in the same area on both sides of the
body, and the client will identify where the touch occurred.
D. The client will close the eyes. The nurse will then gently touch the client, and the client will identify where the touch occurred.
D. Point localization is tested by briefly touching the client and then asking the client to identify the points touched. Graphesthesia is the ability to identify what is being drawn on the client's body when the client's eyes are closed. Two-point discrimination is tested by having the client identify the number of points felts when touched with the ends of two applicators at the same time. Extinction is tested by simultaneously touching the client in the same area on both sides of the body at the same points and having the client identify the area touched.
83The nurse is performing the Romberg test on a client during a neurological assessment. How should the nurse perform this test? Place the following steps in the correct order.
A. Ask the client to stand erect with arms at the sides and the feet together.
B. Ask the client to close the eyes for 20 seconds.
C. Ask the client to stand on one foot and bend the knee on which the client is standing. D. Ask the client to hop on one foot.
E. Repeat on the opposite side.
A,B,C,D,E
84During a routine follow up visit, an older adult client asks the nurse, “I’ve noticed that my sense of smell has decreased over the years and I’m concerned about the cause.” What is the nurse’s best response?
A. “Over time the sense of smell decreases in some people, and this is normal.”
B. “Congenital problems may sometimes cause a loss of smell.”
C. “There may be a tumor or lesion present in the frontal lobe.”
D. “Injury of the nerve tissue at the top of the nose may be the cause.”
A. The statement, “Over time the sense of smell decreases in some
people, and this is normal,” is the nurse’s best response, because the sense of
smell may be decreased in some older adult clients. The statement, “Congenital problems may sometimes cause a loss of smell,” is correct, but the client reported a decrease the sense of smell over time, not an absence of the sense of smell since birth. The statement, “There may be a tumor or lesion present in the frontal lobe,” is not the best response, because although it references a potential cause of an inability to smell, the nurse does not have enough information based on the client’s statement to introduce this as a potential cause to the client.
85When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Which sensations arecarried by this tract? Select all that apply.
A. Pain
B. Temperature C. Position
D. Vibration
E. Light touch
A,B,E. Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract, whereas sensations of position, vibration, and fine touch travel by way of the posterior columns.
86The nurse is assessing a 39-year-old woman who has a 20-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the woman's risk of stroke?
A. Acetaminophen
B. A beta-adrenergic blocker C. ASA
D. An oral contraceptive
Answer: D
Rationale: The use of oral contraceptives, especially in smokers over 35, constitutes a significant risk factor for stroke. Acetaminophen, ASA, and beta blockers usually decrease an individual's risk of stroke.
87The nurse is conducting a focused neurological assessment of an 81-year-old client. When analyzing the assessment data, the nurse should be aware of what age-related neurological change?
A. Impaired judgment
B. Tremors accompanying intentional movements C. Loss of remote memory
D. Loss of sensation in distal extremities
Answer: B
Rationale: Older adults may experience intentional tremors (tremors that occur with intentional movements). Such tremors are not associated with disease.
Impairments in judgment, remote memory, and limb sensation are considered pathologic in clients of all ages and warrant further assessment.
88The nurse has positioned a client supine and asked her to perform the heel- to-shin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain?
A. Balance and coordination
B. Light touch sensation C. Deep tendon reflexes D. Leg strength
Answer: A
Rationale: Deviation of the heel to one side or the other during the heel-to-shin test may be seen in cerebellar disease. As such, further assessment of balance and coordination is likely indicated. This assessment finding is not suggestive of deficits in reflexes, sensation, or strength.
89The nurse has placed her hands behind the client's head and flexed the client's neck forward as far as the client can tolerate. During the test, the client experiences leg pain and bends his knees. This assessment finding is suggestive of what health problem?
A. Ischemic stroke
B. Meningitis
C. Bell palsy
D. Brain stem lesion
B. Pain and flexion of the hips and knees during neck flexion are positive Brudzinski signs, suggesting meningeal inflammation. This finding is not suggestive of stroke, Bell palsy, or a brain stem lesion.
90The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test?
A. The client moves her feet apart to prevent herself from falling.
B. The client is unable to consistently touch her finger to her nose while her eyes are close. C. The client experiences pain during neck flexion and extension.
D. The client experiences pain when clenching her teeth.
A. The Romberg test assesses balance; swaying or repositioning during the test constitutes positive findings. The Romberg test does not address pain during neck flexion or teeth clenching. It does not require the client to touch the nose with a finger.
91The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed, constricted pupils bilaterally. The nurse should consider what possible cause for this assessment finding?
A. Recent narcotic use
B. Hemorrhagic stroke C. Recent seizure activity D. Cerebellar lesion
A. Narcotics can cause fixed, constricted pupils. This abnormal finding is not typically associated with stroke, seizures, or cerebellar lesions.
92Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait?
A. Scissors gait
B. Parkinsonian gait C. Spastic hemiparesis D. Foot drop
B. A parkinsonian gait is characterized by a shuffling gait with turns accomplished in a very stiff manner. The client also has a stooped-over posture with flexed hips and knees. A scissors gait involves thigh overlap. Spastic hemiparesis is characterized by dragging one toe. In foot drop, the client lifts the foot and knee high with each step, then slaps the foot down hard on the ground
93What would the nurse expect to hear when auscultating the lungs of a client who is dehydrated?
A. Friction rub
B. Decreased breath sounds
C. Sibilant wheeze D. Stridor
friction rub
94A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?
A. Hyperresonance
B. Dullness
C. Resonance D. Tympany
Hyperresonance
95While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following?
A. Pneumonia
B. Pectus excavatum
C. Funnel chest D. Emphysema
Emphysema
96A client is diagnosed with bronchitis. Which of the following would the nurse hear on auscultation?
A. Sibilant wheezes
B. Fine crackles
C. Sonorous wheezes D. Coarse crackles
Sonorous wheezes
97The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following?
A. Client is hypoventilating
B. Client may have overdosed on narcotics
C. The pattern is expected with this condition D. These are normal Kussmaul's respirations
The pattern is expected with this condition
98What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?
A. Biot's
B. Bradypnea
C. Kussmaul's
D. Cheyne-Stokes
Cheyne-stokes
99When percussing the scapula of a client, what would the nurse expect to hear? A. Resonance
B. Dullness
C. Flatness
D. Hyperresonance
Flatness
100When assessing the apices of the lungs, the nurse would locate them at which position?
A. At the level of the diaphragm
B. Near the level of the eighth rib
C. Slightly above the clavicle D. At about the tenth rib
Slightly above the clavicle
101A nurse asks a client to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following?
A. Fremitus
B. Egophony
C. Chest expansion D. Bronchophony
Fremitus
102A nursing instructor is discussing variations in the size of the thorax and impact on lung capacity. Which race would the instructor identify as having a larger thorax?
A. African Americans
B. Asian Americans
C. Native Americans D. Caucasians
Caucasians
103A group of students is studying for a test about lung cancer. The students demonstrate understanding of the material when they identify which risk factor(s)? Select all that apply.
A. Asian American heritage
B. Female gender
C. Exposure to arsenic
D. Use of beta carotene supplements
E. Cold, dry air
F. Diet high in fruits and vegetables
exposure to arsenic, use if beta carotene supplements
104Which of the following would be best for a nurse to use when assessing for fremitus in a client?
A. Dorsal hand surface
B. Pads of fingers C. Ball of hand D. Fist
Ball of hand
105The nurse is preparing to auscultate the breaths sounds of a client's anterior chest. The nurse notes that the client's chest has a large amount of hair on it. Which of the following would the nurse do?
A. Give the client a razor and soap and ask him to shave the hair on his chest
B. Have the client put his T-shirt back on and auscultate through the shirt
C. Omit this part of the assessment and document this
D. Have the client breath more forcibly during the exam and listen with the bell
have the client put his t shirt back on and auscultate through the shirt
106The school nurse assesses unequal shoulder and scapula height in an adolescent. What would the nurse assess next?
A. Lateral aspect of the thorax
B. Lung volume c. hip levels d. spinal column
spinal column
107While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?
A. Vesicular breath sounds
B. Bronchovesicular breath sounds
C. Adventitious breath sounds D. Bronchial breath sounds
bronchial breath sounds
108The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse will assess which lobe from the anterior surface only?
A. Left upper lobe
B. Left lower lobe
C. Right upper lobe D. Right middle lobe
right middle lobe
109The nurse is observing the respiratory effort of a client and notes that the
client’s intercostal spaces are retracting on inspiration. The nurse will assess the client for the presence of which condition(s)? Select all that apply.
A. Obstruction
B. Atelectasis
C. Thoracic muscle tenderness
D. Barrel chest
E. Pectus excavatum
obstruction, atelectasis
110The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding?
A. Ask the client if she has recently exerted herself.
B. Report the finding to the client's primary care provider. C. Ask the client if she has smoked recently.
D. Palpate the client's anterior and posterior thorax.
ask the client if she has recently exerted herself
111The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique? A. Keep the client's shirt or gown in place to maintain privacy.
B. Begin with the bell of the stethoscope on the client's anterior chest.
C. Tell the client that you will be asking him or her to breathe as quickly and deeply as possible.
D. Place the diaphragm on the client's posterior chest wall.
place the diaphragm on the client's posterior chest wall
112The nurse is performing a breast exam. Which area would be most important for the nurse to assess?
A. Upper inner quadrant
B. Lower inner quadrant
C. Upper outer quadrant D. Lower outer quadrant
upper outer quadrant
113When taking a health history for a female client, which factor would the nurse identify as placing the client at increased risk for breast cancer?
A. Consumption of high-fat diet
B. First child after age 30
C. Low level of physical activity
D. bottle feeding her children
first child after age 30
114Which of the following would a nurse include when discussing risk factors about breast cancer for a group of women?
A. Early menarche
B. Having a baby before age 20 years
C. High-protein diet consumption D. Early menopause
Early menarche (first occurence of menstruation)
115A 42-year-old female client says that they are worried because they were never taught how to do a breast self-examination, and has never had a mammogram. Which response by the nurse would be most appropriate?
A. "You should do the exam. It is the best way to detect breast cancer early."
B. "Your primary healthcare provider can help determine which screening options are best for you."
C. "Mammograms do not always detect the lumps that you might feel."
D. "Once you hit the age of 50, you really will not have a choice about doing them."
Your primary healthcare provider can help determine which screening options are best for you
116An 18-year-old woman complains because one breast is larger than the other. Which of the following would the nurse do next?
A. Ask whether she has any other symptoms.
B. Reassure the woman that this finding is normal.
C. Ask if she has a family history of breast cancer. D. Find out whether this is a new problem.
find out whether this is a new problem
117The nurse is examining the breasts of a woman with Paget's disease. Which of the following would the nurse expect to find?
A. Orange-peel skin
B. Nipple retraction
C. Dark, pink areola
D. Red, scaly, crusty areas
D
118A nurse is preparing to palpate a woman's breasts. Which of the following would be most appropriate?
A. Place the arm opposite the breast to be examined over the client's head.
B. Put a small pillow under the breast that is going to be examined.
C. Use a bimanual technique if the client has small breasts.
D. Begin palpating at the upper outer quadrant working toward the nipple.
put a small pillow under the breast that is going to be examined
119When palpating the axillae, which finding would the nurse document as normal? A. Node size: 1.2 cm
B. Fixed
C. Hard
D. Discrete
discrete
120After teaching a group of students about the structure and function of the breasts, the instructor determines that the teaching was successful when the students identify which of the following?
A. The areola contain the openings of the lactiferous ducts.
B. The nipple contains elevated sebaceous glands.
C. The fatty tissue layer determines breast size and shape.
D. The amount of the three types of tissue is fairly consistent.
the fatty tissue layer determines breast size and shape
121A woman reports a sudden onset of spontaneous nipple discharge. What would the nurse do next?
A. Refer the client for cytologic study of the discharge.
B. Observe the breast for eversion of the nipples.
C. Reassure the woman that this is a result of hormonal fluctuations. D. Collect a sample for culture and sensitivity testing.
refer the client for cytologic study of the discharge
122 The nurse is preparing to inspect a woman's breasts for retraction and dimpling. Which position would be most appropriate?
A. Standing
B. Supine
C. Semi-Fowlers D. Sitting
sitting
123A nurse has completed the assessment of a client's breasts. The nurse should suspect that the client has fibroadenomas based on which findings?
A. Lobular, ovoid, or round lesions
B. Irregular, firm cysts
C. Round, defined mobile cysts D. Nondefined, mobile cysts
lobular, ovoid, or round lesions
124When palpating a female client's axillae, which action is most appropriate?
A. Have the client hold the arm of the side being examined slightly away from the body.
B. Tell the client to raise her arm on the side being examined up over her head.
C. Hold the client's elbow of the side being examined with one hand.
D. Have the client lean forward from the waist with arms outstretched.
hold the client's elbow of the side being examined with one hand
125The nurse is beginning the inspection of a young adult client's breasts. The client states, "My left breast has always been a bit bigger than the right." How should the nurse best respond to the client's statement?
A. "Many women have this, and it's rarely a sign of a health problem."
B. "That's very normal, and it usually resolves over time as you get older."
C. "If you lose some weight, the size disparity will likely decrease."
D. "I'll make sure to refer to the doctor to get this assessed further."
many women have this and it's rarely a sign of a health problem
126The nurse is examining a client's breasts and notes the presence of pronounced dimpling. How should the nurse best respond to this assessment finding?
A. Confirm whether the client has breast implants in place.
B. Ask the client about any history of mastitis (breast infection).
C. Explain to the client that this is a normal, age-related change.
D. Promptly refer the client for further medical assessment.
promptly refer the client for further medical assessment
127During chest auscultation, the nurse is assessing the client for the presence of a murmur of aortic regurgitation. How will the nurse proceed with the exam?
A. Ask the client to sit up, lean forward, and exhale.
B. Use the bell of the stethoscope and listen at the apex of the heart.
C. Ask the client to assume a left lateral position.
D. Have the client hold a deep breath and elevate the head of the bed 45 degrees.
ask the client to sit up, lean forward, and exhale
128The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action?
A. Isometric contraction
B. Closure of the semilunar valves
C. Beginning of diastole
D. Closure of the atrioventricular valves
closure of the atrioventricular valves
129nurse assesses a client's jugular venous pulse to gather information about which of the following?
A. Left arterial pressure.
B. Left ventricular diastolic filling.
C. Right ventricular pressure.
D. Hemodynamics of the right side of the heart.
Hemodynamics of the right side of the heart
130On examination, the nurse would expect what finding if a client is in right- sided failure?
A. Increased jugular venous pressure
B. Decreased right-sided volume
C. Decreased central venous pressure
D. Decreased stroke volume
Increased jugular venous pressure
131A client complains of palpitations and a feeling of anxiety. Which of the following would be most appropriate for the nurse to keep in mind?
A. This is a normal response by the heart's conduction system.
B. This is the body's response to an increase in cardiac output.
C. The heart is attempting to increase cardiac output. D. The heart is responding to increased renal perfusion.
the heart is attempting to increase cardiac output
132Which characteristic of the first heart sound would the nurse expect to hear in a client with mitral insufficiency?
A. Split
B. Diminished
C. Accentuated D. Varying
diminished
133A nurse is demonstrating the technique for auscultating heart sounds. Which of the following would be most important for the nurse to emphasize?
A. Start at the apex.
B. Listen over each of the heart chambers. C. Use both the bell and diaphragm.
D. Cover the entire precordium.
cover the entire precordium
134A group of students is reviewing information about the different types of murmurs. Which of the following would they identify as examples of midsystolic murmurs?
A. Innocent
B. Mitral regurgitation
C. Mitral stenosis
D. Ventricular septal defect
innocent
135After teaching a group of students about the great vessels, the instructor determines that the students need additional teaching when they identify which of the following as a great vessel?
A. Aorta
B. Pulmonary vein C. Femoral artery
D. Inferior vena cava
femoral artery
136The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse?
A. Perform the exam with the client in a supine position.
B. Have the client look straight ahead with chin slightly lifted.
C. Have the client sit up at a 90-degree angle.
D. Inspect the suprasternal notch or around the clavicles.
Inspect the suprasternal notch or around the clavicles
13731. A nurse is preparing a health education session for a local communitygroup. When addressing the relationship between coronary artery disease (CAD) and culture, what information would the nurse include?
A. Caucasians usually possess greater lifestyle risks for CAD than African
Americans.
B. Hypertension is more prevalent in African Americans than among Caucasians.
C. Hypertension is seen more in white women than in African-American women.
D. Hispanic Americans have a higher rate of CAD than white Americans.
hypertension is more prevalent in african americans than among caucasians
138The nurse is assessing a client who has a complex cardiac history. The nurse has asked the client to lean forward while in a sitting position. This position will allow the nurse to do which of the following?
A. Assess the client's heart sounds while preventing shortness of breath.
B. Identify heart sounds that may be inaudible in other positions. C. Assess the impact of the client's heart disease on his mobility. D. Differentiate heart sounds from breath sounds.
identify heart sounds that may be inaudible in other positions
139The nurse is preparing to assess a client's carotid arteries. Which nursing action would be most appropriate?
A. Palpate each artery individually to compare.
B. Palpate the arteries before auscultating them.
C. Use the diaphragm of the stethoscope.
D. Ask the client to breathe in and out deeply.
palpate each artery individually to compare
140A nurse is having difficulty identifying a client's heart sounds, specifically S1 and S2. What would be most appropriate for the nurse to do?
A. Use the bell of the stethoscope to help distinguish the sounds.
B. Palpate the carotid pulse while auscultating the heart.
C. Determine the pulse deficit. D. Palpate the apical impulse.
palpate the carotid pulse while auscultating the heart
141The nurse's auscultation of a 22-year-old client's apical heart rate reveals the presence of S3. When the client stands upright, the S3 is no longer audible. How should the nurse respond to this assessment finding?
A. Make a referral to the client's primary care provider promptly.
B. Perform a focused respiratory assessment.
C. Recognize this as an early sign of left-sided heart failure. D. Recognize this as a normal assessment finding in this client.
recognize this as a normal assessment finding in this client
142The nurse is auscultating a client's heart sounds and hears what she believes to be a murmur. How should the nurse proceed with gathering further assessment data related to the suspected murmur?
A. Auscultate with the bell and then without the stethoscope.
B. Ask the client to "bear down" (perform the Valsalva maneuver) while
auscultating.
C. Ask the client to inhale and exhale deeply while auscultating.
D. Auscultate with the client in a variety of different positions.
auscultate with the client in a variety of different positions
143The nurse's auscultation of the client's heart sounds reveals the presence of a split S1. What conclusion should the nurse draw from this assessment finding?
A. The client's ventricles are not contracting simultaneously.
B. The client's aortic valve is incompetent.
C. The client has left ventricular hypertrophy.
D. The client's atria are not synchronized with the ventricles.
the clients ventricles are not contracting simultaneously
144When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication?
A. Vitamin supplement with iron
B. Nonsteroidal anti-inflammatory drug
C. Antidepressant
D. Hormone replacement
vitamin supplement with iron
145A nurse determines that the liver span of an older adult male client measures 6 cm at the MCL. How would the nurse would interpret this finding?
A. It is a normal-sized liver.
B. The liver is larger than normal.
C. The liver is smaller than normal.
D. The liver has atrophied.
it is a normal sized liver. 6-12 at MCL and 4-8 at MSL
146While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating what complication? A. Hernia
B. Malignancy
C. Infection
D. Aneurysm
infection
147Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus?
A. Refer the client to an oncologist.
B. Provide a dietician consult for the client.
C. Counsel the client regarding hernia repair.
D. Stop palpating and get medical assistance.
stop palpating and get medical assistance
148Assessment of a client reveals a distended abdomen with some bulging of the flanks. Which test would be most accurate in confirming nurse's suspicions?
A. Shifting dullness
B. Fluid wave
C. Abdominal x-ray
D. Ultrasound
ultrasound
149The nurse is performing an abdominal assessment on a client with suspected appendicitis. How should the nurse assess for psoas sign in the client?
A. Applying deep palpation pressure to the client's right lower quadrant, then suddenly releasing
B. Tapping finger pads over the client's abdominal wall, feeling for a floating mass
C. Flexing the client's right hip and knee, rotating the hip internally and externally
D. Flexing the client's right hip, applying downward pressure on the right thigh
flexing the client's right hip, applying downward pressure on the right thigh
150When measuring abdominal girth in a client with ascites, the nurse would place the client in which position?
A. Sitting
B. Standing
C. Supine
D. Prone
standing
151An instructor is explaining the various causes associated with abdominal distention. Which of the following would the instructor include? Select all that apply.
A. Fat
B. Stool
C. Gas
D. Hernia
E. Fibroid tumors
remember the 6 f's. Fat, stool, gas, fibroid tumors
152A client is experiencing parietal abdominal pain. The nurse would expect the client to describe the pain as which type of sensation?
A. Dull
B. Steady
C. Cramping D. Burning
steady
153A nurse is describing viscera to a group of nursing students in the clinical area, differentiating solid viscera from hollow viscera. Which of the following would the nurse describe as hollow viscera? Select all that apply.
A. Liver
B. Stomach
C. Pancreas
D. Gallbladder
E. Small intestine
F. Urinary bladder
stomach, gallbladder, small intestine, urinary bladder
154The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate?
A. "I'm going to examine the area where you're having pain first to get a better picture of what's going on."
B. "Before I get ready to examine the painful area, I will let you know in plenty of time." C. "You don't need to worry about anything. I will make sure to be very gentle during the exam."
D. "Since you're having pain in a certain area, I won't have to do a very thorough
exam there."
Before i get ready to examine the painful area, I will let you know in plenty of time
155During deep palpation of the client's abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which nursing action would be most appropriate?
A. Refer the client for medical follow-up.
B. Evaluate further for a problem with the spleen. C. Assess urinary output.
D. Document the position of the liver.
document the position of the liver
156A nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion? A. Tenderness on palpation
B. Diastasis recti
C. Cullen sign
D. Tympany on percussion
cullen sign
157A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. What bowel sound would the nurse expect to assess in this client?
A. Normoactive
B. Hyperactive C. Hypoactive D. Absent
absent
158The nurse is percussing a client's liver and is assessing liver descent. What would the nurse have the client do next?
A. Cough forcefully
B. Hold the breath
C. Breathe in and out deeply
D. Perform the Valsalva maneuver
hold the breath
159While performing an abdominal assessment, the nurse auscultates a friction rub over the lower right costal area. The nurse should assess for other findings associated with which condition?
A. Hepatic abscess
B. Splenic infarction
C. The presence of pleural fluid
D. paralyzed diaphragm
hepatic abscess
160A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?
A. Positive Rovsing sign
B. Psoas sign present
C. Obturator sign positive
D. Positive skin hypersensitivity test
positive rovsing sign
161The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?
A. Absorbing electrolytes
B. Secreting digestive enzymes
C. Absorbing large amounts of water D. Secreting bile
absorbing large amounts of water
162A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor?
A. Excessive fat and sugar intake
B. Overuse of laxatives
C. Obesity
D. Inadequate abdominal muscle tone
overuse of laxatives
163The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?
A. Review the client's blood work for low platelets and hemoglobin.
B. Assess the client for signs and symptoms of fluid volume overload. C. Assess the client's nutritional status.
D. Assess the client for other signs and symptoms of liver disease.
assess the client for other signs and symptoms of liver disease
164The nurse is assessing the gastrointestinal system of an 81-year-old client. What age- related change should the nurse consider when collecting and analyzing assessment data?
A. The client is more vulnerable to impaired nutrition due to decreased appetite.
B. The client derives less nutritional value from food because of decreased enzyme production.
C. The client's liver will be significantly larger than that of a younger client.
D. The client will have greater bowel motility than a younger adult.
the client is more vulnerable to impaired nutrition due to decreased appetite
165The nurse is performing light palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment?
A. Ask the client to breathe slowly and deeply.
B. Perform auscultation prior to palpation.
C. Explain the procedure to the client before palpating.
D. Position the client sitting upright.
ask the client to breathe slowly and deeply
166Which finding, if noted when inspecting a client's mouth, would require immediate follow-up?
A. Thrush
B. Leukoplakia
C. Koplik spots D. Canker sore
Answer: B
Rationale: Leukoplakia is a precancerous lesion that requires immediate follow- up. Although thrush, which indicates a candidal infection; Koplik spots, which are an early sign of measles; and canker sores, which are associated with adrenocortical insufficiency, are abnormal findings, the evidence of leukoplakia is serious and needs immediate evaluation.
167A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information?
A. History of allergies
B. History of dysphagia
C. Frequency of nosebleeds D. Tonsillar enlargement
A Rationale: Rhinorrhea (thin, watery, clear nasal drainage) may indicate chronic allergy, which is the primary area for assessment and will yield the most pertinent information. Dysphagia would suggest a problem with the throat.
Nosebleeds may be seen with overuse of nasal sprays, excessively dry mucosa , hypertension, leukemia, and other blood disorders. Tonsillar enlargement may be associated with tonsillitis.
168While examining a client, the nurse notes fasciculation of the tongue. Which of the following would the nurse do next?
A. Have the client do a 24-hour diet recall
B. Review the client's medication regimen
C. Prepare the client for a thyroid screening D. Assess the client's cranial nerves
D
169A client with postnasal sinus drainage is seen in the clinic. When assessing the throat, the nurse would anticipate seeing which color drainage?
A. Green
B. Clear
C. Gray
D. Yellow
D
170The nurse is assessing a client's tonsils and note that they touch the uvula. The nurse would document this finding as which of the following?
A. 1+
B. 2+
C. 3+ D. 4+
C
171An older adult client with receding gums comes to the clinic. The nurse notes gum ischemia and worn tooth surfaces. Which question would be most important for the nurse to ask?
A. "Have you lost any teeth recently?"
B. "Do you have any difficulty chewing food?" C. "Have you had any mouth sores recently?" D. "Are you able to taste the food you eat?"
Answer: A
Rationale: The symptoms are normal age-related changes, which include increased susceptibility to periodontal disease and tooth loss. Asking about recent tooth loss would be most important given these specific symptoms. Further investigation could include questions about problems chewing due to loss of teeth if that is the case. Mouth sores and ability to taste are unrelated to the findings.
172While checking the preadmission history, the nurse notes that the client's history reveals deep tongue fissures. Which of the following orders would take priority?
A. Anterior-posterior and lateral chest x-ray
B. Complete blood count with differential
C. Dietitian referral
D. Intravenous fluid replacement
Answer: D
Rationale: Deep tongue fissures are seen in dehydration, so intravenous fluid therapy would be a priority. Chest x-ray may be indicated if the client exhibited cyanosis or respiratory difficulties. A complete blood count would be appropriate if the client exhibited signs and symptoms of anemia or shock such as pale mucosa or circumoral cyanosis. Dietician referral might be indicated if the assessment revealed a nutritional deficiency.
173The nurse assesses thick white plaques on the hard palate of a client. Which of the following would the nurse do next?
A. Further evaluate for AIDS.
B. Refer the client for medication.
C. Assess laboratory values for zinc deficiency. D. Assess the client for signs of jaundice.
B. yeast infection
174A client is noted to have a bifid uvula. The nurse understands that this finding is most common in which ethnic group?
A. Italian Americans
B. Native Americans
C. African Americans
D. Non-Hispanic Americans
B
175When examining a child who complains of a sore throat, the nurse notes swelling on either side of the child's oropharynx. The nurse would include which of the following when documenting this finding?
A. Enlarged pharyngeal tonsils
B. Enlarged palatine tonsils C. Enlarged adenoids
D. Enlarged lingual tonsils
B
176The nurse is inspecting the nasal mucosa of a client with chronic allergies. Which finding(s) should the nurse document as being consistent with the client’s condition? Select all that apply.
A. Small, pale, round, firm overgrowths
B. Perforated septum
C. Ulcers
D. Thick yellow-green purulent discharge
E. Swelling
F. Bluish gray color
A,E,F Chronic allergies may result in the presence of small, pale, round, firm overgrowths; swelling; and bluish gray color in the nasal mucosa. A perforated septum and ulcers may be seen with the use of cocaine, trauma, or chronic infection. Thick yellow- green purulent discharge is common with infection.
177When assessing a client for possible oral cancer, the nurse should most closely inspect which area?
A. Buccal mucosa
B. Hard palate
C. Area under the tongue D. Along the gum line
Answer: C
Rationale: Although cancers develop in the lining, in the salivary glands, tonsils, or base of the tongue, the area underneath the tongue is the most common site of oral cancer.
178In which client would the nurse identify receding gums as an expected assessment finding?
A. A 4-year-old girl who has all of her primary teeth
B. A 20-year-old man who has type 1 diabetes mellitus
C. A 39-year-old woman who has just finished a course of oral antibiotics D. A 77-year-old man who describes himself as being healthy
D
179The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis?
A. Resonance on percussion
B. Dull sounds
C. Tympanic sounds D. Pain on percussion
D
180When assessing the ear, which finding would be cause for concern? A. Darwin tubercle
B. Red, flaky cerumen
C. Tender tragus
D. Pearly gray tympanic membrane
Answer: C
Rationale: A tender tragus is associated with otitis externa or a postauricular cyst. Darwin's tubercle is a clinically insignificant finding. Normally, cerumen may be yellow, orange, red, brown, gray or black and soft, moist, dry, flaky, or even hard. A pearly gray tympanic membrane is a normal finding
181The nurse would suspect a problem at which area when pressure builds up on either side of the tympanic membrane?
A. Cochlea
B. Eustachian tube
C. Vestibulocochlear nerve D. Organ of Corti
b. The eustachian tube equalizes the pressure on either side of the tympanic membrane, which separates the external ear from the middle ear.
182A client has a sensorineural hearing loss. Which condition would the nurse most likely identify as a cause?
A. Perforated eardrum
B. Otosclerosis
C. Inner ear problem D. Otitis media
c
183A 60-year-old client has difficulty hearing high-pitched sounds. The nurse would document this finding as which of the following?
A. Vertigo
B. Otalgia
C. Tinnitus
D. Presbycusis
d. Presbycusis, a gradual hearing loss that often begins with a loss of the ability to hear high-frequency sounds, is common after age Vertigo refers to a true spinning motion. Otalgia refers to ear pain. Tinnitus refers to ringing in the ears.
184While assessing the ears of an 8-year-old client, the nurse observes white spots on the tympanic membrane with no redness present. Which action would be most appropriate? A. Assess the client for trauma to the skull. B. Determine whether impacted cerumen is present.
C. Ask the mother whether the child has had numerous ear infections. D. Assess the child for further symptoms of acute otitis media.
c. White spots on the tympanic membrane indicate scarring from previous infections. Therefore the nurse would ask the mother about a history of previous ear infections. A bluish or dark red color to the membrane would suggest skull trauma. Impacted cerumen would prevent the nurse from viewing the tympanic membrane. A red, bulging eardrum and a distorted, diminished, or absent light reflex would suggest acute otitis media.
185The results of a Rinne test show bone conduction is greater than air conduction. Which of the following would be most appropriate?
A. Complete a full hearing assessment
B. Generate a nursing diagnosis so interventions may be initiated
C. Write an initial plan of care and evaluate the results in 24-hours D. Refer the client for further evaluation
d
186A group of students is reviewing the structures of the ear in preparation for test. The students demonstrate understanding of the material when they identify which structure as part of the middle ear?
A. Tympanic membrane
B. Pinna C. Cochlea D. Malleus
D
187A client asks why cerumen is important, stating, "It just clogs up the ears anyway." How should the nurse best respond?
A. "It helps protect the delicate ear drum from loud noise that may be
damaging."
B. "It helps to keep the ear drum soft and functioning well."
C. "It helps to amplify the sound waves through the inner ear."
D. "It helps create the translucent, pearly color of the ear drum." Answer:
b
188The results of a client's Rinne test suggest that bone conduction and air conduction are both reduced. What nursing action would be most appropriate?
A. Perform a Romberg test.
B. Take a swab of the client's tympanic member.
C. Repeat the test in 5 to 10 minutes.
D. Refer the client for further evaluation.
d
189A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which information would the nurse describe?
A. Young children have a tendency to stick objects into their ear canal.
B. The size and shape of children's eustachian tubes makes them vulnerable. C. Children's immune systems lack the maturity to fight infections.
D. Children generally have poorer hygiene than adults.
B
190The nurse's assessment of an older adult client's ears and hearing suggests the possible presence of conductive hearing loss. What is the most likely etiology of this abnormal assessment finding?
A. Otitis media
B. Cranial nerve VIII damage C. Trauma to the temporal lobe D. Age-related hearing changes
A
191A clinic client's primary complaint is earache (otalgia). What question should the nurse include in the health interview?
A. "What do you do for a living?"
B. "Do you know if your vaccinations are up to date?"
C. "Do you take medications or supplements?" D. "Have you been swimming lately?"
D
192Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding?
A. Repeated ear infections
B. Trauma
C. Age-related changes D. Acute otitis media
D
193A 12-year-old client was brought to the emergency department after being hit in the head with a ball during a baseball game. What assessment finding in the ear would suggest to the nurse that an injury to the skull has occurred?
A. White spots on the tympanic membrane
B. Dark red or bluish tympanic membrane
C. Yellowish, bulging tympanic membrane
D. Translucent, pearly gray tympanic membrane
Answer: B
Rationale: A blue or dark red tympanic membrane indicates blood behind the eardrum due to trauma to the skull. A yellow appearance is suggestive of ear infection, and white spots or streaks are caused by recurrent infections. A translucent, pearly gray tympanic membrane is an expected finding.
194A client seeks medical attention for an earache. For which health problem should the nurse assess this client? Select all that apply.
A. Ear infection
B. Sinus infection
C. Dental problem D. Tension headache E. Cerumen blockage
A,B,C,E
195During an assessment the nurse learns that a client has been experiencing tinnitus "for weeks." Which medication should the nurse consider as causing this client's symptom? Select all that apply.
A. Aspirin
B. Digoxin
C. Verapamil
D. Furosemide
E. Acetaminophen
Answer: A, D
Rationale: Tinnitus or ringing in the ears may be associated with certain ototoxic medications which include furosemide and aspirin. Tinnitus is not identified as an adverse effect of digoxin, verapamil, or acetaminophen.
196When conducting the Weber test a client reports hearing the sound better in the right ear. What should this finding indicate to the nurse?
A. Conductive hearing loss in the left ear
B. Conductive hearing loss in the right ear
C. Infection of the auditory canal of the left ear D. Ruptured tympanic membrane of the right ear
B Rationale: With conductive hearing loss, the client reports hearing the sound better in the poor ear which in this case is the right ear
197A client complains of excessive tearing of the eyes. Which assessment would the nurse do next?
A. Inspect the palpebral conjunctiva
B. Assess the nasolacrimal sac
C. Perform the eye positions test D. Test pupillary reaction to light
b. Excessive tearing is caused by exposure to irritants or obstruction of the lacrimal apparatus. Therefore the nurse should assess the nasolacrimal sac. Inspecting the palpebral conjunctiva would be done if the client complains of pain or a feeling of something in the eye. The client is not exhibiting signs of problems with muscle strength such as drooping, so performing the eye position test, which assesses eye muscle strength and cranial nerve function, is not necessary. Testing the pupillary reaction to light evaluates pupillary response and function of the oculomotor nerve.
198During a health history, a 42-year-old male client reveals that he is seeing spots before his eyes. The nurse interprets this finding as the result of which of the following?
A. Increased ocular pressure
B. Vitamin A deficiency
C. Normal findings for client's age D. Vascular spasm
C
199Which of the following would a nurse expect to assess in a client with esotropia?
A. Eye turning outward
B. Eye malalignment
C. Eye turning inward D. Eye oscillating
C
200A nurse examines an older adult client. Which of the following would the nurse document as a normal finding?
A. Ectropion
B. Episcleritis
C. Chalazion
D. Exophthalmos
A
201What would the nurse expect to assess when examining the eyes of a client who reports a history of severe allergies?
A. Generalized redness
B. Pinguecula
C. Areas of dryness D. Nodular appearance
C
202A nurse is assessing the eyes of a young child. Which finding would the nurse document as normal?
A. Pseudostrabismus
B. Tropia
c. nystagmus
d. exotropia
A
203When observing the red reflex in a client who says, "I hope you can see it because I have cataracts," which of the following would the nurse find?
A. Black spokes pointing inward
B. White arc around the limbus
C. Thickened bulbar conjunctiva D. A red spot on the retina
A
204The nurse is performing a cardinal fields of gaze test on a client who has an inner ear infection. What would be an expected finding?
A. Strabismus
B. Phoria
C. Tropia
D. Nystagmus
D
205A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate?
A. Ask the client to remove the glasses before testing.
B. Have the client keep the glasses on but occlude one eye.
C. Test the client's near visual acuity instead.
D. Use the E chart rather than the Snellen chart for testing.
A
206The nurse is preparing to assess a client's visual fields to evaluate her gross peripheral vision. Which test would the nurse perform?
A. Cover test
B. Corneal light reflex test
C. Confrontation test D. Eye position test
C
207During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect? A. Myopia
B. Presbyopia C. Cataracts D. Tropia
B. Presbyopia is indicated when the client moves an object away from the eyes to focus. It is a common condition in clients over age 45. Myopia is impaired far vision. Cataracts typically are associated with painless blurring, light sensitivity, poor night vision, and a need for a brighter light to read. Tropia refers to a misalignment of the eyes.
208Inspection of a client's eyelids reveals significant lid swelling, moderate redness, but little pain. Which of the following would the nurse suspect?
A. Blepharitis
B. Hordeolum
C. Chalazion
D. Exophthalmos
C
209When using the ophthalmoscope, which of the following would the nurse do? A. Use the small round beam of white light
B. Use the right eye to examine the client's left eye
C. Move the ophthalmoscope around to get the best view
D. Approach the client at a 15-degree angle to the client's side
D
210After teaching a group of students about visual fields and visualpathways, the instructor determines that the teaching was successful when the students identify which of the following?
A. The optic nerves from each eyeball cross at the optic chiasma.
B. The visual field of each eye is divided into six quadrants.
C. The left side of the brain views the right side of the world.
D. The visual field of each eye provides a separate, distinct view.
A
211A nurse examines a client's retina and finds cotton-wool patches. Which of the following would the nurse suspect?
A. Glaucoma
B. Diabetes mellitus
C. Papilledema D. Optic atrophy
B
212A review of a client's history reveals cranial nerve IV paralysis. What finding would the nurse expect to assess?
A. The eye cannot look to the outside side.
B. Ptosis will be evident.
C. The eye cannot look down when turned inward. D. The eye will look straight ahead.
C
213A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, "Do you wear sunglasses during exposure to the sun?" the nurse is addressing a known risk factor for what health problem?
A. Presbyopia
B. Cataracts C. Nystagmus D. Glaucoma
B
214A nurse has performed the corneal light reflex test during a client's eye examination. During this test, the nurse appraised the client's eye alignment in which way?
A. By comparing the reflection of the light on the client's eye surface
B. By comparing the speed of pupillary constriction
C. By comparing how quickly the client blinks each eyelid
D. By comparing the relative color of the sclerae before and after light exposure
A
215A client wants to use beta-carotene supplements to reduce the risk of developing cataracts and age-related macular degeneration. For which reason should the nurse counsel the client to avoid using this supplement?
A. Smokes cigarettes
B. Eats a high-fat diet
C. Uses insulin for diabetes D. Has a sedentary lifestyle
A
216A client is concerned about a bright red area on the sclera. What should the nurse say to the client about this finding?
A. “You need to see an ophthalmologist immediately.”
B. “This can mean the pressure in your eye is too high.”
C. “You are in the process of having a detached retina.”
D. “This can occur with sneezing or coughing and is harmless.”
D
217Which factor if present in a client's lifestyle and health practices assessment would alert the nurse to the need for performing a more thorough head and neck assessment?
A. Alcohol abuse
B. Recreational drug use
C. Smokeless tobacco use D. Multiple sex partners
C. head and neck cancer
218When talking to a client before starting the physical exam, the nurse notes that the client's head is tilted to one side. Which of the following would the nurse examine first?
A. Hearing acuity
B. Thyroid gland
C. Mental status D. Lymph nodes
A
219The nurse examines a client and assesses a temporal artery that is hard, thick, and tender. The nurse would gather additional information related to which area?
A. Mental status
B. Hearing
C. Neurologic status D. Vision
D A hard, thick, and tender temporal artery suggests temporal arteritis, which can lead to blindness. Additional information about mental status, hearing, or neurologic status would not be needed based on this finding.
220Which vessel is the nurse assessing if the major artery of the neck is being examined? A. Carotid
B. Jugular
C. Temporal
D. Radial
A
221A group of students are reviewing the structures of the head and neck in preparation for an examination. The students demonstrate understanding of the material when they identify that the face has how many bones?
A. 8
B. 14 C. 18 D. 24
14. The face has 14 bones: 2 maxilla, 2 zygomatic, 2 inferior conchae, 2 nasal, 2 lacrimal, 2 palatine, 1 vomer, and 1 mandible. The cranium has 8 bones.
222A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?
A. 1
B. 2
C. 3 D. 4
b
223The nurse questions a client about any radiation therapy to the neck area based on the understanding about which of the following? A. Radiation therapy in that area can lead to enlarged lymph nodes.
B. The client may not be able to flex and extend his neck for the examination. C. Radiation therapy has been linked to the development of thyroid cancer. D. The client may experience dizziness and light-headedness more easily.
C
224A client describes their frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines?
A. "Do they occur with nausea?"
B. "When you consume alcohol, do you get a headache?"
C. "Do you have any eye pain?"
D. "Do you have any visual changes before the headache?"
D. typical migraine headache has prodromal symptoms that may include visual disturbances, vertigo, tinnitus, and/or numbness or tingling of the fingers and toes. Nausea, correlation with alcohol consumption, and eye pain may occur with migraines, but may also occur with other types of headaches.
225A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation?
A. Sternocleidomastoid muscle
B. Sternal notch
C. Submental space
D. Supraclavicular space
B. To palpate the trachea, the nurse would first place a finger in the sternal notch and then feel each side of the notch and palpate the tracheal rings
226The nurse is assessing the cervical spine of an older adult client. Which finding will the nurse document as abnormal?
A. Stiffness and rigidity
B. Cervical curvature
C. Accumulation of fat around cervical vertebrae D. Visible and palpable C7 vertebrae
A
227A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding?
Tenderness
228The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess?
A. Sunken face
B. Drooping of one side
C. Mask-like expression D. Asymmetry of earlobes
c
229 A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which principle?
A. The thyroid gland is not normally palpable in female clients.
B. Many clients have an additional (third) thyroid lobe.
C. The thyroid gland is not normally palpable until clients are in their thirties or forties. D. Palpation creates a risk of rupturing the thyroid gland in some older adult clients.
B
230A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers?
A. Teaching about genetic screening
B. A nutritional health program
C. Teaching about monthly self-examination D. A smoking cessation program
D
231A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify? Select all that apply.
A. Sternocleidomastoid muscle
B. Hyoid bone
C. Cricoid cartilage D. Carotid artery E. Esophagus
C,D
232The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform?
A. Obtain a full set of vital signs.
B. Percuss the client's thyroid.
C. Auscultate the client's thyroid.
D. Perform a swallowing assessment.
c
233The nurse is concerned that a client is at risk for the development of head and neck cancer. What finding caused the nurse to have this concern? Select all that apply.
A. Wears dentures
B. Smokes cigarettes
C. Has bleeding gums
D. Takes acetaminophen
E. Ingests alcohol every day
b,e
234The nurse notes that a client's trachea is pushed to the right side of the neck. What health problem could this client be experiencing? Select all that apply.
A. Tumor
B. Pneumothorax
C. Aortic aneurysm
D. Pulmonary embolism E. Enlarged thyroid lobe
abce
235The nurse notes that a client's right lobe of the thyroid gland is larger than the left. What should the nurse consider as being the reason for this finding?
A. Thyroiditis
B. Malignancy
C. A normal finding D. Hyperthyroidism
c
236A client is admitted for treatment of hypothyroidism. What will the nurse expect to assess in this client? Select all that apply.
A. Edema around the eyes
B. Exophthalmosis Decreased ability to taste D. Dry, coarse, and sparse hair E. Puffy, dull face
ADE
237During a scrotal exam, the nurse notes an enlarged scrotal sac that easily transilluminates. Which of the following would the nurse suspect?
A. Tumor
B. Hernia
C. Varicocele D. Hydrocele
D
238Which question would be most important to ask a married male client with a varicocele?
A. "Do you want to have children?"
B. "Have you and your wife attempted a pregnancy together?"
C. "Does intercourse cause you pain?"
D. "Have you ever felt a mass during your testicular exam?"
b
239When inspecting a client's inguinal area for bulging, what would be most appropriate for the nurse to have the client do?
A. Bend forward from the waist
B. Cough after turning his head
C. Hold his breath after exhaling
d. stand on one foot
b
240Inspection of a client's penis reveals that the urethral meatus is located on the ventral side of the penis. The nurse documents this finding as which of the following?
A. Epispadias
B. Hypospadias
C. Paraphimosis D. Phimosis
b
241The nurse is reviewing lifestyle changes with a client who is attempting to reduce the risk for colon and prostate cancer. Which statement by the client requires further follow- up by the nurse?
A. “I have been increasing the fiber in my diet.”
B. “I have started to finally get my weight under control.” C. “I am now abstaining from alcohol.”
D. “I am on a high-protein diet that includes red meats.”
d
242Which of the following would be most important for the nurse to remember when performing the physical examination of the anus and rectum? (Select all that apply.) A. Perform the steps of the exam quickly.
B. Use gentle finger movements.
C. Use adequate lubrication.
D. Watch for nonverbal signs of discomfort. E. Explain all the steps before beginning.
bce
243When describing the prostate gland to a group of students, the instructor would explain that this gland does which of the following?
A. Secretes a thin, milky fluid to promote sperm motility
B. Produces the ejaculate that nourishes the sperm
C. Secretes mucus to make female vaginal sections more acidic D. Aids in transporting the sperm away from the testes
A
244When examining a newborn male infant, the nurse notes that neither testicle is descended. How would the nurse document this finding?
A. Epididymitis
B. Orchitis
C. Cryptorchidism D. Varicocele
c
245While interviewing a teenage male client, the nurse reviews the various structures of the male genitalia. The client asks, "So what does this epididymis do?" What would the nurse include in the response?
A. “It allows sperm to mature.”
B. “It transports sperm away from the testes.” C. “It separates the testes from the scrotal wall.” D. “It produces sperm and male sex hormones.”
a
246During a client's genitourinary exam, the nurse notes that the client's scrotum is enlarged and easily transilluminates. What should the nurse suspect?
A. Tumor
B. Hernia
C. Varicocele D. Hydrocele
d
247 A client complains of scrotal pain, and the nurse elicits a positive Prehn sign. The nurse would refer the client for treatment of what condition?
A. Strangulated hernia
B. Tortuous varicocele
C. Epididymitis D. Scrotal mass
c
248A client's electronic health record reveals that he had surgery as an infant to correct the fact that his urethra was located on the ventral side of his penis. The nurse should recognize that this client had what condition?
A. Epispadias
B. Hypospadias C. Paraphimosis D. Phimosis
b
249Palpation of a male client's urethra produces a yellowish-white discharge. What is the nurse's best action?
A. Obtain a urine sample for culture and sensitivity testing.
B. Obtain a sample of the discharge for culture.
C. Ask the client to void and then repeat palpation of the client's urethra. D. Palpate the client's scrotum and testes for the presence of fluid.
b
250 A nurse is performing transillumination as part of the assessment of a client's swollen scrotum. What finding constitutes a normal scrotum?
A. The testes transilluminate, but the other regions of the scrotum do not.
B. Transillumination of the scrotum results in a pale yellow or white glow.
C. Transillumination of the scrotum results in a red glow. D. Contents of the scrotum do not transilluminate.
d
251A male client has presented for follow-up to a diagnosis of genital warts. The nurse should expect to assess for what type of lesions?
A. Reddened ulcers that occasionally bleed B. Pimple-like vesicles
C. Firm, shiny nodules
D. Moist, fleshy papules
d
252A nurse is describing Skene glands, explaining that these glands would be found at which location?
A. Inside the vaginal orifice
B. Beside the posterior vaginal opening
C. Above the clitoris
D. On either side of the urethral opening
d
253A client has been to the clinic multiple times in the past year with vaginal infections, the most frequent of which was candidiasis. The nurse would assess the client for symptoms most likely related to which condition?
A. Intestinal parasites
B. Urinary tract infections C. Hypothyroidism
D. Diabetes mellitus
d
254During the health history, the nurse teaches a client about toxic shock syndrome (TSS) and ways to reduce risks. The nurse determines that the teaching was successful when the client makes which statement(s)? Select all that apply.
A. "I will get a Pap smear regularly."
B. "It is important to use latex condoms."
C. "I should avoid the prolonged continual use of tampons."
D. "I should stop using oral contraceptives."
E. “I will not be using menstrual cups.”
F. “I am going to watch for symptoms even if I’m not menstruating.”
c,e,f
255After teaching a group of students about the female genitalia, the instructor determines that the teaching was successful when the students identify which of the following as internal genitalia? Select all that apply.
A. Mons pubis
B. Vagina
C. Clitoris
D. Adnexa
E. Labia majora
F. Bartholin glands
b,d
256The nurse is about to do a general routine screening assessment of the genitalia, anus, and rectum for a female client. What should the nurse include in the exam? Select all that apply.
A. Inspect the mons pubis, labia majora, and perineum.
B. Inspect the labia minora, clitoris, urethral meatus, and vaginal opening. C. Inspect the perianal area and sacrococcygeal area.
D. Palpate Bartholin glands and urethra.
E. Inspect the cervix, vagina, and vaginal walls.
F. Palpate the rectum and rectal sphincter.
a,b,c
257The nurse is presenting a class to a group of high school students about sexually transmitted infections. What would the nurse include as a major risk factor for cervical cancer?
A. Gonorrhea
B. Candidiasis
C. Syphilis
D. Human papilloma virus
d
258The nurse is assessing a female client's genitourinary system. What finding would lead the nurse to suspect a problem with the ovaries during palpation?
A. Slight tenderness on palpation
B. Walnut-sized ovaries
C. Immobile ovaries
D. Smooth ovarian surface
c
259The nurse is assessing the genitalia and rectum of a 71-year-old client. When assessing the client's vagina, the nurse should know that age-related changes increase the client's risk of what abnormal finding?
A. Trichomonas vaginitis B. Bacterial vaginosis
C. Candidal vaginitis
D. Atrophic vaginitis
d
260A nurse is preparing a female client for a genitourinary examination that has been scheduled for later in the week. What anticipatory guidance should the nurse provide to the client?
A. "Stop taking any antibiotics for 24 hours before your examination."
B. "Make sure not to douche for 48 hours before the examination."
C. "Don't bathe or shower on the morning of the appointment."
D. "Drink at least 48 ounces of fluid the morning before the appointment."
b
261An adult client has sought care at the clinic, stating that she believes she has "a raging yeast infection." The nurse would expect to assess what type of
vaginal discharge?
A. Thick, white vaginal discharge
B. Copious clear, foul-smelling discharge C. Yellowish discharge with a metallic odor D. Blood-tinged vaginal discharge
a