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Test bank for health assessment in nursing 6th edition by
weber
Nursing Process for Symptom Management (Houston Community College)
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TEST BANK FOR HEALTH
ASSESSMENT IN NURSING 6TH
EDITION BY WEBER ALL CHAPTERS
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TEST BANK FOR
HEALTH
ASSESSMENT
IN NURSING
6TH EDITION
BY WEBER
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CHAPTER 1: NURSE’S ROLE IN HEALTH ASSESSMENT: COLLECTING AND ANALYZING DATA
1. A nurse on a postsurgical unit is admitting a client following the client's
cholecystectomy (gall bladder removal). What is the overall purpose of assessment for
this client?
A) Collecting accurate data
B) Assisting the primary care provider
C) Validating previous data
D) Making clinical judgments
2. A client has presented to the emergency department (ED) with complaints of abdominal
pain. Which member of the care team would most likely be responsible for collecting the
subjective data on the client during the initial comprehensive assessment?
A) Gastroenterologist
B) ED nurse
C) Admissions clerk
D) Diagnostic technician
3. The nurse has completed an initial assessment of a newly admitted client and is applying
the nursing process to plan the client's care. What principle should the nurse apply when
using the nursing process?
A) Each step is independent of the others.
B) It is ongoing and continuous.
C) It is used primarily in acute care settings. N
D) It involves independent nursing actions.
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and
perform a comprehensive health assessment. Which of the following actions should the
nurse perform first?
A) Review the client's medical record.
B) Obtain basic biographic data.
C) Consult clinical resources explaining the client's diagnosis.
D) Validate information with the client.
5. Which of the following client situations would the nurse interpret as requiring an
emergency assessment?
A) A pediatric client with severe sunburn
B) A client needing an employment physical
C) A client who overdosed on acetaminophen
D) A distraught client who wants a pregnancy test
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10. A nurse has completed gathering some basic data about a client who has multiple health
problems that stem from heavy alcohol use. The nurse has then reflected on her personal
6. In response to a client's query, the nurse is explaining the differences between the
physician's medical exam and the comprehensive health assessment performed by the
nurse. The nurse should describe the fact that the nursing assessment focuses on which
aspect of the client's situation?
A) Current physiologic status
B) Effect of health on functional status
C) Past medical history
D) Motivation for adherence to treatment
7. After teaching a group of students about the phases of the nursing process, the instructor
determines that the teaching was successful when the students identify which phase as
being foundational to all other pha ses?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who has been
admitted for the treatment of community-acquired pneumonia. Following the
completion of this assessment, the nurse periodically performs a partial assessment
primarily for which reason?
A) Reassess previously detected
N problems
B) Provide information for the client's record
C) Address areas previously omitted
D) Determine the need for crisis intervention
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city
neighborhood. Which client would the nurse determine to be in most need of an
emergency assessment?
A) A 14-year-old girl who is crying because she thinks she is pregnant
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
C) A 3-year-old child with fever, rash, and sore throat
D) A 20-year-old man with a 3-inch shallow laceration on his leg
feelings about the client and his circumstances. The nurse does this primarily to
accomplish which of the following?
A) Determine if pertinent data has been omitted
B) Identify the need for referral
C) Avoid biases and judgments
D) Construct a plan of care
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11. The nurse is collecting data from a client who has recently been diagnosed with type 1
diabetes and who will begin an educational program. The nurse is collecting subjective
and objective data. Which of the following would the nurse categorize as objective data?
A) Family history
B) Occupation
C) Appearance
D) History of present health concern
12. An older adult client has been admitted to the hospital with failure to thrive resulting
from complications of diabetes. Which of the following would the nurse implement in
response to a collaborative problem?
A) Encourage the client to increase oral fluid intake.
B) Provide the client with a bedtime protein snack. N
C) Assist the client with personal hygiene.
D) Measure the client's blood glucose four times daily.
13. The nurse at a busy primary care clinic is analyzing the data obtained from the following
clients. For which clients would the nurse most likely expect to facilitate a referral?
A) An 80-year-old client who lives with her daughter
B) A 50-year-old client newly diagnosed with diabetes
C) An adult presenting for an influenza vaccination
D) A teenager seeking information about contraception
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The
instructor determines that the teaching was successful when the students identify which
of the following as the major method used by nurses early in the history of the
profession? A) Natural senses
B) Biomedical knowledge
C) Simple technology
D) Critical pathways
15. When describing the expansion of the depth and scope of nursing assessment over the
past several decades, which of the following would the nurse identify as being the
primary force? A) Documentation
B) Informatics
C) Diversification
D) Technology
16. A group of nurses are reviewing information about the potential opportunities for nurses
who have advanced assessment skills. When discussing phenomena that have
contributed to these increased opportunities, what should the nurses identify?
A) Expansion of health care networks
B) Decrease in client participation in care
C) The shrinking cost of medical care
D) Public mistrust of physicians
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17. A nurse has documented the findings of a comprehensive assessment of a new client.
What is the primary rationale that the nurse should identify for accurate and thorough
documentation?
A) Guaranteeing a continual assessment process B)
Identifying abnormal data N
C) Assuring valid conclusions from analyzed data
D) Allowing for drawing inferences and identifying problems
18. A nurse has received a report on a client who will soon be admitted to the medical unit
from the emergency department. When preparing for the assessment phase of the nursing
process, which of the following should the nurse do first? A) Collect objective data.
B) Validate important data.
C) Collect subjective data.
D) Document the data.
19. A community health nurse is assessing an older adult client in the client's home. When
the nurse is gathering subjective data, which of the following would the nurse identify?
A) The client's feelings of happiness
B) The client's posture
C) The client's affect
D) The client's behavior
20. A nurse on the hospital's subacute medical unit is planning to perform a client's focused
assessment. Which of the following statements should inform the nurse's practice? A)
The focused assessment should be done before the physical exam.
B) The focused assessment replaces the comprehensive database.
C) The focused assessment addresses a particular client problem.
D) The focused assessment is done after gathering subjective data.
21. The nurse is reviewing a client's health history and the results of the most recent physical
examination. Which of the following data would the nurse identify as being subjective?
Select all that apply.
A) ìI feel so tired sometimes.î
B) Weight: 145 lbs
C) Lungs clear to auscultation
D) Client complains of a headache
E) ìMy father died of a heart attack.î
F) Pupils equal, round, and reactive to light
22. The nurse has been applying the nursing process in the care of an adult client who is
being treated for acute pancreatitis. Place the nurse's actions in their proper sequence
from first to last.
A)
B)
C)
D)
E)
Identifying outcomes C,B,A,E,D
Determining client's nursing problem N
Collecting information about the client
Determining outcome achievement
Carrying out interventions
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23. A nurse is completing an assessment that will involve gathering subjective and objective
data. Which of the following assessment techniques will best allow the nurse to collect
objective data?
A) Inspection
B) Therapeutic communication
C) Interviewing
D) Active listening
24. The nurse is performing a health assessment on a community-dwelling client who is
recovering from hip replacement surgery. Which of the following actions should the
nurse prioritize during assessment?
A) Focus the assessment on the client as a member of her age group.
B) Interpret the information about the client in context.
C) Corroborate the client's statements with trusted sources.
D) Gather information from a variety of sources.
25. A client comes to the health care provider's office for a visit. The client has been seen in
this office on occasion for the past 5 years and arrives today complaining of a fever and
sore throat. Which type of assessment would the nurse most likely perform?
A) Comprehensive assessment
B) Ongoing assessment
C) Focused assessment
D) Emergency assessment
26. A nurse has assessed a client who was admitted to the medical unit to treat acute
complications of type 1 diabetes. During the assessment, the client admitted that his
blood sugar monitoring when he is at home is ìa bit sporadic.î How should the nurse best
respond to this assessment finding?
A) Identify a nursing diagnosis of Ineffective Health Maintenance.
B) Identify a collaborative problem that should involve the occupational therapist.
C) Make a referral to the unit's social work department.
D) Reassess the client's blood glucose level.
27. The nurse is utilizing the Health Belief Model in the care of a client whose type 1
diabetes is inadequately controlled. When implementing this model, the nurse should
begin by assessing which of the following?
A) The client's motivation for change N
B) The client's medical comorbidities
C) The client's learning style
D) The client's prognosis for recovery
28. A nurse will complete an initial comprehensive assessment of a 60-year-old client who is
new to the clinic. What goal should the nurse identify for this type of assessment? A)
Identify the most appropriate forms of medical intervention for the client.
B) Determine the most likely prognosis for the client's health problem.
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C) Identify the status of the client's airway, breathing, and circulation.
D) Establish a baseline for the comparison of future health changes.
30. A client who is new to the facility has a recent history of chronic pain that is attributed
to fibromyalgia. The nurse has reviewed the available health records and suspects that
pain management will be a major focus of nursing care. How can the nurse best validate
this assumption?
A) Review the client's medication administration record for analgesic use.
B) Ask the client about the most recent experiences of pain.
C) Meet with the client's spouse and daughter to discuss the client's pain.
D) Collaborate with the physician who is treating the client.
N
29. A nurse who provides care in a hospital setting is creating a plan of nursing care for a
client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent
ongoing assessments. The frequency of these nursing assessments should be primarily
determined by what variable? A) The client's age
B) The unit's protocols
C) The client's acuity
D) The nurse's potential for liability
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Answer Key
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
D
B
B
A
C
B
A
A
B
C
C
D
B
A
D
A
C
C
A
C
A, D, E
C, B, A, E, D
A
B
C
A
A
D
C
B
N
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CHAPTER 2: COLLECTING
THE
INTERVIEW
AND HEALTH
HISTORY
CHAPTER 2: COLLECTING SUBJECTIVE DATA: THE INTERVIEW AND HEALTH HISTORY
1.
A nurse is preparing to assess a client who is new to the clinic. When beginning the
collection of the client database, which of the following actions should the nurse
prioritize?
A)
Establishing a trusting relationship
B)
Determining the client's strengths
C)
Identifying potential health problems
D)
Making clinical inferences
2. A nurse is interpreting and validating information from an older adult client who has
been experiencing a functional decline. The nurse is in which phase of the interview?
A)
Introductory
B)
Working
C)
Summary
D)
Closing
3. A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and
the nurse is collecting subjective data prior to surgery. Which statement by the nurse
could be construed as judgmental?
A)
“How often do your adult children typically visit you?”
B)
“Your husband's death must have been very difficult for you.”
C)
“You must quit smoking because it affects others, not only you.”
D)
“How would you describe your feelings about getting older?” N
4. A nurse is interviewing a 22-year-old client of the campus medical clinic. Which
nonverbal behavior should the nurse adopt to best facilitate communication during this
phase of assessment?
A)
Standing while the client is seated
B)
Using a moderate amount of eye contact
C)
Sitting across the room from the client
D)
Minimizing facial expressions
5. A nurse is providing feedback to a colleague after observing the colleague's interview of
a newly admitted client. Which of the following would the nurse identify as an example
of a closed-ended question or statement?
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A)
B)
C)
D)
“Tell me about your relationship with your children?”
“Tell me what you eat in a normal day?”
“Are you allergic to any medications?”
“What is your typical day like?”
6. A client has presented to the emergency department and is having difficulty describing
her vague sensation of physical discomfort and unease. How can the nurse best elicit
meaningful assessment data about the nature of the client's complaint?
A)
Ignore the complaint for now and return to it later in the assessment.
B)
Provide a laundry list of descriptive words.
C)
Restate the question using simpler terms.
D)
Wait in silence until the client can determine the correct words.
7. A nurse is eliciting a client's health history and the client asks, “Can I take the herb
ginkgo biloba with my other medications?” What action would be best if the nurse is
unsure of the answer?
A)
Promise to find out the information for the client.
B)
Change the subject and return to this topic later.
C)
Teach the client to only take prescribed medications.
D)
Encourage the client to ask the pharmacist or primary care provider.
8. The nurse is preparing to assess the mental status of a 90-year-old client who is being
admitted to the hospital from a long-term care facility. Which of the following should
the nurse assess first?
A)
The client's sensory abilities
B)
The client's general intelligence C) The presence of any phobias N
D) The client's judgment and insight
9. A nurse provides care in a rural hospital that serves a community that has few minority
residents. When interviewing a client from a minority culture, the nurse has enlisted the
assistance of a “culture broker.” How can this individual best facilitate the client's care?
A)
By interpreting the client's language and culture
B)
By evaluating the client's culturally based health practices
C)
By teaching the client about health care
D)
By making the client feel comfortable and safe
10. Upon entering an exam room, the client states, “Well! I was getting ready to leave. My
schedule is very busy and I don't have time to waste waiting until you have the time to
see me!” Which response by the nurse would be most appropriate? A) “Our schedule is
very busy also. We got to you as soon as we could.”
B) “No one is forcing you to be here, and you are free to leave at any time.”
C) “Would you like to report your complaints to someone with power?”
D) “You're certainly justified in being upset, but I am ready to begin your exam now.”
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11. A nurse has admitted a client to the medical unit and is describing the purpose for
obtaining a comprehensive health history. Which of the following purposes should the
nurse describe?
A)
“This helps us to complete your health record accurately.”
B)
“This helps us to establish a trusting interpersonal relationship.”
C)
“This helps us to evaluate the seriousness of your risk factors for disease.” D)
“This helps us have an appropriate focus for the physical examination.”
12. A clinic nurse has reviewed a new client's available health record and will now begin
taking the client's health history. Which of the following questions should the nurse ask
first when obtaining the health history?
A)
“Do you have adequate health insurance coverage?”
B)
“Are you generally fairly healthy?”
C)
“What is your major health concern at this time?”
D)
“Did you bring all your medications with you?”
13. A client has presented for care with complaints of persistent lower back pain. When
using the mnemonic COLDSPA, which question should the nurse use to evaluate the
“P”?
A)
“What makes it worse?”
B)
“When did it start?”
C)
“How does it feel?” N
D)
“How would you rate your pain?”
14. A medical nurse has completed the review of systems component of the client's health
history. Which assessment finding should the nurse document under the review of
systems?
A)
“High school diploma plus 2 years of college”
B)
“Caregiver reliable source of information”
C)
“Menarche at age 13”
D)
“Lungs clear to auscultation bilaterally”
15. A client has been admitted following an unexplained weight loss of 15 pounds over the
past 3 months. How should the nurse best assess the subjective component of the client's
nutritional status?
A)
Ask the client to explain MyPlate.
B)
Obtain a 24-hour diet recall.
C)
Ask about the contents of one typical meal.
D)
Elicit the client's favorite foods.
16. A client's elevated body mass index (BMI) has prompted the nurse to assess the client's
activity and exercise level. Which statement would indicate to the nurse that the client is
getting the recommended amount of exercise?
A)
“I walk briskly on the treadmill once or twice a week.”
B)
“I play basketball with a team every Friday night without fail.”
C)
“I go to a step class for an hour three times a week.”
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D)
“I swim for at least half an hour each Saturday morning.”
17. During an assessment, the nurse determines that a client sees more than one primary care
provider and has obtained prescriptions from each provider. Which method would be
most appropriate to determine a client's current medication regimen? A) Ask the client to
identify which medications taken every day.
B) Ask the client to bring all the medications and supplements to an interview.
C) Ask the caregiver whether the client is taking prescribed medications.
D) Ask the client about the use of any over-the-counter medications.
18. The nurse is preparing to assess an adult woman's activities related to health promotion
and maintenance. Which question should the nurse ask to obtain the most objective and
thorough assessment data?
A)
“Do you always wear your seatbelt when driving?”
B)
“How much beer, wine, or alcohol do you drink?”
C)
“Do you use condoms with each sexual encounter?” N
D)
“Could you describe how you perform self-breast exams?”
19. A nurse is creating a genogram of a client's family health history. The nurse should use
which of the following symbols to denote the client's female relatives?
A)
Circle
B)
Square
C)
Triangle
D)
Rectangle
20. A client has just been admitted to the postsurgical unit from postanesthetic recovery, and
the nurse is in the introductory phase of the client interview. Which of the following
activities should the nurse perform first?
A)
Collaborate with the client to identify problems.
B)
Explain the purpose of the interview.
C)
Determine the client's vital signs.
D)
Obtain family health history data.
21. During the interview, the client states, “Is today the 12th? My wife died 2 months ago
today.” Which of the following responses would be most appropriate?
A)
“What was the cause of your wife's death?”
B)
“How does that make you feel right now?”
C)
“You probably must be sad.”
D)
“Are you feeling sad, depressed, angry, or upset?”
22. The nurse is using the mnemonic “COLDSPA” to assess a client's complaint of lower
abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse
is assessing which aspect of the complaint?
A)
Character
B)
Onset
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C)
D)
Severity
Pattern
23. The nurse is obtaining information about a client's past health history. Which client
statement would best reflect this component of assessment?
A)
“My mom's still alive, but my dad died 10 years ago of heart failure.”
B)
“I have a brother with leukemia and a sister with hypertension.”
C)
“I had surgery 5 years ago to repair an inguinal hernia.”
D)
“I have been having some pain when I urinate for the last several days.”
N
24. A nurse is teaching a recent nursing graduate about the significance of verbal and
nonverbal communication during client care. The new graduate demonstrates an
understanding of these techniques by citing what example of verbal communication?
A)
Maintaining an open attitude
B)
Using silence appropriately
C)
Providing a laundry list of descriptors when needed
D)
Maintaining an open and encouraging facial expression
25. The admission of a new resident to a long-term care facility has necessitated a thorough
health history. Place the following focuses in the correct sequence in which the nurse
should perform them, beginning with the section obtained first.
A)
Family health history
B)
Reason for seeking care
C)
Biographic data
D)
Review of body systems
E)
History of present concern
F)
Past health history
26. The nurse is completing a review of systems for a client. Which of the following
information would the nurse document related to the client's musculoskeletal system?
Select all that apply.
A)
Joint stiffness
B)
Rhinorrhea
C)
Shortness of breath
D)
Chest pain
E)
Muscle strength
F)
Knee swelling
27. The nurse is completing an assessment of a 50-year-old female client who has sought
care for recurrent migraines that have not responded to treatment. Following the review
of systems, how should the nurse best document unremarkable results of the subjective
portion of the gastrointestinal assessment?
A)
“Client's gastrointestinal health is within reference ranges for age.”
B)
“Client denies GI signs and symptoms.”
C)
“Gastrointestinal problems are absent.”
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D)
“Client denies recent constipation, diarrhea, bowel incontinence, or abdominal
pain.”
28. A 60-year-old woman with a bunion will undergo surgery later today. The client tells the
nurse in the surgical daycare admitting department, “I'm sure I've been asked these N
questions before. Can't we just focus on my foot and not all these other topics?” How
should the nurse best explain the rationale for obtaining a health history?
A)
“In general, it's necessary for us to gather as much information about each client
as possible.”
B)
“We want to make sure your nursing care matches your needs as closely as
possible.”
C)
“The care team needs to cross-reference your diagnostic testing with the
information that I'm asking you about.”
D)
“We don't want to make the mistake of focusing solely on the medical problem
that brought you here.”
29. During the nurse's assessment of the client's exercise and activity habits, the client
laughs and then states, “Unless you're including channel surfing, I don't really do much
of anything.” How should the nurse best follow up this client's statement? A) Briefly
describe some of the potential benefits of regular exercise.
B) Ask the client if he understands the risk factors for heart disease and diabetes.
C) Explain to the client that he should be performing aerobic exercise for 20 to 30
minutes at least three times a week.
D) Document the nursing diagnosis of Risk for Activity Intolerance related to
sedentary lifestyle.
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Answer Key
30.
A 1.
B 2.
C 3.
B 4.
C 5.
B 6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
A nurse is obtaining subjective data from an adult client who is new to the clinic. The
nurse
has asked the client, “Where do you usually turn for help in a time of crisis?”
A
What
domain is this nurse assessing?
B
A)
The
client's family relationships
C
B)
B The client's current level of social and relational stability
C)
C The client's critical thinking and problem-solving abilities
D)
B The client's stress management and coping strategies
A
A
A
D
D
C
A
C
B
C
B
D
A
B
B
C
N
C
C
C, B, E, F, A, D
A, E, F
D
B
A
D
!
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CHAPTER 3: COLLECTING OBJECTIVE DATA: THE PHYSICAL EXAMINATION
1. A client has presented to the clinic for the treatment of an ovarian cyst. Which of the
following would be most important for the nurse to do immediately before performing
this woman's physical exam?
A) Explain the purpose of the interview to the client.
B) Construct the client's family genogram.
C) Establish the client's reliability as historian.
D) Collect necessary equipment essential to the exam.
2. A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test
and pelvic examination. The nurse is implementing actions to help reduce a client's
anxiety during the physical exam. Which of the following would be most appropriate?
A) Ensuring client's privacy by providing an examination gown
B) Providing a comfortable, warm room temperature
C) Arranging exam equipment on a bedside tray table
D) Explaining why standard precautions are being used
3. A nurse is admitting a new client to the subacute medical unit and is completing a
comprehensive assessment. The nurse is appropriately applying standard precautions by
performing which of the following actions?
A) Performing hand hygiene between examinations of each body part
B) Discarding in the trash can the safety pin that was used to assess sensory perception
C) Wearing gloves to palpate the tongue and buccal membranes N
D) Wearing a gown, gloves, and mask during the physical exam
4. The nurse is using a Wood's light for a client who has complaints of itching, burning,
and peeling of the skin between his toes. The nurse is assessing for what etiology of the
client's symptoms? A) Parasitic infection
B) Fungal infection
C) Bacterial infection
D) Allergic reaction
5. A nurse has gathered the necessary equipment for the physical assessment of an adult
client. For which of the following assessments would it be most appropriate for a nurse
to use a centimeter-scale ruler for measurement?
A) Mid-arm circumference
B) Client's height
C) Skin lesion size
D) Pupillary size
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6. The nurse is preparing to assess an older adult client's near vision. Which of the
following pieces of equipment would be most appropriate for the nurse to use?
A) Newspaper
B) Snellen chart
C) Ophthalmoscope
D) Penlight
7. A nurse practitioner is performing a comprehensive physical examination of a 51yearold man. After performing a digital-rectal exam for prostate enlargement and
tenderness, the nurse checks the fecal material on the gloved finger for the presence of
which of the following?
A) Parasites
B) Blood
C) Bacteria
D) Fungus
8. The nurse is examining an older adult client and using a goniometer. Which of the
following would the nurse be assessing?
A) Extremity edema
B) Joint flexion/extension
C) Two-point discrimination
D) Vibratory sensation N
9. A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She
says ìAbsolutely not! There's no way I'll let you do that to me!î Which response by the
nurse would be most appropriate?
A) Explain the importance of the pelvic exam and Pap smear, but respect the client's
wishes and omit the exam.
B) Tell the client that this is the only way she can be checked for cancer.
C) Ask the client if she would prefer another practitioner to perform the exam.
D) Proceed with the pelvic exam and document the client's protests in the health record.
10. The nurse is preparing to perform a physical examination on a female client who has
been transferred to the medical unit from the emergency department. The nurse should
begin the collection of objective data with which of the following examinations?
A) Head and neck examination
B) Palpation of lymph nodes
C) Breast examination
D) Vital signs
16. The emergency department (ED) nurse is assessing for kidney tenderness in a client who
has presented with complaints of dysuria and back pain. What assessment technique
should the nurse utilize?
A) Deep palpation
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B) Indirect percussion
C) Moderate palpation
D) Blunt percussion
17. In the course of performing a client's physical assessment, the nurse has changed from
using the diaphragm of the stethoscope to using the bell. The nurse is most likely
assessing which of the following?
A) Heart sounds
B) Bowel sounds
C) Breath sounds
D) Femoral pulses
18. An instructor is teaching a student about the proper use of a stethoscope. The instructor
determines the need for additional teaching when the student states which of the
following?
A) ìPlastic tubing should be longer than 3 feet.î
B) ìThe bell is used after using the diaphragm.î
C) ìWhen using the bell, push on it lightly.î N
D) ìA diaphragm picks up low-pitched sounds.î
19. A nurse is preparing to perform the physical examination of an adult client who has
presented to the clinic for the first time. Which of the following statements should guide
the nurse's use of a stethoscope during this phase of assessment? A) Auscultation can be
performed through clothing.
B) The diaphragm should be held firmly against the body part.
C) The bell of the stethoscope can best detect bowel sounds.
D) Use of the bell is reserved for advanced practice nurses.
20. A nurse is appraising a colleague's assessment technique as part of a continuing
education initiative. The nurse demonstrates the proper technique for light palpation by
performing which of the following actions?
A) Depressing the skin 1 to 2 centimeters with the dominant hand
B) Feeling the surface structures using a circular motion
C) Placing the nondominant hand on top of the dominant hand
D) Using one hand to apply pressure and the other hand to feel the structure
26. A nurse is reviewing the four basic physical examination techniques and their sequence
prior to receiving a new client from postanesthetic recovery. The nurse should plan to
perform which technique first?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
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27. The nurse is percussing the area over the client's lungs and hears a loud, low-pitched,
hollow sound. The nurse documents this finding as which of the following?
A) Flatness
B) Resonance
C) Tympany
D) Dullness
28. A 20-year-old female client has presented to the clinic, and the nurse is preparing to
perform a comprehensive assessment. The client states, ìI'd really like to have my mom
in the room. That's okay, isn't it?î How should the nurse best respond to the client's
request?
A) ìOf course. There's a chair in the exam room where she can sit.î
B) ìThat's no problem. I'll just have to get you to sign a privacy waiver first.î
C) ìThat's fine, but be aware that some of the examinations might be embarrassing for
N
you or her.î
D) ìIt's best to undergo the examination alone in order to make sure I get accurate data,
but if you really want her present, we can do that.î
29. The nurse is inspecting the dominant hand of an older adult client and notes the presence
of irregularly shaped brown lesions on the dorsal surface of the client's hand. What
action should the nurse perform next?
A) Obtain a tissue sample for pathology
B) Compare the appearance of the client's other hand
C) Palpate the lesions for tenderness and warmth
D) Perform health promotion teaching about sun protection
30. A young man has presented to the clinic with a 2-week history of head congestion, fever,
and malaise. What assessment technique should the nurse utilize to assess for sinus
tenderness? A) Light palpation
B) Deep palpation
C) Direct percussion
D) Blunt percussion
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Answer Key
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
D
A
C
B
C
A
B
B
A
D
D
B
B
C
D
D
A
C
B
B
B
D
C
A, C, E, F
C
A
B
A
B
C
N
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CHAPTER 4: VALIDATING AND DOCUMENTING DATA
1. Which of the following would be most important to ensure accurate data when gathering
client information?
A) Documenting the data
B) Validating the data
C) Identifying client support systems
D) Determining client needs
2. A nurse obtains the following information from a client. Which statement would the
nurse need to validate?
A) "I've recently lost 20 pounds."
B) "I feel very weak and tired."
C) "I've had two cesarean deliveries."
D) "I am generally healthy and happy."
3. A client who had a mastectomy is being discharged home. The client lives alone. Which
data would be most important to validate for this client?
A) If the client has transportation for follow-up appointments
B) If the client usually functions independently
C) What support systems are in place to assist the client
D) If the client has a religious belief regarding illness
4. When describing the importance of documenting initial assessment data to a group of
new nurses, which of the following would the nurse emphasize as the primary reason?
A) Health care institutions have established policies regarding documentation.
B) Incorrect conclusions may be made without documentation of initial data.
C) It satisfies legal standards established by health care organizations and institutions.
D) It becomes the foundation for the entire nursing process.
5. After teaching a group of students about documenting the nursing history and physical
examination, the instructor determines that the teaching was successful when the
students refer to this information as which of the following?
A) Subjective data and objective data
B) Interpretation and inference
C) Observation and inspection
D) Data and results
16. The nurse obtains the following information. The nurse would need to validate the data
for which client?
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A)
B)
C)
D)
A new mother who says she is tired
A client who is laughing and talking with a temperature of 104°F
A young girl with a small right lower quadrant scar who reports she had an
appendectomy
A man who has been a diabetic for 25 years
17. Which method of validation would be most appropriate when the nurse is unsure if a
murmur is heard when assessing heart sounds?
A) Verify with another health care professional.
B) Recheck through reassessment.
C) Compare objective data with subjective data.
D) Clarify data with the client.
18. A nurse is providing in-service training to a group of nurses in a facility that has just
begun to use an integrated cued checklist for documentation. Which of the following
would the nurse include as the purpose of this type of documentation?
A) It helps cluster data
B) It provides lines for comments.
C) It includes specialized data D) It standardizes data collection.
19. A group of nursing students are reviewing the purposes of assessment documentation
in preparation for a class discussion. The students demonstrate understanding of the
information when they identify which of the following as one of the primary purposes?
A)
It provides a chronologic source of client assessment data.
B) It creates a data base for care that was not rendered to the client.
C) It replaces the client acuity classification system.
D) It directly formulates the nursing diagnoses.
20. The nurse compares subjective data and objective data to achieve which of the
following?
A) Formulation of nursing diagnoses
B) Identification of missing data
C) Determination of documentation form to use
D) Validation of data
21. A nurse is preparing an in-service education program for a group of staff nurses about
documentation, including documentation of assessment data. The nurse demonstrates
understanding of the significance of documentation by including a discussion of which
of the following as playing a role in this area? Select all that apply.
A) Joint Commission
B) State nurse practice act
C) Medicare
D) Local city government
E) Institutional agency
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22. A nurse has completed an assessment and is about to document the findings. Which
statement best reflects accurate documentation? A)
Client appears upset about
upcoming surgery.
B) Client was interviewed about previous history of hypertension
C) Skin pale, warm, and dry without evidence of lesions
D) Client's oral intake is satisfactory
23. A nurse is using a nursing minimum data set to document assessment information. The
nurse most likely would be working in which setting?
A) Acute care facility
B) Long-term care facility
C) Urgent care center
D) Health clinic
24. While gathering a nursing history about a client's previous hospitalizations and
surgeries, the nurse finds out that this is the client's first hospitalization and that he
hasn't had any surgeries. The nurse would document which of the following?
A) Client denies prior hospitalizations and surgeries
B) Client has not been hospitalized before nor has he had any surgery
C) Client answered no to previous hospitalizations or surgery
D) Negative for past hospitalizations
25. An instructor is describing various ways that a nurse can validate data to a group of
nursing students. The instructor determines that additional teaching is necessary when
the students identify which of the following as a reliable method?
A) Repeating the assessment
B) Asking additional questions
C) Having the client repeat what was said
D) Checking findings with another health care professional
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26. A nurse is working on a unit for clients with neurological conditions. Which assessment
form would the nurse most likely use to document assessment data?
A) Open-ended form
B) Focused assessment form
C) Frequent assessment form
D) Ongoing assessment form
27. A group of students is reviewing information from class about the purposes of
assessment documentation. The students demonstrate understanding of the material
when they state which of the following?
A) “Documentation helps support reimbursement but gives little epidemiologic data.”
B) “Documentation provides a permanent legal record of care given and not given.”
C) “Documentation is a viable means of communication but is repetitious.”
D) “Documentation helps determine client education needs but not staff mix.”
Answer Key
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
B
A
C
D
A
C
D
C
D
C
D
A
C
A
A
B
A
A
A
D
A, B, C, E
C
B
A
C
B
B
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CHAPTER 5: THINKING CRITICALLY TO ANALYZE DATA AND MAKE INFORMED
NURSING JUDGMENTS
1. A nurse has completed a comprehensive assessment of a client and has begun the
process of data analysis. Data analysis should allow the nurse to produce which of the
following direct results? A) Outcomes evaluation
B) Nursing diagnoses
C) Holistic interventions
D) An interdisciplinary plan of care
2. A new nursing graduate recently made an oversight during the analysis of a client's
assessment data that resulted in a postoperative complication. What characteristic of data
analysis makes it a challenging aspect of nursing practice? A) Abnormal data must be
identified.
B) It requires the prior identification of nursing diagnoses.
C) It requires sophisticated diagnostic reasoning skills.
D) Conclusions must be clearly and accurately documented.
3. A hospital nurse has identified a need to improve her critical thinking skills in an effort
to improve client care. The nurse should identify which of the following characteristics
of critical thinking?
A) It is an innate skill that some individuals possess and which others do not.
B) It does not include past experiences.
C) It is based primarily on getting correct and timely information. N
D) It involves reflections on thoughts before reaching conclusions.
4. The emergency department has collected extensive data from a client who has presented
with a new onset of severe abdominal pain. What nursing action should the nurse
perform before proceeding with data analysis? A) Validate the collected data.
B) Formulate a nursing diagnosis.
C) Make inferences about the data.
D) Identify the client's strengths.
5. A nurse has completed a client's initial assessment and is preparing to identify abnormal
data and the client's strengths. Successful completion of this phase of the nursing process
most requires which of the following? A) Knowledge of anatomy and physiology
B) Awareness of the client's medical prognosis
C) Inferences about the client
D) Knowledge about the referral process
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6. A nurse is planning a client's care following the completion of an initial assessment.
When formulating a risk nursing diagnosis, which piece of data would be most useful?
A) The client has an elevated white blood cell count.
B) The client is 66 years of age.
C) The client has pain in her joints, especially in the morning.
D) The client is separated from her usual social supports.
7. During the assessment interview, the client made numerous statements that suggested his
life generally exists in a state of harmony and balance. This fact would most likely
prompt the nurse to identify which of the following?
A) Actual nursing diagnosis
B) Risk nursing diagnosis
C) Collaborative problem
D) Health promotion diagnosis
8. A nurse is caring for a client who has been admitted with an infected venous ulcer. The
nurse determines that the client will need medical interventions as well as nursing
interventions. The nurse would identify which of the following?
A) Actual nursing diagnosis
B) Referral
C) Risk nursing diagnosis
D) Collaborative problem N
9. A nurse has assessed a client and identified data that are associated with the diagnoses of
Impaired Physical Mobility and Activity Intolerance. How can the nurse best determine
which nursing diagnosis is most applicable to the client? A) Document preliminary
conclusions.
B) Identify abnormal data.
C) Check the defining characteristics of the diagnoses.
D) Test the nursing diagnoses clinically.
10. A nurse is analyzing the assessment data of a client who has been admitted with
exacerbation of heart failure. The nurse has determined that the cue clusters meet the
defining characteristics of specific nursing diagnoses. Which of the following would the
nurse do next?
A) Explain the client's problems to the client and his or her family.
B) Verify it with the client and with other health care professionals.
C) Validate the diagnosis with the physician.
D) Work with the client to begin planning interventions.
11. A nurse's data analysis has led to the formulation of a risk nursing diagnosis. Which of
the following best demonstrates accurate documentation of a risk nursing diagnosis?
A) Risk for fatigue related to increased job demands, as manifested by feelings of
exhaustion and frequent naps
B) Risk for infection, as manifested by lack of client knowledge of wound care
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C) Risk for violence related to history of overt, aggressive acts
D) Risk for altered respiratory function related to environmental allergens, as
manifested by asthma
12. A nurse is preparing to document conclusions after analyzing data, and he or she
includes information about related factors and manifestations. The nurse is formulating
which of the following? A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Collaborative problem
D) Problem for referral
13. A nurse is applying the diagnostic reasoning process in the care of a client. What is the
correct sequence of the steps that the nurse should perform? A) Check for defining
characteristics.
B)
Draw inferences. D,E,B,C,A
ses.
C)
Propose possible nursing diagnoN
D)
Identify abnormal data and strengths.
E)
Cluster data.
14. The nurse has collected objective and subjective data during the assessment of a client
who has been admitted for the treatment of an exacerbation of chronic obstructive
pulmonary disease (COPD). During the current phase of the diagnostic reasoning
process, the nurse is writing down thoughts about each cue cluster of data that was
collected. The nurse is involved in which step of the diagnostic reasoning process?
A) Step One: Identify Abnormal Data and Strengths
B) Step Two: Cluster Data
C) Step Three: Draw Inferences
D) Step Four: Propose Possible Nursing Diagnoses
15. A nurse is determining whether the data for a client support a potential nursing
diagnosis. The nurse is most likely engaged in which step in the diagnostic reasoning
process?
A) Step Three: Draw Inferences
B) Step Four: Propose Possible Nursing Diagnoses
C) Step Five: Check for Defining Characteristics
D) Step Six: Confirm or Rule Out Diagnoses
16. A nurse is applying the diagnostic reasoning process in the care of a client with a number
of comorbidities. Which of the following descriptions best characterizes Step Two,
Clustering Data?
A) Hypothesizing of any potentially applicable health promotion diagnoses, risk
diagnoses, and actual diagnoses
B) Documentation of all professional judgments along with any data that support those
judgments
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C) Examining identified abnormal findings and strengths for cues that are related
D) Evaluation of both subjective and objective data to identify strengths and abnormal
findings
17. An experienced nurse is teaching a recently graduated colleague about common pitfalls
encountered in the diagnostic reasoning process. The experienced nurse should identify a
need for further teaching if the new graduate identifies which of the following as a N
pitfall?
A) View of things as either right or wrong
B) Overemphasis on details
C) Inclusion of valid data
D) Clustering of unrelated cues
18. A nurse on a busy acute medical unit asks a clinical educator for suggestions on how to
best develop expertise in using diagnostic reasoning skills to arrive at correct
conclusions. Which of the following statements would be most appropriate?
A) “You need to cluster the data more rapidly.”
B) “This skill comes with accumulating experience.”
C) “Try to be more efficient in documenting the data.”
D) “This is a skill that only comes with an advanced practice designation.”
19. A nurse has identified a goal of developing his critical thinking skills. In order to
facilitate this goal, what action should the nurse prioritize?
A) Applying quick decision-making
B) Seeking new experiences
C) Maintaining an open mind
D) Maintaining a stable and static knowledge base
20. After teaching a group of students about the second phase of the nursing process, the
instructor determines that additional teaching is needed when the students identify which
of the following as a component?
A) Organizing data
B) Clustering data
C) Formulating a medical diagnosis
D) Generating hypotheses
21. An experienced medical-surgical nurse has identified critical thinking as an integral
component of diagnostic reasoning. How can the relationship between these two
concepts be best described?
A) Critical thinking is the practical application of diagnostic reasoning skills.
B) Critical thinking and diagnostic reasoning are synonymous.
C) Critical thinking is the foundation of the process of diagnostic reasoning.
D) Critical thinking is the domain of the novice nurse, whereas diagnostic reasoning is
N
present in experts.
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22. During an educational inservice, nursing have been encouraged to conduct a selfappraisal of their critical thinking skills. Which of the following questions can best guide
this appraisal?
A) “Do I tend to make errors in my nursing practice?”
B) “Do I get good feedback from clients and their families?”
C) “Am I open to the fact that I may not be right?”
D) “Am I a resource to my colleagues during a crisis?”
23. A nurse has admitted a client to the medical unit who has just been diagnosed with
endocarditis secondary to IV drug use. The nurse has completed the collection of
objective and subjective data. What question should guide the next step in the nurse's
data analysis?
A) “What are this client's strengths?”
B) “What is this client's prognosis?”
C) “Why does this client use opioids?”
D) “What are this client's hopes for the future?”
24. The nurse is attempting to cluster the data that she collected during the initial assessment
of an older adult client. The nurse notes that the client had a swollen left knee and
complained of “a bit of soreness” in the joint, but the nurse does not have enough data to
support a nursing diagnosis of Impaired Physical Mobility. What should the nurse do
next?
A) Document a suspected nursing diagnosis of Impaired Physical Mobility.
B) Assess the client further for evidence of reduced mobility and decreased range of
motion.
C) Make a referral to the physical therapist.
D) Plan interventions that will conservatively manage the client's joint dysfunction.
25. A nurse has been clustering the data that he collected during the initial assessment of a
frail elderly client. When making inferences about the data clusters, the nurse is unsure
whether to associate a cluster of data with a nursing diagnosis or with a collaborative
problem. What question may best guide the nurse's decision? A) “Can an unlicensed care
provider meet this person's needs?”
B) “Is this problem acute or is it chronic?”
C) “Can this issue be addressed on an outpatient basis?”
D) “Does this issue require medical intervention?”
26. A nurse is providing care for a client who has longstanding type 2 diabetes. In recent
days, the client's blood glucose levels have been higher and more volatile than usual. N
After drawing this inference, the nurse should take what action?
A) Make appropriate referrals
B) Assess the client more frequently
C) Document the medical diagnosis of hyperglycemia
D) Beginning collecting subjective data
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27. The nurse's assessment of a client with a decreased level of consciousness reveals that
the client is incontinent of urine. During the process of data analysis, the nurse would be
justified in identifying what risk nursing diagnosis? A) Risk for Injury related to urinary
incontinence
B) Risk for Infection related to urinary incontinence
C) Risk for Bowel Incontinence related to urinary incontinence
D) Risk for Impaired Skin Integrity related to urinary incontinence
28. A nurse has selected several nursing diagnoses in the process of data analysis of a client
with poorly controlled type 1 diabetes. One of these diagnoses is Ineffective Health
Maintenance related to infrequent blood glucose monitoring as manifested by elevated
HgA1C. The nurse recognizes the need to corroborate this diagnosis with the client.
How should the nurse best do this?
A) “I think you have a nursing diagnosis of Ineffective Health Maintenance.”
B) “Would you agree that there's room for improvement in your routines around blood
sugar monitoring?”
C) “After assessing you, I believe that you're not maintaining your health effectively,
specifically around your diabetes.”
D) “How do you think that you could better maintain your health?”
29. Data analysis of assessment data from a client who presented to the emergency
department has resulted in the nurse making a syndrome nursing diagnosis. What is a
primary characteristic of this type of diagnosis?
A) The client's health problem cannot be conveyed using standard nursing language.
B) The client's current signs and symptoms are the result of a longstanding health
problem.
C) The client has health problems that will require multidisciplinary care.
D) The client has a number of nursing diagnoses that typically occur together.
30. A nurse has collecting extensive data during a client assessment and is performing the N
first step in the process of data analysis. Successful completion of this step requires the
nurse to do which of the following?
A) Differentiate between expected findings and abnormal findings.
B) Validate nursing diagnoses with the client and the client's family.
C) Integrate the client's medical diagnosis with nursing diagnoses.
D) Perform health promotion education.
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Answer Key
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
B
C
D
A
A
D
D
D
C
B
C
B
D, E, B, C, A
C
D
C
C
B
C
C
C
C
A
B
D
A
D
B
D
A
N
!
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CHAPTER 6: ASSESSING MENTAL STATUS AND SUBSTANCE ABUSE
1. The nurse is preparing to assess the remote memory of a client who has a diagnosis of
early stage Alzheimer's disease. Which question would be most appropriate for the
nurse to use?
A) ìCan you tell me what you have eaten in the last 24 hours?î
B) ìWhen did you get your first job?î
C) ìWhat did you do last evening?î
D) ìHow are an apple and orange the same?î
2. When assessing the mental status of a 67-year-old woman, the nurse detects some
difficulty with free-flow of thought and the woman's ability to follow directions. Which
of the following would the nurse do first? A) Use a Geriatric Depression Scale.
B) Refer for further medical evaluation.
C) Assess the client's vision and hearing.
D) Refer the client to social services for home assistance.
3. The nurse utilizes the Depression Questionnaire on a client who has recently moved to
a long-term care facility. The total score is 22. Which of the following would be most
appropriate for the nurse to do next? A) Refer for further evaluation.
B) Evaluate benefits versus risks of a mental health label.
C) Assess further for dementia. N
D) Document this as a normal score.
4. The nurse notes that an older adult client is wearing multiple layers of clothing on a
warm fall day. Which of the following would be the nurse's priority assessment at this
time?
A) Asking whether the client often feels cold
B) Assessing the client's developmental level
C) Reviewing the client's culture for possible influence
D) Observing the client's overall hygiene
5. A nurse is working in a clinic in a low-income neighborhood and assesses a female
adult client who states that she has a urinary tract infection. The nurse notes that the
client is unkempt, wearing stained clothing, and has a strong body odor. The client
mentions that she was evicted from her apartment two weeks ago. Which nursing
diagnosis would the nurse most likely identify for this client?
A) Caregiver role strain related to fatigue
B) Impaired skin integrity related to neurologic deficits
C) Deficient fluid volume related to possible urinary tract infection D) Self-care deficit
related to possible homelessness
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6. When preparing to obtain information about a client's mental and psychosocial status,
which of the following would the nurse need to do first?
A) Question the patient about his or her usual lifestyle and behaviors.
B) Perform a neurologic examination to determine any deficits.
C) Check the client's level of consciousness for changes.
D) Explain the purpose of the exam and types of questions.
7. A nursing student has been assigned to the care of a client whose history suggests the
need for a mental status assessment. This client most likely has a history of health
problems affecting what body system?
A) Respiratory
B) Neurologic
C) Cardiovascular
D) Renal
8. The nurse begins the physical examination of a newly admitted client by assessing the
client's mental status. What is the nurse's best rationale for performing the mental status
exam early in the assessment?
A) The client will be less anxious early, providing the nurse with more accurate and
reliable data. B) The exam can provide clues about the validity of the client's
responses now and N
throughout.
C) The exam provides data about mental health problems that the client may be afraid
to report.
D) The client's fears about having a serious illness may be alleviated by the results of
the exam.
9. A client's recent episode of becoming lost near his home has prompted the nurse to use
the Saint Louis University Mental Status (SLUMS) Assessment Tool. The nurse should
begin this assessment by asking what question?
A) ìHow would you respond if someone said that you might have dementia?î
B) ìCan I ask you some questions about your memory?î
C) ìDo you generally consider yourself to be an intelligent person?î
D) ìI want to ask you some questions to see if you have Alzheimer's.î
10. Assessment of a client who has suffered a recent stroke reveals that he is unresponsive
to all stimuli and his eyes remain closed. The nurse documents the client's level of
consciousness as which of the following?
A) Obtunded
B) Stupor
C) Coma
D) Lethargy
11. An emergency department nurse has utilized the Confusion Assessment Method
(CAM) in the assessment of a 79-year-old client with a new onset of urinary
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incontinence. This assessment tool will allow the nurse to confirm the presence of what
health problem?
A) Delirium
B) Vascular dementia
C) Schizophrenia
D) Psychosis
12. The nurse is assessing a client using the Glasgow Coma Scale following an acute
hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating
which of the following?
A) Deep coma
B) Coma
N
C) Obtunded
D) Alert and oriented
13. A woman brings her 69-year-old husband to the clinic for an evaluation because he has
become increasingly forgetful. Which of the following would lead the nurse to suspect
that the client has Alzheimer's disease? Select all that apply. A) ìHe repeats the same
story, word for word, over and over again.î
B) ìHe took a fall when he was replacing a light bulb last month.î
C) ìI have to balance the checkbook now because he just won't do it.î
D) ìIf I don't tell him when to shower, he won't and will fight me on it.î
E) ìHe got lost walking to the pharmacy around the corner the other day.î
14. As part of a mental status assessment, the nurse asks a client to draw the face of a
clock.
This will allow the nurse to assess which of the following domains of mental status?
A) Concentration and orientation
B) Perceptions and thought processes
C) Visual perceptual and constructional ability
D) Expressions and feelings
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20. A nurse asks a client the following question: ìWhat do you do if you have pain?î The
nurse is assessing which of the following aspects of cognitive function?
15. A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders
Identification Test (AUDIT) as part of the standard admission protocol. After obtaining
a score of 9 from a recently admitted client, the nurse should recognize the possibility of
which of the following?
A) Hazardous and harmful alcohol use
B) Imminent liver disease
C) Acute pancreatitis
D) Alcoholism
16. A nurse is assessing a client who is exhibiting decorticate posturing. Which of the
following would the nurse observe?
A) Extended upper extremities
B) Internally rotated lower extremities
C) Pronated forearms
D) Flexed hands at the side of the body
17. The nurse observes a client's entire body posture to be somewhat stiff, with his
shoulders elevated upward toward the ears. The nurse would most likely interpret this to
indicate that the client is experiencing which of the following?
A) Confusion
B) Anxiety
C) Powerlessness
N
D) Restlessness
18. A nurse is reviewing a depression questionnaire completed by a client. Which of the
following would the nurse interpret as being suggestive of depression?
A) ìOccasionally I feel like my attention wanders.î
B) ìI haven't noticed any change in my appetite.î
C) ìIt usually takes me over an hour to fall asleep.î
D) ìI might wake up once during the night but not often.î
19. A gerontologic nurse is assessing the speech of an older adult client. Which of the
following would the nurse characterize as an expected assessment finding?
A) Repetition
B) Rapid speech
C) Moderate pace
D) Loud tone
A) Orientation
B) Judgment
C) Abstract reasoning
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D) Memory
21. A nurse is providing care for a client who has hepatic encephalopathy secondary to
chronic alcohol abuse. The nurse's assessment reveals that the client often provides
incorrect answers to assessment questions. As well, the client makes statements that are
not grounded in reality. What nursing diagnosis is suggested by these assessment data?
A) Impaired Verbal Communication related to hepatic encephalopathy AMB confusion
B) Acute Confusion related to hepatic encephalopathy
C) Ineffective Health Maintenance related to alcohol abuse AMB decreased cognition
D) Ineffective Coping related to alcohol abuse
22. A client has presented to the emergency department (ED) with a lower leg laceration that
she suffered ìwhile I was on a bender last night.î The nurse recognizes the need to screen
for alcohol use and will implement the CAGE questionnaire. What question will the
nurse ask during this assessment?
A) ìHave you ever experienced a memory blackout after drinking?î N
B) ìHave you ever vomited blood after drinking alcohol?î
C) ìHave you ever been treated for alcohol abuse?î
D) ìHave you ever felt guilty about your alcohol use?î
23. A woman has accompanied her 80-year-old husband to a scheduled clinic visit and
expresses concern about subtle declines in his cognition. Which of the following
principles should guide the nurse's assessment of the client's mental status?
A) The nurse must modify the cognitive assessment to exclude assessments requiring
reading or writing.
B) The nurse should first explain to the couple that senility is expected among adults
over age 80.
C) The nurse must differentiate between age-related changes and the signs and
symptoms of dementia.
D) The nurse must explain that the results of the assessment will be used to determine
if admission to long-term care is necessary.
24. The intensive care nurse is working with a client who has increased intracranial pressure
secondary to a traumatic brain injury. The nurse is performing the hourly assessment of
the client's level of consciousness and observes that the client's eyes are closed. How
should the nurse first stimulate the client to assess for arousability?
A) Gently shake the client's right shoulder and then his left shoulder.
B) Rub the client's sternum with the knuckles.
C) Speak to the client clearly from a close distance.
D) Press down on one of the client's nail beds.
25. A nurse is conducting a mental status assessment of a 70-year-old male client who is
being treated for depression. When assessing the client's facial expression and eye
contact, the nurse should consider which of the following?
A) The nurse should inform the client that his facial expression is being assessed.
B) Reduced eye contact is an age-related physiological change.
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C) Facial expression should be disregarded if the client has a diagnosed mental illness.
D) Eye contact is strongly influenced by cultural norms.
26. A 21-year-old woman has been admitted to the emergency department following an
accident that is suspected of being a suicide attempt. When assessing the client's
perceptions, what question should the nurse ask the client?
A) ìHow would you describe your health these days?î
B) ìAre you able to smell and taste as well as you've been able to in the past?î N
C) ìIf you found a stamped envelope on the street, what would you do?î D) ìCan you
tell me the circumstances surrounding your accident?î
27. A nurse in the emergency department is utilizing the SAD PERSONAS assessment
guide during the mental status assessment of a client. What is the most likely rationale
for the nurse's choice of this assessment tool?
A) The client may have a high risk for suicide.
B) The client may have major depression.
C) The client may have schizophrenia or psychosis.
D) The client may be using alcohol excessively.
28. An 88-year-old woman has been admitted to the acute medical unit for the treatment of a
urinary tract infection that is thought to be progressing to urosepsis. When assessing the
client's orientation, how should the nurse best gauge the client's orientation to time?
A) ìCan you tell me approximately what time it is right now?î
B) ìAre you able to tell me today's date?î
C) ìCan you tell me the date and the day of the week?î
D) ìAre you able to tell the month and the year that we're in?î
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29. During
Answer
Key the mental status assessment of a new client, the nurse has asked the client to
1.
2.
3.
4.
5.
6.
7.
8.
309.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
describe some of the similarities and differences between a tennis ball and a soccer ball.
Despite
adequate time and cuing, the client is unable to state any similarities or
B
differences.
The nurse should document what assessment finding?
C
A)
A
deficit
in practical intelligence
A
B)
A An inability to follow directions accurately
C)
D A deficit in abstract reasoning
D)
D A lack of spatial orientation
B
B
The
B nurse is assessing an older adult client's mental status. Consistently, the client
pauses
after the nurse poses a question, but then the client provides a response that is
C
correct
or appropriate. How should the nurse best interpret this characteristic of the
A
client?
D
A)
A, C,Slight
D, E delays in mental processing are normal in older adults.
B)
The
client may be trying to anticipate the nurse's desired response.
C
C)
A The client is displaying a sign of early Alzheimer's disease.
D)
B The client may be experiencing an early sign of delirium.
B
C
C
B
B
D
N
C
C
D
A
A
D
C
A
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CHAPTER 8: ASSESSING GENERAL STATUS AND VITAL SIGNS
1. A nurse has completed the general survey of a client who has been transferred to the
unit. The information gathered during the general survey primarily provides the nurse
with which of the following? Select all that apply.
A)
An indication of the level of physical distress experienced by the client
B)
Clues about the overall health of the client
C)
A direct link to the client's medical diagnosis
D)
Indications about normal variations in the status of body systems E)
Data
relating to the patient's level of social support
2. A nurse is preparing to assess an adult client's body temperature. At which time of the
day would the nurse expect to obtain the lowest body temperature?
A)
Early morning
B)
Early afternoon
C)
Late afternoon
D)
Late evening
3. The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse
assess first?
A)
Temperature
B)
Pulse
C)
Respiration
D)
Blood pressure
N
4. A nurse is reviewing a colleague's documentation of a client assessment. The nurse reads
that the client's radial pulse was 2+. How should the nurse interpret this assessment
finding?
A)
The client's radial pulse occluded easily.
B)
The client's radial pulse occluded with moderate pressure.
C)
The client's radial pulse occluded with very firm pressure.
D)
The client's radial pulse could not be manually occluded.
5. The nurse is conducting an assessment of an older adult client who has a diagnosis of
chronic heart failure. How can the nurse best assess the effects of the client's stroke
volume?
A)
Take the blood pressure while the client is standing.
B)
Measure the strength of the radial pulse.
C)
Add the radial pulse and the systolic blood pressure.
D)
Calculate the difference between the diastolic and systolic pressures.
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6. A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and
who is lying in bed rather than sitting in a chair. The nurse should interpret the client's
blood pressure reading in light of what principle?
A)
The client's blood pressure will be slightly highly than the client's norm.
B)
Position rarely affects the client's blood pressure.
C)
The client's blood pressure will be slightly lower than standing readings.
D)
There will be questionable accuracy of the blood pressure reading.
7. The nurse is completing an initial assessment of a client who is new to the ambulatory
clinic. Before assessing the client's blood pressure, a nurse asks him what his usual blood
pressure is. The nurse bases this action primarily on what rationale? A) It provides
identifiable data about the client.
B) It verifies the client's cardiac function.
C) It assesses the client's distant memory recall.
D) It indicates the client's involvement in his health care.
8. The nurse has begun a client's assessment and is applying the blood pressure cuff on a
client's arm. Which action would be most appropriate? A) The cuff is wrapped loosely
around the arm.
B) The cuff is placed about 1 inch above the antecubital area.
C) The bladder inside the cuff encircles 50% of the arm circumference.
D) The nurse can fit three to four fingers under the inflated cuff. N
9. Which of the following would be most important for the nurse to do when assessing a
client's blood pressure?
A)
Palpate the pulsations of the ulnar artery.
B)
Hold the client's arm slightly flexed with palm down.
C)
Inflate the cuff 30 mm Hg above where the radial pulse disappears.
D)
Deflate the cuff about 5 mm Hg per second.
10. The nurse is auscultating a client's blood pressure and identifies the portion of the blood
pressure cycle reflecting the break in sounds occurring between the first and second
sounds. This is known as which of the following?
A)
Auscultatory gap
B)
Korotkoff sounds
C)
Phase V
D)
Diastolic value
11. When assessing an older adult client with osteoporotic thinning and vertebral collapse,
which of the following findings would the nurse expect to identify?
A)
Lordosis
B)
Increased arm swing
C)
Narrowed gait
D)
Kyphosis
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12. A nurse observes the posture of a male client and finds him leaning forward and bracing
himself while sitting on the exam table. Which of the following would the nurse most
likely suspect?
A)
Chronic obstructive pulmonary disease
B)
Neurological deficit
C)
Metabolic disorder
D)
Vestibular disorder
13. The nurse is completing the general survey of a client and determines that the client's
temperature is 102∞F. Which of the following would the nurse also expect to find?
A)
Weak, thready pulse
B)
Heart rate greater than 100 bpm
C)
Respiratory rate between 12 and 20 breaths/minute
D)
Diastolic blood pressure 10 mm Hg greater than normal
N
14. The nurse is completing the assessment of a client who takes a beta-adrenergic blocker
and a diuretic. Which assessment would be most important for the nurse to complete to
ensure safety with a client receiving antihypertensive agents?
A)
Noting a widened pulse pressure
B)
Asking whether the client is experiencing headaches C) Assessing for a rise in
blood pressure when standing
D) Evaluating for orthostatic hypotension
15. A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates
correct technique for this assessment?
A)
Application of firm pressure on the wrist area along the side of the fifth digit
B)
Use of two middle fingers lightly applied to wrist area along the thumb side
C)
Use of the thumb and index finger applied to obliterate the wrist area along the
thumb side
D)
Application of the bell of the stethoscope to the antecubital area of the upper
extremity
16. The nurse is assessing the skin condition and color of an African-American client.
Which of the following would the nurse document as an abnormal finding?
A)
Evenly distributed color
B)
Light to medium dark brown skin
C)
Ashen gray skin color
D)
Lack of visible pores
17. The nurse is admitting a client to surgical daycare and is assessing the client's vital signs.
When obtaining the client's oral temperature, where should the nurse insert the
thermometer?
A)
At the gum line between the check and tongue
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B)
C)
D)
Deep in the posterior sublingual pocket
On either side of the frenulum at gingival level
Just past the teeth, below the tongue
18. An older adult client has been admitted to the medical unit after suffering an
exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following
should the nurse do to assess the depth of the client's respirations? A) Count the
respirations for 30 seconds and multiply by 2.
B) Place the client's arm across the chest while palpating the pulse.
C) Observe the client's chest expansion bilaterally.
D) Percuss the client's posterior thorax N
19. Due to a change in the client's level of consciousness, a nurse is now assessing a client's
temperature by the axillary route. Previously, the client had an oral temperature of
98.4∫F. Which finding would the nurse interpret as corresponding most closely to the
client's previous temperature?
A)
F
B)
97.4 F C) 98.9∫F
D) 99.4∫F
20. A nurse in the surgical daycare department has called a client in from the waiting room
and is meeting the client for the first time. The nurse immediately observes that the
client has a noticeably ìstoopedî posture. How should the nurse best follow up this
abnormal assessment finding?
A)
Facilitate a referral to the hospital's rheumatology department
B)
Perform a focused assessment of the client's musculoskeletal system
C)
Obtained a detailed family health history from the client
D)
Document the assessment finding and inform the anesthesiologist
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25. A nurse at an ambulatory clinic is preparing to begin the collection of objective
assessment data from a female client. After meeting the client and bringing her into the
21. A nurse is completing a general survey of a client's health and is beginning by
measuring the client's vital signs. What assessment question constitutes the ìfifth vital
signî?
A) ìCan you tell me the date and month?î
B) ìCan I check your oxygen saturation level?î
C) ìAre you experiencing any shortness of breath?î
D) ìAre you having any pain right now?î
22. An 84-year-old man has been admitted to the emergency department from an extended
care facility. Facility staff suspect that the client has pneumonia, and his malaise,
productive cough, shortness of breath, and adventitious breath sounds are consistent
with this diagnosis. However, the nurse's assessment of the client's vital signs yields an
oral temperature of 97.5∞F. How should the nurse best interpret this assessment
finding?
A) The client likely has a cardiac health problem, not a respiratory health problem.
B) The client's signs and symptoms are related to hypothermia rather than infection.
C) The client's normothermic temperature does not rule out the presence of an
infection.
D) The client's infection is no longer localized and has become systemic.
23. The nurse is performing an assessment of a hospital client at the beginning of a shift.
When assessing the client's heart
N rate, the nurse will most likely palpate what artery?
A) Femoral artery
B) Aorta
C) Ulnar artery
D) Radial artery
24. The nurse has completed the initial assessment of a client and is now performing data
analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this
client's pulse pressure?
A) 44 mm Hg
B) 92 mm Hg
C) 114 mm Hg
D) 184 mm Hg
examination room, what instruction should the nurse provide?
A) ìI'll get you to lay down flat on the exam table, please.î
B) ìPlease have a seat on the edge of the exam table.î
C) ìI'll start the assessment with you standing up and then help you onto the table.î D)
ìWhere would you like me to conduct your health assessment?î
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26. The nurse has assisted a 74-year-old woman from a chair to the examination table during
an assessment, and the nurse observes that the client moves particularly slowly and
stiffly. The nurse should question the client regarding a possible history of what health
problem? A) Rhabdomyolysis
B) Diabetes
C) Kyphosis
D) Arthritis
27. A community health nurse is conducting a home visit to a client who requires wound
care. The nurse observes that the client is diaphoretic and wishes to measure the client's
temperature. The nurse asks if the client has a thermometer in her home, and she states
that she owns an ìear thermometer.î What principle should guide the nurse's use of a
tympanic thermometer? N
A) Tympanic temperature is slightly higher than oral temperature.
B) Tympanic temperature is only used if all other methods are unavailable.
C) Tympanic temperature varies more widely than oral, rectal, and axillary
temperatures.
D) In adults, tympanic temperature is equal to axillary temperature.
28. The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an
amplitude that is weak and thready. How should the nurse respond to this assessment
finding?
A) Call a code blue from the bedside and prepare for resuscitation.
B) Assess the client's jugular venous pressure.
C) Assess the client's pulse at the carotid site.
D) Palpate the client's femoral pulse.
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29. The
nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an
Answer
Key
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
irregular rhythm. How should the nurse follow up this assessment finding?
A)
the client's apical pulse.
A, B,Auscultate
D
B)
A Palpate the client's ulnar pulse.
C)
A Administer a dose of nitroglycerin.
D)
B Reposition the client in a side-lying position.
D
C
D
B
C
A
D
A
B
D
B
C
B
C
B
B
D
C
N
D
A
B
D
A
C
A
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CHAPTER 9: ASSESSING PAIN: THE 5TH VITAL SIGN
1. A palliative care nurse is explaining the basis of pain to a group of nurses who provide
care on a general medical unit. Which of the following factors would the nurse include?
Select all that apply.
A) Physiologic
B) Psychosocial
C) Cutaneous
D) Somatic
E) Visceral
2. A group of students is reviewing information about pain transmission and the fibers
involved. The students demonstrate understanding when they state that A-delta primary
afferent fibers transmit pain that is felt as which of the following?
A) Burning
B) Throbbing
C) Sharp
D) Aching
3. A nurse is assessing the pain of a client who has had major surgery. The client also has
been experiencing depression. Which of the following principles should guide the
nurse's assessment of a client's pain?
A) The client is likely experiencing less pain than he is reporting.
B) The client's depression exists independently of the level of pain. N
C) It is likely that the client's pain rating will be influences by his emotional state.
D) The degree of surgery will be the key indicator for level of pain experienced.
4. A client has received a diagnosis of chronic nonmalignant pain. The nurse who is
planning this client's nursing care should understand that this client has experienced this
pain for at least how many months?
A) 3
B) 6
C) 9
D) 12
5. A nurse educator is presenting an in-service program to a group of nurses who will be
working on an oncology unit. Which of the following characteristics of cancer pain
should the nurse describe?
A) Its basis is usually chronic neuropathy.
B) It is most often caused by a specific recent trauma.
C) It usually appears in the first month after cancer develops.
D) It is typically caused by compressed peripheral nerves.
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6. A nurse is admitting a client to the postsurgical unit following breast reconstruction
surgery. Which of the following would the nurse use as the primary assessment for the
client's pain?
A) The client's spiritual view of the pain
B) Current pain therapies used preoperatively
C) The client's report of her pain
D) Psychosocial questions related to her perceptions of pain
7. The nurse is using the Verbal Descriptor Scale to assess a client's pain. The nurse will
prioritize which of the following data?
A) The client's facial expressions
B) The client's report on a 0 to 10 numeric scale
C) The client's rating on a 0 to 10 visual analog scale
D) The client's explanation of how her pain feels
8. The nurse collects vital signs on a hospital client who has recently been experiencing
pain. Which of the following would suggest most strongly to the nurse that the client is
experiencing pain?
A) Respiratory rate of 18 breaths per minute
B) Temperature of 99.1∞F
C) Heart rate of 110 beats per minute
D) Blood pressure of 120/70 mm Hg N
9. Based on the analysis of assessment data from a client with pain, the nurse writes a
health promotion diagnosis. Which of the following diagnoses would be most
appropriate?
A) Readiness for enhanced spiritual well-being related to coping with prolonged
physical pain
B) Risk for activity intolerance related to chronic pain and immobility
C) Bathing self-care deficit related to severe pain
D) Chronic pain related to chronic inflammatory process of rheumatoid arthritis
10. A nurse is preparing to document a collaborative problem for a client with pain. Which
of the following would be most appropriate?
A) ìImpaired physical mobility related to chronic painî
B) ìRisk for powerlessness related to chronic painî
C) ìReadiness for enhanced comfort levelî
D) ìRC: peripheral nerve compressionî
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21. A hospital's protocols for assessment have been modified in light of standards
11. The nurse is assessing a client whose chronic pain is poorly controlled. Which
assessment finding should the nurse expect under these circumstances?
A) Decreased heart rate
B) Hypoglycemia
C) Increased urinary output
D) Decreased gastric motility
12. A client rates his pain as 9 on a scale of 1 to 10. The nurse would expect to assess which
of the following?
A) Constricted pupils
B) Hypotension
C) Increased serum glucose
D) Flaccid muscles
13. The nurse is assessing a client's pain. Which question would be most appropriate to ask
the client when the goal is to identify precipitating factors that might have exacerbated
the pain?
A) ìWhat were you doing when the pain first stated?î
B) ìDo concurrent symptoms accompany the pain?î
C) ìWhen did the pain start?î
D) ìIs the pain continuous or intermittent?î
N
14. A client has questioned why the nurse asked him how his family members usually treat
their pain. Which of the following would be the most appropriate response by the nurse?
A) ìIt is just a way for me to more fully understand you and your upbringing.î
B) ìIt helps me to direct interventions toward your cultural history.î
C) ìIt helps me to determine how the family understands and perceives pain.î
D) ìIt will allow me to see if you are more likely to react to pain in a negative manner.î
15. When assessing pain in an older adult client who is alert and oriented, which assessment
tool would be most appropriate to use?
A) Numerical rating scale
B) Faces Pain Scale-Revised
C) FLACC Scale
D) Graphic rating scale
established by the Joint Commission. What change would bring practice into alignment
with these standards?
A) Teaching all new clients about the basic pathophysiology of pain
B) Assessing clients' pain objectively rather than subjectively
C) Identifying pain as the fifth vital sign and assessing clients accordingly
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D) Triaging clients according to the type of pain that they are experiencing
22. An emergency department nurse is assessing a client's complaint of upper abdominal
pain. Using the COLDSPA mnemonic, with what assessment question would the nurse
begin?
A) ìCan you describe to me how your pain feels?î
B) ìHow would you rate your pain on a 10-point scale?î
C) ìIs your pain affecting your ability to cope?î
D) ìWould you describe your pain as acute, or as chronic?î
23. A nurse is providing care for an 84-year-old client who has diagnoses of middle-stage
Alzheimer disease and a femoral head fracture. What assessment tool should the nurse
use to assess the client's pain?
A) Graphic Rating Scale
B) Numeric Rating Scale (NRS)
C) Verbal Descriptor Scale N
D) Faces Pain Scale-Revised (FPS-R)
24. A female client with bone cancer is experiencing pain that has become more severe over
the past several days. When modifying the client's plan of care, the nurse identifies a
need to assess the affective dimension of the client's pain. How can the nurse best
accomplish this goal?
A) Document the ways that the client's pain affects her activities of daily living.
B) Determine whether the client is able to independently treat her pain.
C) Closely monitor the effects of the client's pain on her emotions.
D) Ask the client to rate her pain during every physiological assessment.
25. A nurse is attempting to apply the principles of cultural competency in the care of a
72year-old Asian-American woman who has a spinal cord compression. Which of the
following statements should guide the nurse's care?
A) The client may view pain as a sign of weak character.
B) The client may be reluctant to accept opioids.
C) The client may tend to overreport her pain.
D) The client may be unable to understand quantitative assessment scales.
26. A female client with advanced-stage vascular dementia has been showing signs of pain
over the past several hours. The nurse is unable to obtain a self-report from the client due
to her cognitive impairment. When applying the Hierarchy of Pain Assessment
Techniques, how should the nurse proceed with assessment? A) Search for potential
causes of pain.
B) Ask the client's family if they believe she is in pain.
C) Perform interventions as if the client were in pain.
D) Use a visual assessment tool rather than a verbal tool.
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27. A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit.
The nurse has transferred the client from the stretcher to a bed and asked the client if he
is experiencing pain. The client acknowledges that he is in pain. What should be the
nurse's next action?
A) Ask the client to briefly explain his cultural background.
B) Assess the client's pain according to COLDSPA.
C) Assess the client's self-management skills.
D) Assess the client's pain by obtaining a set of vital signs.
28. A nurse is providing care to a client who has been in a motor vehicle accident and who
has facial lacerations and a pelvic fracture. How can the nurse best determine the
reliability and accuracy of data obtained during a pain assessment?
A) Ask the primary care provider to validate the assessment data. N
B) Compare the findings to the client's preinjury level of health.
C) Compare the findings to the most recent previous pain assessment.
D) Validate the assessment data with the client.
29. A nurse is performing a detailed pain assessment of a client who has sought care for
debilitating migraines. When assessing for precipitating factors, what question should the
nurse ask?
A) ìIs there anything that's given you relief in the past?î
B) ìHave your migraines gotten more severe in the last few months?î
C) ìWhat were you doing immediately before your last migraine?î D) ìHow long does a
typical migraine last?î
30. An older adult client with osteoarthritis has tearfully admitted to the nurse that she is no
longer able to climb the stairs to the second floor of her house due to her knee pain.
What nursing diagnosis is suggested by this client's statement?
A) Ineffective coping related to knee pain
B) Activity intolerance related to knee pain
C) Ineffective role performance related to osteoarthritis
D) Situational low self-esteem related to osteoarthritis
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Answer Key
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
A, B
C
C
B
D
C
D
C
A
D
D
C
A
C
A
B
C
C
B
B
C
A
D
C
B
A
B
D
C
B
N
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CHAPTER 10: ASSESSING FOR VIOLENCE
1. A nurse is preparing a presentation for a local community group on family violence and
child abuse. Which of the following would be most appropriate for the nurse to research
when defining child abuse in legal terms?
A) The Prevent Child Abuse America group
B) The Child Abuse Prevention and Treatment Act
C) The Child Abuse Prevention Network
D) The Child Well-being and Domestic Violence Project
2. A Director of Nursing is preparing to host a program on domestic violence. This
director wants to target nurses who may not have had this information in their
educational programs. The director should especially target nurses educated prior to
what year?
A) 1975
B) 1984
C) 1991
D) 1995
3. A nurse in the emergency room suspects intimate partner violence (IPV) after examining
a client. Another nurse questions how often this occurs. Which response by the nurse
would be most accurate?
A) 100,000 women each year seek medical care for injuries caused by intimate partner
violence.
B) Its incidence has surpassed that of accidents and stranger rapes and muggings.
C) Of all murdered women, 15% are victims of intimate partner violence.
D) One in three women treated for major injuries are victims of intimate partner
violence.
4. A group of students is reviewing the theories associated with abuse. The students
demonstrate understanding of the psychoanalytic theory when they identify that
violence results from the need to do which of the following?
A) Control others
B) Show authority
C) Be in charge
D) Discharge hostility
15. A group of students is reviewing the events that are associated with the cycle of
violence. Which statement by the students demonstrates understanding of the topic?
A)
It occurs in a predictable pattern.
B) There are five phases in the cycle.
C) During phase 2, the victim can often stops the abuser.
D) Criticism is part of phase 3.
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16. A new graduate nurse asks a more experienced nurse, “I know abuse is a problem, but
why must we screen all women during routine health contacts for potential abuse?”
Which response by the more experienced nurse would be most appropriate?
A) “The Family Violence Prevention Fund mandates it.”
B) “Consistent risk factors for women at risk have not been identified.”
C) “The prevalence for physical abuse is 30%.”
D) “The abuse is typically part of the presenting problem.”
17. Which of the following would be most important for a nurse to keep in mind when
assessing a client for possible physical abuse?
A) The abuse is often part of the presenting problem.
B) Physical abuse usually involves only about 5% of women.
C) The abuse may start any time during a relationship.
D) Abuse rarely occurs in women younger than age 25 years.
18. Which of the following would be least effective when interviewing a client who is a
suspected victim of abuse?
A) Using direct questions about being injured
B) Displaying a concerned empathetic approach
C) Interrupting the client for more information
D) Emphasizing the nurse's availability to talk
19. A nurse is interviewing a child who is suspected of being abused. Which of the following
would be most appropriate? A)
Ask questions that are highly detailed
B) Use direct, nonleading questions
C) Offer the child a reward for answering questions
D) Use simple yes and no questions regardless of the child's age
20. While talking with an older adult client, the client states, “My son takes care of all my
money. He controls the purse-strings in the house. I have little to say in how my money
is spent.” Further assessment reveals that the client hasn't had his prescription
medications renewed for the past two months. The nurse suspects which type of
abuse?
A) Physical
B) Economic
C) Psychological
D) Sexual
21. The nurse is assisting a female client who is being physically abused about a safety plan.
The client prefers to return home. Which of the following would the nurse need to do
first?
A) Have the client complete a danger assessment
B) Notify the neighbors about the abuse
C) Tell her to have her bags packed
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D)
Give the client the number of a shelter
22. A nurse asks a client to complete an intimate partner violence assessment screening.
Which statement by the nurse would be most appropriate?
A) “We are required by law to ask you these questions.”
B) “We routinely screen everyone because violence affects so many people.”
C) “We don't think you're abused but we have to ask.”
D) “This is just something we need to do for reimbursement.”
23. A woman and her partner come to the emergency department. The woman has
bruising on both upper extremities and a fracture of the left arm. The client states that
she fell down the stairs. Which of the following would lead the nurse to suspect that
the client is a victim of violence?
A) Client freely answers questions asked about the injury
B) Partner states that client is very clumsy and accident prone
C) Partner leaves the examination room when asked
D) Client holds partner's hand when arm is being examined
24. When assessing an older adult about possible mistreatment, which of the following
questions would be most appropriate to use initially?
A) “Have you ever been abused?”
B) “Did you ever signs papers you didn't understand?”
C) “What is a typical day in your life like?”
D) “Are you alone often at home?”
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25. A victim of intimate partner violence tells a nurse, “I don't' know how I'd live if I left my
husband. And what about my children? I have no skills and haven't worked since I was a
teenager.” When developing the plan of care for this client, which nursing diagnosis
would most likely apply?
A) Anxiety related to the physical escalation of the violence
B) Impaired parenting related to family violence
C) Low self-esteem related to lack of confidence in ability
D) Risk for violence related to inadequate coping abilities
26. When preparing a discussion about violence, which of the following would the nurse
include?
A) Abuse is primarily limited to lower socioeconomic groups.
B) Family violence is a public health problem.
C) Males experiencing intimate partner abuse have more options for help.
D) The majority of states now require the reporting of child abuse.
Answer Key
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
B
C
B
D
A
A
A
D
C
A
C
A
C
D
A
B
C
C
B
B
A
B
B
C
C
B
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CHAPTER 11: ASSESSING CULTURE
1. The nurse is interviewing a female Hispanic client who is scheduled for a cardiovascular
education program. The client states, ìI can't eat and I don't sleep because my daughter
left to return to Mexico. I am sad and nervous. I need rest.î The nurse suspects that she is
suffering from susto. Which action by the nurse would be best? A) Give her a
multivitamin supplement.
B) Encourage her to exercise.
C) Reschedule the education program.
D) Refer her to a counselor.
2. A nurse is admitting a client who is from another culture. Prior to caring for a client
from another culture, the nurse should place primary importance on which action?
A) Examining personal biases and prejudices
B) Researching characteristics of the specific culture
C) Asking colleagues about ways to approach the client
D) Developing awareness of the culture's health practices
3. A nurse educator is leading a group of nurses in exercises aimed at improving cultural
competence. Which of the following would the educator use to best describe an aspect of
the term ìcultureî?
A) Transmission occurs to another generation through genetics.
B) It is shared through norms for behaviors, values, and beliefs. C)
It is adapted to
a specific environment. N
D) It is experienced by all people even without human contact.
4. A nurse states, ìHispanic people have no clue about primary prevention of illness.î The
nurse is demonstrating which of the following?
A) Stereotyping
B) Ethnicity
C) Cultural incompetence
D) Prejudice
5. A nurse is assessing a client of East Asian descent. Which biological variation would the
nurse expect?
A) Dry cerumen in the client's ears
B) Profuse perspiration in the client's axillary area
C) Strong body odor
D) Longer eustachian tubes
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6. A nurse who provides care in a busy, inner-city clinic performs physical examinations
on clients of various cultures. In a client from which group would the nurse expect to
find the greatest amount of body odor from perspiration?
A) Inuit
B) Asian
C) Caucasian
D) Native American
7. An African-American woman collapses at the funeral of her mother and later states that
she could hear everything people were saying to her but, for a brief period, she could not
move. The nurse interprets this as which of the following?
A) Spell
B) Falling out
C) Empacho
D) Susto
8. A nurse has identified the goal of becoming more culturally sensitive and competent.
What is the primary rationale for cultural sensitivity in health care settings?
A) Recognize that cultural diversity exists.
B) Understand individual differences.
C) Prevent offending the client.
D) Obtain accurate assessment
N data.
9. Based on a colleague's feedback, a nurse learns that she is aware of cultural differences
in a general way but does not know what the specific differences are or how to
communicate with a person of a specific culture. This nurse exhibits which of the
following?
A) Unconscious incompetence
B) Conscious incompetence
C) Conscious competence
D) Unconscious competence
10. A group of students is reviewing material on cultural competence. The students
demonstrate understanding of this concept when they identify which of the following as
the starting point?
A) Cultural awareness
B) Cultural desire
C) Cultural skill
D) Cultural knowledge
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16. The nurse is assessing the diet and nutritional status of a client from a different culture.
Which of the following questions would be appropriate for the nurse to ask? Select all
that apply.
A) ìWhat foods do you commonly eat?î
B) ìDo you have any special routines for eating?î
C) ìAre there any foods that you can't eat?î
D) ìDo you eat three meals a day?î
E) ìDo you have certain foods to keep you healthy?î
17. When considering the various cultural aspects associated with death rituals, which of the
following should guide a nurse's practice?
A) Most cultures have similar durations for the length of time a person grieves.
B) A person's view of death is likely to be different from the original ethnic group's
practice.
C) Responses to death and grief are fairly consistent among different cultures.
D) Rituals for burial and bereavement are likely to reflect original cultural practices.
18. A nurse is assessing an Asian client and observes several reddened and bruised areas on
the skin. Further assessment reveals that the client was using cupping to treat back pain.
The nurse understands this as which of the following?
A) Placing heated glass jars on the skin that are allowed to cool
B) Rubbing ointment into the skin with a spoon N
C) Attaching smoldering herbs to acupuncture needles
D) Placing warm burning herbs directly on the skin
19. A nurse educator is reviewing the unit's resources about religious groups and their views
about blood and blood products, organ donation, and autopsy. A member of which group
is most likely to refuse a blood transfusion?
A) Christian Scientists
B) Jehovah's Witnesses
C) Orthodox Jews
D) Roman Catholics
20. A cardiac care nurse works with a diverse client population. The nurse would assess a
client from which cultural group for an increased effect of an antihypertensive
medication?
A) Eskimos
B) Native Americans
C) Hispanics
D) Chinese
21. A nurse's reflection of his practice reveals that he tends to see his own culture as the
ìgold standardî to which all other cultures should aspire. This nurse should create
learning goals to address what phenomenon?
A) Ethnocentrism
B) Unconscious incompetence
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C) Stereotyping
D) Acculturation
22. A nurse is participating in an educational exercise in which she is conducting a
selfexamination of her own biases. This activity addresses what construct of cultural
competence? A) Cultural desire
B) Cultural knowledge
C) Cultural skill
D) Cultural awareness
23. A nurse is caring for a 70-year-old client from a different culture whose breast cancer
has metastasized. The nurse observes that the client tends to defer responsibility for
decision making around treatment options to her eldest son. How should the nurse
respond to this?
A) Explain the disconnect between the client's practice and the principle of client
autonomy. N
B) Confirm that the client wants her son to make decisions and follow those decisions
accordingly.
C) Attempt to dialogue with the client when her son is not present.
D) Refer the family to social work in order to further explore alternative
decisionmaking practices.
24. A clinic nurse is conducting a comprehensive assessment of a 70-year-old male client of
Native American ethnicity. The nurse observes that the client rarely makes eye contact
and holds his head low during the assessment. How should the nurse best interpret this
practice?
A) The client may not understand the purpose of the assessment.
B) The client may be showing the nurse respect.
C) The client may be a victim of intimate partner violence.
D) The client may not trust the nurse's expertise.
25. A nurse is validating assessment findings with a client, and the client proceeds to
describe some of the psychological and spiritual components that she believes underlie
her disease process. This understanding of the cause of illness is most closely associated
with which of the following? A) Northern European cultures
B) The Western biomedical model
C) African-American culture
D) Asian cultures
26. A nurse is working with a 22-year-old woman of Asian ethnicity who has been
diagnosed with bipolar disorder. When planning culturally appropriate care, the nurse
should consider which of the following?
A) There may a lack of acceptance that the client's behavior is abnormal.
B) The client's family may see her illness as punishment for misdeeds.
C) The client's family may see her psychiatric disorder as evidence of bad character.
D) There may be shame associated with having a psychiatric disorder.
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27. A nurse is assessing an African-American client who has a longstanding diagnosis of
hypertension. The nurse should be aware that the client may experience a greaterthanaverage effect of what medication?
A) A diuretic
B) An angiotensin-converting enzyme inhibitor N
C) A calcium channel blocker
D) A beta-adrenergic blocker
28. A nurse will be working in a clinic in South Asia for several weeks, where the majority
of residents have darkly pigmented skin. The nurse should expect a higher-than-average
incidence of what integumentary health problem?
A) Contact dermatitis
B) Vitiligo
C) Psoriasis
D) Eczema
29. A nurse is relying heavily on gestures and simplified language during the assessment of
a client from another culture who speaks minimal English. During the lengthy
assessment, the nurse asks the client if she is ìokayî by making a circle with his thumb
and forefinger. The nurse should be aware of which of the following? A) In some
cultures, this gesture denotes confusion.
B) In some cultures, this gesture is offensive.
C) This gesture has meaning only in American cultures.
D) In some cultures, this gesture denotes pain.
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Answer Key
30.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
A nurse admits to a colleague, ìI sometimes tend to avoid clients from other cultures
because
it's awkward and it's usually frustrating for me and for the client.î This nurse is
C
likely
lacking in what construct of cultural competency?
A
A)
Cultural
desire
B
B)
A Cultural knowledge
C)
A Cultural health
D)
C Cultural harmony
B
D
B
B
A
C
D
B
C
A, B, C, E
D
A
B
D
A
D
N
B
B
D
D
A
B
B
A
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1. A nurse is working with a client who has received a terminal diagnosis. To help the
nurse identify the client's possible coping responses, which of the following would be
most important for the nurse to understand about spirituality?
A) It varies in different situations.
B) It increases in significance with illness.
C) It decreases in importance with age.
D) It remains static throughout the lifespan.
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2. A nurse is planning care that is grounded in the fact that clients are holistic beings.
Which of the following lists of components constitute the view of clients as holistic
beings?
A) Physical identity, psychosocial identity, religious identity
B) Mind, body, spirit
C) Id, ego, superego
D) Spiritual identity, egocentric nature, naïve identity
3. A nurse is planning a spiritual assessment of a client who is experiencing intractable
losses in function as a result of disease. Which of the following principles should inform
the nurse's assessment?
A) Knowledge of the most common spiritual practices in the community is a priority.
B) Reviewing all religious denominations before approaching a client is important.
C) It is of little importance N
for a nurse to understand his or her own spirituality.
D) Spirituality is a complex phenomenon that is not normally describable.
4. A nurse interviews a pregnant client and learns that her beliefs around health care do not
involve participation in comprehensive prenatal care. To which religious view would the
client most likely adhere?
A) Faith Assembly of Indiana
B) Buddhist
C) Christian Scientist
D) Jehovah's Witness
sh
Th
5. A nurse is admitting a client to a long-term care facility. In order to elicit reliable and
valid data during the spiritual assessment, the nurse understands that the focus must be
on which of the following?
A) Objectivity when performing the assessment
B) Sharing a common religious affiliation with the client
C) Repeating the assessment in several weeks
D) Providing spiritual interventions prior to assessment
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6. The nurse chooses to use a formal assessment technique when doing a client's spiritual
assessment. Which of the following techniques would be most appropriate?
A) Self-response assessment instrument
B) Acronyms related to spirituality
C) Open-ended questions
D) A systematic guide for question choices
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7. A nurse is preparing to begin work in a diverse, urban community with members of
numerous different religious traditions. The nurse should identify which statement as
best reflective of Buddhism?
A) Some holy days include fasting from dawn to dusk.
B) The soul has no beginning or end.
C) Outcomes are predetermined.
D) Beliefs focus around the Koran.
8. A client tells the nurse that the intravenous line must be placed in his right hand. Based
on the nurse's understanding of the major religions, the nurse identifies this request as
reflecting which of the following?
A) Judaism
B) Christianity
C) Islam
N
D) Hinduism
9. The nurse is caring for the family of a client who has just died. The family requests that
the client's arms not be crossed and that any of the clothing and dressings containing
blood be left and be prepared for burial with the client. The nurse understands this
family's request as indicative of what religious beliefs?
A) Judaism
B) Buddhism
C) Hinduism
D) Christianity
sh
Th
10. While interviewing a hospitalized client, he states, “The holy days of Ramadan are
coming soon. I am not to have any food or drink from sunrise to sunset during this
time.” Further assessment reveals that the client's request is associated with which
religion?
A) Christianity
B) Judaism
C) Islam
D) Hinduism
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11. A nurse assesses a client's spirituality and religious practices. During the assessment, the
nurse notes that the client is very quiet and rarely asks any questions of the health care
workers. The nurse recognizes that this behavior may be associated with which religion?
A) Islam
B) Buddhism
C) Hinduism
D) Christianity
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12. The nurse is preparing a client for cancer chemotherapy treatment. While talking with
the nurse, the client says, “Miracles do happen, and I'm praying for one.” The nurse
interprets this statement as suggesting which religious preference?
A) Judaism
B) Buddhism
C) Islam
D) Christianity
13. The nurse is reviewing a client's spirituality using the SPIRIT Spiritual Assessment
Tool. Which of the following would the nurse assess when addressing the letter “P”?
A) Powers
B) Personal spirituality
C) Spiritual prognosis
N
D) Prayer
14. When taking the Daily Spiritual Experiences Scale, a client says the word “God” in the
scale is bothersome. Which response by the nurse would be most helpful in encouraging
a client to complete the scale?
A) “Substitute whatever word you prefer that would represent the divine or holy.”
B) “You can skip those questions and answer only those you are comfortable with.”
C) “Don't be concerned about the wording; just answer the best way you know how.”
D) “It is perfectly fine to leave out any question that contains the word 'God.'”
sh
Th
15. A nurse has collected extensive data relating to a client's spirituality. Which type of data
would the nurse need to validate the information obtained during this assessment?
A) Subjective data
B) Objective data
C) Informal data
D) Formal data
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16. A group of students is reviewing material related to the role of religion and spirituality
in health care choices. The students demonstrate understanding when they identify
which of the following situations as the most prominent ethical dilemma that involves
religion?
A) Providing life-saving therapy
B) Failure to seek timely medical care
C) Implementing spiritual care
D) Treating clients' psychological needs
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17. A nurse is preparing an in-service program about spirituality and religion for a group of
colleagues. When describing the effects on clients of religion and spirituality, which of
the following should the nurse include? Select all that apply.
A) Improved client sense of well-being
B) Enhanced coping with end-of-life issues
C) Increased mortality levels
D) Increased timely use of health care
E) Increased adherence to medical regimens
18. A nurse is completing a comprehensive assessment of a client who has been referred to
the clinic. Which of the following would be most appropriate for the nurse to ask when
beginning to assess the client's spirituality?
A) “What religion are you?”N
B) “What gives you hope or peace?”
C) “Do you believe in God?”
D) “Would you like to speak to a chaplain?”
sh
Th
19. When assessing a client's spirituality, the nurse has the client complete a Brief Religious
Coping Questionnaire. When reviewing the completed questionnaire, the nurse
identifies which of the following as indicating positive religious coping?
A) Client feels stress is something from God that is to be endured.
B) Client wonders if God has abandoned him or her.
C) Client looks to God for support in a crisis.
D) Client decides what to do without relying on God.
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20. After teaching a group of students about spirituality and religion, the instructor
determines that the students need additional teaching when a student states which of the
following?
A) Spirituality and religion are important factors that can affect health decisions and
outcomes.
B) Religion and spirituality are separate and distinct, but interrelated concepts.
C) There has been a tremendous growth in the understanding of spirituality in the past
20 years.
D) Nursing has only recently begun to incorporate spirituality into client care.
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21. A nurse is completing an admission assessment of an adult client, during which the
client states, “I've never been a religious man, but I'm definitely spiritual.” How should
the nurse best understand an aspect of the relationship between spirituality and religion?
A) Spirituality is an Eastern concept, whereas religion is associated with Western
cultures.
B) Religion consists of the spiritually focused rituals and practices of a group.
C) Spirituality is the codification of principles that are based on religion.
D) Religion is the state of spiritual certainty that results from cultural influences.
22. A nurse's colleague states, “I think Mrs. Nguyen in room 412 is a Buddhist, so she'll
definitely be a vegetarian.” The nurse should understand what principle of religion and
N care?
spirituality when planning clients'
A) Decisions around a religious client's care should be deferred to the clergy of that
religion.
B) Clients who claim to be spiritual generally oppose meat consumption.
C) The beliefs of members of a particular religion are not necessarily homogeneous.
D) Nurses should avoid planning care on the basis of religion.
sh
Th
23. A nurse recognizes the need to perform a spiritual assessment of a newly admitted
hospital client, but the circumstances surrounding the client's diagnosis and family
dynamics make this challenging. What variable is likely to have the greatest impact on
enhancing the quality of data from the nurse's spiritual assessment?
A) The nature of the nurse's spiritual beliefs
B) The nurse's knowledge of major religions
C) The quality of rapport between the nurse and the client
D) The setting in which the assessment is performed
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24. A nurse recognizes the need to assess a client's spirituality after the client has been
admitted from the emergency department to the medical unit. How should the nurse best
initiate this assessment?
A) “Would you describe yourself as being a religious or spiritual type of person?”
B) “What is the belief system that you most closely adhere to?”
C) “What church do you attend at Christmas and Easter?”
D) “Do you consider yourself to be a moral person with beliefs about the
supernatural?”
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25. A client describes herself as “dumbfounded” that she has been diagnosed with cancer,
stating, “I had such a clear vision from God that I was negative for cancer. Now I have
no idea what I can trust.” This client's statement is suggestive of what nursing
diagnosis?
A) Ineffective role performance
B) Complicated grieving
C) Social isolation
D) Spiritual distress
26. A nurse should conduct an assessment of a client's Risk for Complications after
gathering data related to the client's spirituality. When planning the client's care, the
nurse should be aware that complications are primarily due to the effect of spirituality
N
on what phenomenon?
A) Stress
B) Pain
C) Worry
D) Emotional lability
sh
Th
27. During a client's spiritual assessment, the client explains that the ultimate purpose of her
existence is to achieve a state that she describes as nirvana. The nurse should recognize
that this client ascribes to what religion?
A) Islam
B) Hinduism
C) Buddhism
D) Judaism
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28. A client expresses frustration that the nurse is assessing his spirituality, stating, “I
thought I was here to have my tumor removed, not to figure out what I believe or don't
believe about God.” How should the nurse best justify the need for a spiritual
assessment?
A) “It's important that we plan to make sure that we don't offend you.”
B) “Spirituality actually has a significant effect on your overall health.”
C) “We need to make plans in case there are unexpected outcomes of your surgery.”
D) “Your beliefs determine whether we will focus more on your body or on your
spirit.”
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29. The nurse's assessment of a hospital client's spirituality reveals that the client will accept
very few of the standard treatments for her health problems. How should the nurse
follow up this assessment finding?
A) Report the finding to the appropriate supervisors.
B) Prioritize complementary interventions in the client's care.
C) Consult the client's clergy to weigh options.
D) Document the client's nonadherence to treatment.
sh
Th
30. The nurse is assessing a client's spiritual history using the SPIRIT acronym. The nurse
should begin the assessment by identifying what aspect of spirituality?
A) The client's religious affiliation
N
B) The client's state of health
C) The client's sources of hope
D) The client's spiritual belief system
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Answer Key
N
sh
Th
!
A
B
A
A
A
A
A
D
A
C
A
D
B
A
B
B
A, B, E
B
C
D
B
C
C
A
D
A
B
B
A
C
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
!
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1. The triage nurse suspects malnutrition in an older adult with altered mental status who
has been brought to the emergency department by family members. What visible signs
might the nurse have noticed that would lead to the suspicion of malnutrition? Select all
that apply.




Atrophied tongue
Temporal muscle wasting
Generalized muscle weakness
Dry eyes
Explanation:
Clinical findings of malnutrition can occur throughout the body. Visible signs include muscle
wasting, particularly in the temporal area; muscle weakness and decreased muscle size; tongue
atrophy; and bleeding or changes in the integrity or hydration status of the skin, hair, teeth, gums,
lips, tongue, eyes, and, in men, genitalia. A productive cough is not a visible sign of malnutrition.
2. In which disease process should a nurse expect to see a client with the presence of pitting
edema? End stage renal disease
Explanation:
Pitting edema is a sign of fluid retention; is commonly seen in client with cardiac or renal disease
because the circulatory system cannot handle the excess fluid; it leaks into the tissues. Pitting
edema is most commonly seen in the lower extremities. Colon cancer, diabetes mellitus, and
liver disease do not normally cause pitting edema because these disease processes do not involve
fluid retention.
3. A patient has a BMI of 28. The nurse should assess which areas for additional risk factors
for heart disease? Select all that apply.



blood pressure
cholesterol
activity level
4. Which of the following is the BMI that indicates the lowest risk of developing health
problems? 23
Explanation:
A BMI in the normal range (18.5;24.9) carries the lowest risk of developing health problems.
Being either underweight or overweight increases a person's risk of developing health problems.
5. An individual is considered obese when his or her BMI is: 30-39
Explanation:
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Prep U Assessing Nutritional Status
Those persons with a BMI of 30 to 39 are considered obese. Persons with a BMI of less than 24
are risk for problems associated with poor nutritional status. A BMI of 25 to 29 are considered
overweight. Those with a BMI of greater than 40 are considered extremely obese.
6. A waist circumference of greater that which of the following is indicative of excess
abdominal fat in men? 40
Explanation:
A waist circumference greater than 40 inches for men or 35 inches for women indicates excess
abdominal fat. Those with a high waist circumference are at increased risk for diabetes,
dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation.
7. A nurse is measuring an adult female client’s mid-arm circumference (MAC) as part of
her overall assessment of the client’s nutritional status. Which of the following is the
standard reference for the MAC for an adult female? 28.5 cm
Explanation:
The standard MAC is based on the client’s sex and age. This is a human body composition
measurement, which helps to evaluate the client’s nutritional status. The standard reference of
MAC for an adult female client is 28.5 cm. Ninety percent of the standard reference of MAC in
an adult female is 25.7 cm and represents one who is moderately malnourished. The standard
reference of MAC is 29.3 cm in adult males. Ninety percent of the standard reference of MAC in
adult males is 26.3 cm and represents one who is moderately malnourished.
8. A nurse is calculating the ideal body weight for a female client who 5 feet 5 inches and
has a medium body frame. Which of the following is this client's ideal body weight? 125
Explanation:
Ideal body weight for a female is 100 lb for 5 ft + 5 lb for each inch over 5 ft plus or minus 10%
for small or large frame. For this female client with a medium frame, the formula would be as
follows: 100 lb + 25 lb = 125 lb.
9. A nurse collects nutritional information on a client. Which statement by the client needs
to be validated by careful objective data? I drink two large bottles of caffeinated
beverages every day.
Explanation:
Excessive intake of diuretic fluids, such as coffee or other caffeinated beverages, can lead to
dehydration. The nurse needs to validate how much a large bottle contains and collect objective
data to assess for findings of dehydration. Packing a lunch to control calorie intake and
exercising 30 minutes a day is healthy. Eating small amounts of food more frequently is also a
helpful way to control weight.
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Prep U Assessing Nutritional Status
10. A nurse is working with a client with a chronic disease that has contributed to the client
developing cachexia, a type of malnutrition. As a result, the client demonstrates abnormal
metabolic rate, anorexia, muscle wasting, severe weight loss, and general decline in
condition. Which chronic disease, strongly associated with cachexia, does the client most
likely have? Cancer
Explanation:
A population that is particularly at risk for developing malnutrition is the client with cancer.
Wasting syndrome, known as cachexia or cancerous or malignant cachexia, can develop. This
type of malnutrition is characterized by an abnormal metabolic rate, anorexia, muscle wasting,
severe weight loss, and general decline in condition. Cachexia is not associated with
cardiovascular disease, diabetes, or osteoporosis.
11. A nurse is using calipers to assess a client. Which of the following measurements is the
nurse taking? Skinfold thickness
Explanation:
Skinfold calipers are used to measure triceps skinfold thickness to evaluate the degree of
subcutaneous fat stores. Body mass index is calculated by first measuring height and weight by
means of a balance beam scale with height attachment and then entering these values into a
formula. A tape measure is used to measure waist and mid-arm circumferences.
12. A nurse is working with a client who has just been given a prescription for warfarin
(Coumadin). Which foods should the nurse warn this client to avoid due to its
interference with the effectiveness of warfarin? Green, leafy vegetables
Explanation:
Some medications or dietary supplements may decrease the client absorption of nutrients. Other
medications&; therapeutic effects are affected by diet. For example, the therapeutic effects of
warfarin (Coumadin) are lessened with the intake of large amounts of green, leafy vegetables.
Red meat, dairy products, and citrus fruits are not known to interfere with warfarin.
13. What can cause edema in a patient with a weak heart? Overhydration
Explanation:
Edema may be secondary to a protein deficiency or overhydration in a patient with a weak heart.
14. When teaching a nutrition class, what would you recommend for adults older than the age
of 50? Increase foods rich in vitamin B12 and calcium
Explanation:
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Prep U Assessing Nutritional Status
Be prepared to help adolescent females and women of child-bearing age increase intake of iron
and folic acid. Assist adults older than 50 years to identify foods rich in vitamin B12 and
calcium. Advise older adults and those with dark skin or low exposure to sunlight to increase
intake of vitamin D.
15. Waist circumference guidelines may not be accurate for adult clients who are shorter than
152.4 cm (5 ft) in height. This restriction is also a concern for which other anthropometric
measurement? Body mass index (BMI).
Explanation:
As with BMI, waist circumference guidelines may not be as accurate with adult clients who are
shorter than five feet in height.
16. When would a nurse obtain a mid-arm circumference measurement? To provide
percentage of body fat and muscle tissue.
Explanation:
Measure mid-arm circumference (MAC) evaluates skeletal muscle mass and fat stores.
17. A teenaged client is seen by the nurse for report of excessive thirst and weight loss
despite high food intake. Which health condition is most likely responsible for these
symptoms? diabetes mellitus
Explanation:
Diabetes mellitus, juvenile onset, is characterized by symptoms of excessive thirst (polydipsia)
and weight loss despite hunger and high food intake as a result of metabolic changes associated
with this condition. Symptoms associated with hypothyroidism include decreased appetite,
lethargy, and weight gain. Symptoms associated with protein deficiency often include problems
related to quality of skin, hair, and nails. The primary characteristic of anorexia is intentional
food restriction.
18. While conducting a physical examination, the nurse notices the client’s mucous
membranes are pale in color. Which nutritional deficiency is most likely for this client?
anemia
Explanation:
Pale mucous membranes are common in anemia due to decreased blood flow and/or red blood
cells in the body. Vitamin A deficiencies are most likely if the signs and symptoms include
petechiae, ecchymoses, or poorly healing sores. A protein deficiency is most likely if there is the
presence of edema, abdominal distension, or muscle wasting. A vitamin C deficiency is most
likely if the client reports muscle and joint pain, bleeding gums, or poorly healing wounds.
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19. The nurse measures the height and body weight of a female client with high muscle mass.
The client weighs 175 pounds (79.4 kg) and is 68 inches (173 cm) tall. In which of these
categories does the client’s body mass index (BMI) fit best? normal
Explanation:
Although a BMI of 26.6 for a female client would normally be categorized as overweight, this
client has higher muscle mass. This needs to be considered when providing recommendations for
a healthy body weight. Given the factors involved, this client should be categorized with a
normal BMI. The client would be best suited to the overweight category if muscle mass was
deemed low. A BMI of less than 18.5 is best suited to the underweight category. A BMI of 30 or
greater is considered obese.
20. During an assessment the nurse suspects that a client has a vitamin C deficiency. What
information did the nurse use to make this clinical determination? bleeding gums
Explanation:
A manifestation of vitamin C deficiency are bleeding gums. Bone pain is associated with a
vitamin D deficiency. Paresthesias are associated with vitamin B12, pyridoxine, or thiamine
deficiency. Dry flaky skin is associated with a vitamin A, vitamin B-complex, or linoleic acid
deficiency.
1. A nurse is teaching a class on diet and nutrition to a group of mothers who are breastfeeding their infants. What would the nurse tell the group is the emphasis of nutritional
guidelines? Variety
Explanation:
Emphasis of nutritional guidelines is on variety; increased intake of vegetables, fruits, lentils, and
grains, particularly from plant sources; and meeting individual nutritional needs while avoiding
either deficiencies or excesses in nutrient intake.
2. What is the use of dietary assessment data gathered from a client by a nurse? Identify
patient outcomes
Explanation:
Nurses use assessment information to identify client outcomes. The other options are distractors
for the question.
3. When performing a nutritional assessment on a client, a nurse observes that the client has
a red, beefy tongue. The nurse recognizes this finding as a deficiency of which essential
nutrient? Vitamin B
Explanation:
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The suggested implication for a red, beefy tongue is vitamin B deficiency. The finding of a red,
beefy tongue in a client does not indicate thiamine deficiency, or iodine or niacin deficiency.
Altered mental status is due to thiamine deficiency. A swollen neck is caused by iodine
deficiency. Cracks in the corners of the mouth are because of niacin deficiency.
4. A nurse recognizes that a client may be at risk for malnutrition when which lifestyle
behavior is present? Chronic dieting
Explanation:
Chronic dieting, especially with fad diets, can predispose an individual to malnutrition because
the amount of needed nutrients is often lacking in an effort to lose weight quickly. Single
parenthood is not a risk factor for malnutrition unless the parent is unable to gain access to
shopping or suffers form a lower socioeconomic status. Diabetes mellitus is a chronic disease,
not a lifestyle behavior. Excessive exercising may lead to weight loss but not malnutrition.
5. When beginning a height measurement on a 14-year-old, the nurse should instruct the
patient to stand on the scale with his back to the wall. True
6. Which of the following findings from a nutritional history most likely indicate the client
is showing signs of an eating disorder? (Select all that apply.)


Has body mass index of 16
Discusses feeling fat in clothes
Explanation:
Clinical findings associated with an eating disorder include a body mass index below 17.5 and
fears of appearing fat. Seeking help with concerns about weight is a healthy, adaptive behavior.
Clients who experience eating disorders often deny it is a problem and need to be brought to a
health care provider by family members. Exercise for 30 minutes, 3-5 times a week is not likely
related to an eating disorder because it is not deemed excessive. A body mass index of 23
indicating is considered within the healthy range for BMI.
7. Which of the following patients will have an increased metabolic rate and require
nutritional interventions? A person with a serious infection and fever.
Explanation:
Factors that increase metabolic rate include growth, infections, fever, emotional tension, extreme
environmental temperatures, and elevated levels of some hormones. Aging, prolonged fasting,
and sleep decrease metabolic rate.
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8. You are the clinic nurse assessing a new patient that has come in to see a physician. The
assessment data that you collect reveals that the patient is a 23 year-old female weighing
175 lb with a height of 5 ft 3 in. Her body mass index is 31. What would she be
considered? Obese
Explanation:
A body mass index of 31 is considered clinically obese. People who have a BMI lower than 18.5
(or who are 80% or less of their desirable body weight for height) are at increased risk for
problems associated with poor nutritional status. Those who have a BMI of 25 to 29 are
considered overweight; those with a BMI of 30 to 39, obese; and those with a BMI greater than
40, extremely obese.
9. When calculating ideal body weight for women, the health care professional adds how
many pounds for each inch over 5 feet? 5
Explanation:
When calculating ideal body weight for women, add 5 pounds for each additional inch over 5
feet. The other numerical values are incorrect.
10. A nurse assesses a 350-pound adult client who is 6 feet 1 inch tall. What is the estimated
body mass index (BMI) for this client? 46
Explanation:
The BMI is calculated by dividing weight in pounds by height in inches squared and then
multiplying by 703. The body mass index calculated by the nurse should be approximately 46 for
a client who is 6 feet 1 inch (73 inches) tall and 350 pounds.
11. A nurse assesses a 175-pound adult client who is 5 feet 11 inches tall. What is the
estimated body mass index (BMI) for this client? 24.4
Explanation:
The BMI is calculated by dividing weight in pounds by height in inches squared and then
multiplying by 703. The body mass index calculated by the nurse should be 24.4 for a client who
is 5 feet 11 inches tall and 175 pounds.
12. A nurse has just determined a client's body mass index (BMI). Which measurement
should the nurse add to the BMI to increase the predictive ability for health risk to the
client? Waist circumference
Explanation:
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The nurse should add waist circumference to the BMI to increase the predictive ability for health
risk to the client of this measure. It helps to determine the extent of abdominal visceral fat in
relation to the body fat. The mid-arm circumference helps to assess skeletal muscle mass and fat
stores. The triceps skinfold helps to evaluate subcutaneous fat stores. The mid-arm
circumference, along with the triceps skinfold measurement, are used in a formula to calculate
the mid-arm muscle circumference, which is used to evaluate muscle reserve stores.
13. A client with diabetes mellitus visits the health care clinic with reports of excessive thirst
and excessive urination. She states that her appetite has been low for the past 3 months,
and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this
data? Imbalanced nutrition
Explanation:
The nurse should confirm the nursing diagnosis of imbalanced nutrition because the client has
the major defining characteristics of inadequate food intake and weight loss. Fluid volume,
excessive cannot be confirmed because even with the excessive urination the client is losing
weight and there is no major defining characteristic present. The client made no statement about
activity intolerance or that the client does not have enough knowledge to manage the diabetes
properly.
14. A nurse is providing nutritional instruction at a health fair. She instructs passersby on the
characteristics of a nutrient that is the body's first source of energy, sparing use of other
nutrients for this purpose, that raises the blood glucose level, is found in fruit juices, and
that can be converted quickly into energy. To which of the following nutrients is the nurse
referring? Simple carbohydrates
Explanation:
Briefly, carbohydrates are referred to as either simple or complex, depending on their chemical
structure. Simple carbohydrates, such as found in fruit juice, are sugar with a simple structure
that raises the blood glucose level and can be converted quickly into energy. Complex
carbohydrates, such as whole grains, are starches that more slowly convert into energy and can
also be used as an energy source. Carbohydrates are known as protein sparing because the body
uses them for an energy source rather than breaking down proteins to fuel the body's energy
needs. Protein and fat can be used as energy sources but are not the body's first source of energy,
and are metabolized more slowly.
15. The nurse conducting a nutritional assessment should notify the healthcare provider of a
possible eating disorder based on which finding? Absence of menstrual periods
Explanation:
Amenorrhea is a cardinal symptom of eating disorders. Lack of subcutaneous fat with prominent
bones, abdominal ascites, and pitting edema are abnormal findings. Reduced albumin level is a
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sign of cachexia, a highly metabolic state that with accelerated muscle loss that differs from
anorexia nervosa.
16. Parents of a 15 month old state they are worried about the rolls of fat on the toddler's
thighs; so they have switched him over to skim milk. What is the nurse's best response?
"Whole milk is recommended until age 2."
Explanation:
Infants, children, and adolescents require different nutrients based on developmental and growth
factors. For example, fat intake is crucial to brain development in infants and young toddlers.
Therefore, whole milk is recommended for children younger than 2 years.
17. What is the most common measurement used to determine abdominal visceral fat? Waist
circumference.
Explanation:
Waist circumference is the most common measurement used to determine the extent of
abdominal visceral fat in relation to body fat.
18. Because BMI is calculated using only height and weight, the nurse knows that inaccurate
findings would most likely occur in a client who is a bodybuilder.
Explanation:
The use of BMI alone is not diagnostic of a client’s health status. Because BMI does not
differentiate between fat or muscle tissue, inaccurately high or low findings can result for people
who are particularly muscular or for older adults who tend to lose muscle mass.
19. A nurse is caring for several patients in an outpatient setting. Which of the following
patients is most likely to experience a weight gain? A 33-year-old athlete on steroids
Explanation:
A patient taking steroids may gain weight.
20. The nurse is conducting a nutrition history with a young adult with signs and symptoms
of an eating disorder. Which question exemplifies the most effective way for the nurse to
ask about body image? “What would you change about your body, if you could?”
Explanation:
As per the nutrition history, the nurse should ask if there is anything that the client would like to
change about his or her body in order to identify disturbance of body image. The client should be
asked if he or she gathers around a table with others for meals if the nurse is asking about family
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dietary patterns. The client should be asked how much he or she exercises in one week if the
nurse is asking about exercise patterns. The client should be asked how many meals and snacks
he or she eats in one day if the nurse is trying to determine a food pattern.
1. After assessing a new client, the nurse documents findings in the medical record. What is
the best example of documenting normal findings? Nails are strong
Explanation:
Nails are strong; is the documentation that represents a normal finding. Clothing that is too large
might indicate weight loss. Thin, oily hair is not generally a normal finding, nor are white
patches on the oral mucosa.
2. A nurse assesses a 114-pound adult client who is 5 feet 5 inches tall. What is the estimated
body mass index (BMI) for this client? 19 BMI
Explanation:
The BMI is calculated by dividing weight in pounds and height in inches multiplied by 703. The
body mass index calculated by the nurse should be 19 for a client who is 5 feet 5 inches tall.
Assuming the same height and different weight, such as 120 pounds, the BMI would be 20,
whereas for 126 pounds the BMI would be 21, while for 132 pounds the BMI would be 22. The
nurse should obtain the client's weight and height to determine his or her body mass index, which
can be calculated regardless of the client's gender.
3. A nurse recognizes that which of these are possible health risks for a client who is obese?
Select all that apply.



Diabetes
Hypertension
Sleep apnea
Explanation:
The health risks of obesity include diabetes, hypertension, and sleep apnea. Obesity is an
excessive fat in relation to lean body mass. Malnutrition can exacerbate or facilitate diseases like
bulimia and cirrhosis. Anorexia is a disorder whereby food is self-limited or refused. Cirrhosis is
a chronic disease that may interfere with absorption or use of nutrients.
4. How can a nurse best assess a client's dietary habits? Obtain a 24 hour dietary recall of
all foods and fluids consumed
Explanation:
The nurse can best assess dietary habits by asking the client about an average daily intake of
food and fluids, where and when food is consumed, and if there are any conditions or diseases
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that may affect intake or absorption of nutrients. A height and weight may not accurately reflect
dietary intake. One meal will not provide the best assessment of overall dietary habits.
5. A client with a body mass index of 28 tells the nurse she is concerned about her risk for
hypertension. What can the nurse recommend to this patient? Reducing her weight by
5% can lower her risk
Explanation:
Even reducing weight by 5 to 10% can improve blood pressure and lipid levels reducing the risk
of hypertension. A more rapid weight loss is not sustainable and may not lead to long term
prevention of hypertension. This would be the case if the patient consumes no more than 500
calories each day. This restricted level of caloric intake could also lead to nutritional deficiencies.
A 10% weight reduction over 6 months is recommended. A 20% weight reduction over 6 months
could be too severe and lead to nutritional deficiencies and regaining of lost weight, therefore,
having little or no long term impact on preventing hypertension. A daily reduction of 100 calories
will not meet the goal of a healthy and realistic weight loss which can compromise healthy blood
pressure long term.
6. A 74-year-old man has been taking a beta-blocker for several years, and his care provider has
chosen to add a diuretic to his regimen to better control his hypertension. What should the
clinician teach the client about the relationship between his new medication and his
nutritional health? “This will make you urinate more often, so make sure you drink
plenty of fluids.”
Explanation:
Diuretics are associated with reduced fluid intake; clients should thus be encouraged to maintain
and monitor their daily fluid intake. Constipation, nausea, and iron-deficiency are not associated
with diuretic use.
7. A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-ofthumb method, what would be this patient's ideal weight? 145 lb
Explanation:
A general guideline, often called the rule-of-thumb method, determines ideal weight based on
height. This formula is as follows: For adult females: 100 lb (for height of 5 ft) + 5 lb for each
additional inch over 5 ft For adult males: 106 lb (for height of 5 ft) + 6 lb for each additional inch
over 5 ft.
8. A home care nurse is teaching a patient’s daughter meal planning for her mother who is
recovering from a hip replacement surgery. Which of the following meals indicates that the
daughter understands the concept of a nutritionally complete choice based upon the Food
Guide Pyramid? Ham sandwich with tomato on rye bread with peaches and yogurt
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Explanation:
The menu has a choice from each of the food groups from the Food Guide Pyramid. The other
selections are incomplete choices.
9. To calculate the ideal body weight for a woman, the nurse allows 100 pounds for 5 feet of
height.
Explanation:
To calculate the ideal body weight of a woman, the nurse allows 100 pounds for 5 feet of height
and adds 5 pounds for each additional inch over 5 feet. The nurse allows 106 pounds for 5 feet of
height in calculating the ideal body weight for a man. The nurse adds 6 pounds for each
additional inch over 5 feet in calculating the ideal body weight for a man. Eighty pounds for 5
feet of height is too little.
10. A nurse assesses a 105-pound adult client who is 5 feet 8 inches tall. What is the estimated
body mass index (BMI) for this client? 16
Explanation:
The BMI is calculated by dividing weight in pounds by height in inches squared and then
multiplying by 703. The body mass index calculated by the nurse should be 16 for a client who is
5 feet 8 inches tall and 105 pounds.
11. A nurse needs to record the height of a client who refuses to stand because of blisters on the
feet. What alternative method should the nurse implement to obtain the client's height?
Measure the arm span to estimate height
Explanation:
As the client is unable to stand, the nurse should measure arm spam to estimate the height. The
nurse may support or hold the client only when the client is required to stand when recording the
height. The nurse should have the client stretch one arm straight out sideways to record the
height and measure from the tip of the middle finger to the tip of nose and multiply by 2. The
nurse should not obtain this information subjectively from the client. A standard table listing
heights and weights may be used for calculating body mass index but would not be used to
determine the client's height.
12. A nurse is providing nutritional instruction to a client with cardiovascular disease. The nurse
mentions a nutrient that is a necessary component of bile salts (which aid in digestion),
serves as an essential element in all cell membranes, is found in brain and nerve tissue, and is
essential for the production of several hormones such as estrogen, testosterone, and cortisone.
The nurse warns the client, however, that this nutrient when consumed in excess can lead to
heart attacks and strokes. To which of the following nutrients is the nurse referring?
Cholesterol
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Explanation:
Cholesterol is a fatlike substance that the liver produces. A high level of cholesterol can lead to
heart attacks and strokes. However, cholesterol is important to normal bodily functions. It is
necessary as a component of bile salts (which aid in digestion), serves as an essential element in
all cell membranes, is found in brain and nerve tissue, and is essential for the production of
several hormones such as estrogen, testosterone, and cortisone. Ingested fats are saturated,
originating from animal sources or tropical oils and solid at room temperature, or unsaturated,
originating from plant sources and soft or liquid at room temperature. Fats serve many functions
in the body, but not the ones listed here. The primary functions of protein are growth, repair, and
maintenance of body structures and tissue.
13. What precaution should the nurse take when measuring a client's abdominal girth to screen
for cardiovascular risk factors? Place the tape measure behind the client and measure at
the umbilicus
Explanation:
The nurse should place the tape measure behind the client and measure at the umbilicus. The
umbilicus should be the starting point when measuring the abdomen, especially when distention
is apparent. Abdominal measurement is generally taken in the morning after voiding, not after
the client has had a full meal. The ideal position to measure the abdomen is standing, not sitting.
The nurse informs the client that the pen mark on the abdomen should not be washed off only if
the client is being monitored on a regular basis to determine progress of treatment for abdominal
distention.
14. A client suffering from decreased muscle strength has been diagnosed with a low Vitamin D
level. The nurse should recommend that the client increase intake of which vitamin source?
Sunshine
Explanation:
Vitamin D is obtained through exposure to sunlight. Some people who are not exposed to enough
sun may require dietary supplements. Folate can be found in fortified breads, lentils, and orange
juice.
15. The nurse caring for a hospitalized client suspects inadequate food intake. The dietician is
consulted to conduct a calorie count. How should the nurse document the client's breakfast
intake? 2 slices of bacon eaten
Explanation:
When a calorie count is required, detailed documentation of the actual amounts and specific
foods the client has consumed is needed. Two slices of bacon which indicates a specific amount
of a specific food and can be used to determine a calorie count. Only 50% of breakfast eaten is a
specific amount, but without knowledge of what foods were eaten, this is not enough information
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for a calorie count. Drank a small amount of milk and consumed a partial amount of eggs are
both specific about the type of food, but not the amount, so neither is enough information for a
calorie count.
16. You note that your patient has developed mental status changes and paresthesias. What would
you know to assess as a possible cause for these changes? Patient’s hydration status
Explanation:
Note changes in mental status, irritability, inability to concentrate, or paresthesias. Dehydration
and lack of vitamins may cause these symptoms.
17. Based only on anthropometric measurements, which set of clients listed below are at the
greatest risk for diabetes and cardiovascular disease? Females with 88.9 cm (35 in) or
greater waist circumference.
Explanation:
Adults with large visceral fat stores located mainly around the waist (android obesity) are more
likely to develop health-related problems than if the fat is located in the hips or thighs (gynoid
obesity). These problems include an increased risk of type 2 diabetes, abnormal cholesterol and
triglyceride levels, hypertension, and cardiovascular disease such as heart attack or stroke.
18. The nurse measures a male client’s waist circumference as 43 inches (109 cm). Which
statement is most appropriate for the nurse to make given this finding? “Let’s discuss your
risk factors for heart disease.”
Explanation:
Waist circumference is an indicator of central body fat. In men, a waist circumference greater
than 40 inches (102 cm) is strongly associated with an increased risk for heart disease. High
waist circumference alone cannot provide enough information about vitamin deficiency. Other
signs and symptoms must be present and further assessment is warranted prior to making this
statement. Protein deficiency is associated with abdominal distension and ascites, not high waist
circumference. Because waist circumference is a measure of central body fat, it stays consistent
over the course of the day.
19. It would be a priority for the nurse to provide counseling about nutrition and exercise for
weight loss for which client? a client with body mass index of 27 and blood pressure of
145/80 mm Hg
Explanation:
The client with a body mass index (BMI) of 27 is overweight and has hypertension. The nurse
should offer strategies for weight loss to prevent the progression of cardiovascular disease. A
client with a BMI of 18.5 borders on normal and underweight. Despite having a family history of
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heart disease, the client should be discouraged from further weight loss. Other risk factors for
heart disease should be identified and treated as necessary. The client with a BMI of 23 is in the
normal range; therefore, pursuing weight loss is not indicated. Further monitoring of the LDL
cholesterol is warranted, however. The client with a BMI of 25 would be considered on the
borderline of the overweight category; however, the HDL cholesterol is normal. Cardiovascular
risk associated with the BMI is not higher in the absence of other risk factors.
20. A client asks for help with determining the amount and type of foods to consume to improve
nutritional intake. What should the nurse recommend that this client use? My Plate
Explanation:
The U.S. Department of Agriculture’s (USDA’s) Choose My Plate is a tool to help individuals
analyze their diet and set goals for a healthier diet. A calorie counter will not necessarily help the
client select healthful foods. An 1800 calorie diet may be too much or insufficient to meet the
client’s nutritional needs. Healthy People 2020 does not provide direction as to how to improve
nutritional status.
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1. The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin.
During health promotion, the nurse should focus education on which of the following
topics?
A) Management of dry skin
B) Susceptibility to bruising
C) Risks of fungal infections
D) Risks of sun exposure
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2. The nurse is performing an assessment of a client admitted to the emergency department
in status asthmaticus. The nurse should carefully inspect which part of the body in an
effort to differentiate central cyanosis from peripheral cyanosis?
A) Nail beds
B) Sclerae
C) Palms
D) Oral mucosa
3. A 45-year-old African-American client comes to the clinic complaining of fatigue,
thirst, and frequent urination. During the exam, the nurse notices areas of
hyperpigmentation around the neck and in the axillae. Which of the following should
the nurse do next?
A) Document the benign findings.
B) Perform a random bloodNsugar test.
C) Ask the client about a family history of cancer.
D) Refer the client for medical follow-up.
Th
4. An older adult female client is concerned because her skin is very dry. She asks the
nurse why she has dry skin now when she never had dry skin before. The nurse
responds to the client based on the understanding that dry skin is normal with aging due
to a decrease of what?
A) Squamous cells
B) Sweat glands
C) Subcutaneous tissue
D) Sebum production
sh
5. The nurse's assessment of an adult female client reveals the presence of excessive hair
on her face and chest. The nurse should plan further evaluation of which body system?
A) Endocrine
B) Neurologic
C) Cardiovascular
D) Genitourinary
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6. During an integumentary assessment, the nurse notes that the client's fingernails are
very thin and concave. The nurse knows the client needs medical follow-up for further
assessment to rule out which condition?
A) Diabetes mellitus
B) Iron deficiency anemia
C) Vitamin A deficiency
D) Peripheral vascular disease
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7. In which health condition would the nurse most likely expect to assess a capillary refill
time that is longer than 2 seconds?
A) Psoriasis
B) Multiple sclerosis
C) Malignant melanoma
D) Peripheral vascular disease
8. A nurse has been asked to assess an older adult resident of a long-term care facility.
During assessment of the resident's skin, the nurse notes a break in the skin, erythema,
and a small amount of serosanguineous drainage over the resident's sacrum. Inspection
reveals that the area appears blister-like. The nurse should interpret this finding as
indicating which stage of pressure ulcer?
A) Stage I
N
B) Stage II
C) Stage III
D) Stage IV
Th
9. A 15-year-old boy shows the school nurse a ìbumpî on his neck. The nurse observes a
raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the
presence of which of the following?
A) Macule
B) Papule
C) Nodule
D) Pustule
sh
10. While inspecting the skin of an older adult client, the nurse notes multiple small, flat,
reddish-purple macules. The nurse should recognize the presence of which of the
following?
A) Purpura
B) Petechiae
C) Ecchymosis
D) Cherry angioma
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11. A client has sought care because he is concerned that a mole on his scalp may be
evidence of skin cancer. During assessment using the mnemonic ABCDE, which
finding would the nurse identify as being most suggestive of melanoma?
A) Solid, dark brown color
B) Asymmetric, irregular borders
C) Diameter of 3 mm
D) Flat with silvery scales
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12. An older adult client reports that he is experiencing severe trunk pain and is concerned
that he might have shingles. Which type of lesion would the nurse most likely assess?
A) Papule
B) Vesicle
C) Bulla
D) Crust
13. The nurse notes multiple elevated masses with irregular transient borders that are
superficial, raised, and erythematous in a client who complains of an ìitching rash.î
Which question would be most important for the nurse to ask?
A) ìAre you allergic to foods, medications, or other substances?î
B) ìDoes anyone else in your family have a rash like this?î
C) ìHow painful is your rash?î
N to control the itching?î
D) ìWhat have you been doing
14. A client's history reveals that he has been taking oral steroid therapy for several years
for the treatment of an autoimmune disorder. During assessment, the nurse would expect
the client's skin to have what characteristic?
A) Increased thickness and hair loss
B) Increased thinness
C) Pallor
D) Erythema
sh
Th
15. An older adult male client states that he has trouble cutting his toenails because they are
hard and thick, and the nurse notes that they are very long and unkempt. Which system
would be most important for the nurse to assess?
A) Integumentary
B) Digestive
C) Neurologic
D) Circulatory
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16. Assessment of a client's nails reveals brownish-black discoloration and crumbling of the
nail plate. The nurse should suspect which of the following etiologies?
A) Fungal infection
B) Bacterial infection
C) Yeast infection
D) Circulatory disorder
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17. The nurse is preparing to examine a client's skin. Which of the following actions would
be most important for the nurse to do?
A) Ensure that the room is hot to prevent chilling.
B) Wear gloves when preparing to inspect the skin and nails.
C) Expose only the body part that is being examined.
D) Have the client remove clothing from the upper body.
18. A nurse is providing a client with instructions on how to perform self-examination of
the skin. The nurse would encourage the client to perform this examination at which
frequency?
A) Monthly
B) Bimonthly
C) Quarterly
D) Yearly
N
19. Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the
client's back. The nurse would document the configuration as which of the following?
A) Discrete
B) Linear
C) Annular
D) Confluent
sh
Th
20. Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets
this finding as suggestive of which of the following?
A) Oxygen deficiency
B) Acute illness
C) Psoriasis
D) Trauma
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21. A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the
admission assessment of an older adult client. What assessment parameter will the nurse
evaluate when using this scale?
A) The client's current medication regimen
B) The client's ability to change position
C) The pigmentation of the client's skin
D) The client's history of integumentary disorders
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22. A nurse is assessing a 49-year-old client who questions the nurse's need to know about
sunburns he experienced as a child. How should the nurse best explain the rationale for
this subjective assessment?
A) ìRepeated sunburns in childhood may explain the presence of some of your moles.î
B) ìThis is one of the assessments we use to determine whether your parents took
good care of your skin when you were young.î
C) ìWhen you burn your skin as a child, it makes your skin more sensitive and slower
to heal when you're older.î
D) ìHaving bad sunburns when you're a child puts you at risk for skin cancer later in
life.î
23. A nurse is implementing appropriate infection control precautions while performing a
client's skin assessment. During which of the following components of the assessment
should the nurse wear gloves?N
A) When palpating the texture of the client's skin
B) When palpating the client's hair
C) When palpating lesions on the client's skin
D) When palpating the client's nail beds for texture and capillary refill
sh
Th
24. The nurse is conducting an assessment of an adult client who describes herself as being
in good health. Inspection of the client's nail beds reveals the presence of a bluish tone.
The nurse should recognize that this finding is most likely attributable to what
phenomenon?
A) Vasoconstriction
B) Hyperglycemia
C) Hypoxemia
D) Cardiopulmonary insufficiency
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25. A nurse is providing care for a client who has decreased mobility secondary to a recent
stroke. Which of the following assessment findings would be indicative of a stage I
pressure ulcer?
A) There is a nonblanching reddened area on the client's coccyx region.
B) There is scant, frank blood present on the skin surfaces surrounding the client's
coccyx.
C) There is noticeable bruising on and around the client's coccyx region.
D) There is a generalized rash on the client's lower back and buttocks.
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26. A client has sought care because of the development of pruritic lesions between her
toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse
best corroborate this suspicion?
A) Test whether gentle abrasion with an emery board is painful.
B) Apply hydrogen peroxide to see whether the client's pruritus is relieved.
C) Perform a trial with a topical antibiotic.
D) Illuminate the area using a Wood's light.
27. The nurse is assessing a middle-aged female client who is new to the clinic. The nurse
observes the presence of significant facial hair that is uncharacteristic of the client's
ethnicity. What assessment question should the nurse consequently ask?
A) ìHas anyone in your family ever been diagnosed with skin cancer?î
N
B) ìHave you ever been assessed
for diabetes?î
C) ìWhat dietary supplements do you usually take?î
D) ìDo you take steroid medications on a regular basis?î
Th
28. The nurse is assessing a dark-skinned client whose forearms are hands have distinct
regions of depigmentation. The nurse should document the presence of what health
problem?
A) Vitiligo
B) Striae
C) Angiomas
D) Albinism
sh
29. A nurse is assessing an older adult client's risk for pressure ulcers using the Braden
Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health
status would be reflected in her score on this scale?
A) The client has a full-time caregiver.
B) The client is consistently incontinent of urine.
C) The client has a surgical diagnosis.
D) The client adheres to a vegetarian diet.
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EDITION BY WEBER
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and NURSING
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30. A nurse is preparing for an assessment by reviewing a new client's electronic health
record, which documents the presence of macules on the client's left flank and mid-back
regions. The nurse should recognize what characteristic of these skin lesions?
A) The lesions will be raised and have irregular borders.
B) The lesions will be acutely painful.
C) The lesions will produce eschar.
D) The lesions will not be palpable.
sh
Th
N
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D
D
B
D
A
B
D
B
B
B
B
B
A
B
D
B
C
A
A
B
B
D
C
A
A
D
D
A
B
D
N
sh
Th
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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Answer Key
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1. The nurse is preparing to palpate a client's temporal artery. The nurse would place the
hands at which location?
A) On each side of the client's face, anterior and inferior to the ears
B) On each side between the top of the ear and the eye
C) Bilaterally, parallel to and anterior to the sternomastoid muscle
D) Inferior to the lower jaw beneath the client's tongue
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2. A nurse is preparing to assess an adult client's carotid pulses. Which of the following
actions would be contraindicated?
A) Asking the client to flex his or her neck
B) Compressing the arteries bilaterally
C) Performing the examination while the client is seated
D) Asking the client to swallow water
3. The nurse's assessment reveals that a male client can neither turn his head against
resistance nor shrug his shoulders. The nurse should document a potential deficit in the
functioning of which cranial nerve?
A) Abducens (VI)
B) Accessory (XI)
C) Hypoglossal (XII)
D) Trochlear (IV)
N
4. During the health history, a client describes recent episodes of intermittent facial pain
lasting several minutes. The nurse should recognize that this complaint is suggestive of
what health problem?
A) Trigeminal neuralgia
B) Migraine headache
C) Meningitis
D) Temporomandibular joint dysfunction
sh
Th
5. A client describes her 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) ìDo they occur after you have been tense or anxious?î
B) ìWhen you consume alcohol, do you get a headache?î
C) ìDo you have any eye symptoms, such as tearing?î
D) ìDo you have any visual changes before the headache?î
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6. Which 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
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7. A nurse is preparing a presentation for a local community group about preventing
traumatic brain injury. The nurse would discuss which measure as prevention of the
leading cause?
A) Safe use of firearms
B) Safe use of machinery
C) Falls prevention
D) Domestic violence prevention
8. A nurse is palpating the head and neck of a newly referred client. Which of the
following would the nurse suspect if assessment reveals that the client's skull and facial
bones are larger and thicker than normal?
A) Acromegaly
B) Brain tumor
C) Paget disease
N
D) Parkinson disease
9. When talking to a client before starting the physical exam, the nurse notes that the client
consistently tilts her head to one side. Which of the following should the nurse examine
first?
A) Hearing acuity
B) Thyroid gland
C) Mental status
D) Lymph nodes
sh
Th
10. The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender
with absent pulsations. The nurse would gather additional information related to which
aspect of health?
A) Mental status
B) Hearing
C) Neurologic status
D) Vision
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11. A nursing educator is evaluating a colleague's examination of a client's thyroid gland.
The educator would determine that the nurse needs additional instruction when the nurse
demonstrates which technique?
A) Inspection
B) Auscultation
C) Palpation
D) Percussion
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12. A 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
13. When preparing to assess a client's thyroid gland, the nurse should ensure that which
piece of equipment is readily available?
A) Penlight
B) Tongue depressor
C) Centimeter-scale ruler
D) Cup of water
N
14. Which of the following findings should the nurse document after assessing the thyroid
gland of an older adult without abnormalities?
A) Nodularity
B) Tenderness
C) Enlargement
D) Bruits
sh
Th
15. A nurse is assessing an adult client's neck. Which of the following would be most
appropriate when auscultating the client's thyroid gland for bruits?
A) Hyperextend the client's neck.
B) Turn the client's head to the right.
C) Have the client swallow water.
D) Have the client hold his or her breath.
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16. A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic
location should the nurse position his or her hands?
A) At the angle of the client's mandible
B) At the base of the client's skull
C) On the area behind the client's ears
D) Behind the tip of the client's mandible
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17. The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and
the supraclavicular nodes by first locating which muscle?
A) Infraspinous
B) Sternomastoid
C) Trapezius
D) Platysma
18. A nurse has completed an assessment of a client's lymph nodes. Which of the following
data would the nurse document as an abnormal finding?
A) Diameter: 0.75 cm
B) Mobile
C) Tender
D) Discrete
N
19. The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. Which
of the following would the nurse most likely assess?
A) Sunken face
B) Drooping of one side
C) Masklike expression
D) Asymmetry of earlobes
sh
Th
20. During a health history, a client reports complaints of headaches. Which of the
following would lead the nurse to suspect that the client is experiencing cluster
headaches?
A) Pain radiating from eye to temporal region
B) Throbbing and severe pain
C) Report of ringing in the ears prior to headache
D) Complaint of sensitivity to light
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21. A nurse is assessing the head and neck of an adult client. Which vertebra should the
nurse identify as a landmark in order to locate the client's other vertebrae?
A) C3
B) C5
C) C7
D) T2
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22. 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 of the following
principles?
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.
23. A nurse is providing care at an inner-city shelter, and a man who frequents the shelter
presents with a significant frontal growth that is located midline at the base of his neck.
The nurse should recognize the need for what referral?
A) Referral for further assessment of thyroid function
B) Referral for assessment of cranial nerve function
N lymphatic system function
C) Referral for assessment of
D) Referral for further assessment of swallowing ability
24. A 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
sh
Th
25. Assessment of an adult female client's face reveals a moon shape, increased hair
distribution, and a reddened tone to the client's cheeks. What collaborative problem is
most clearly suggested to the nurse by these assessment data?
A) RC: Thyroid crisis
B) RC: Cerebrovascular accident
C) RC: Cushing's syndrome
D) RC: Acromegaly
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26. A nurse is working with a client who has a history of headaches. When preparing to
assess the client's temporomandibular joint (TMJ), the nurse should provide what
instruction?
A) ìI'm going to press on several different places below and in front of your ear.î
B) ìI'm going to put my fingers in front of your ears and ask you to open your mouth
wide.î
C) ìTurn so I can see the side of your face and then open your mouth wide like you're
yawning.î
D) ìWhen I place my hands on your cheeks, clench your teeth and then relax them.î
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27. A 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
28. The 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
N
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.
sh
Th
29. A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When
auscultating the client's thyroid gland, what assessment finding is most consistent with
this diagnosis?
A) Audible referred breath sounds at the site of the thyroid
B) An audible S3 sound at the site of the thyroid
C) A sound of turbulent blood flow in the thyroid
D) Irregular S1 and S2 rhythms in the thyroid
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30. A nurse has completed the assessment of an older adult client's head and neck and is
now analyzing the assessment findings. Which of the following findings should the
nurse attribute to age-related physiological changes?
A) Increased size of a single thyroid nodule
B) A nonpalpable carotid pulse
C) Decreased strength of temporal artery pulsations
D) Tenderness of lymph nodes on palpation
sh
Th
N
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B
B
B
A
D
C
C
A
A
D
D
B
D
A
D
D
B
C
C
A
C
B
A
D
C
B
B, C
C
C
C
N
sh
Th
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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Answer Key
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1. A client tells the clinic nurse that she has sought care because she has been experiencing
excessive tearing of her eyes. Which assessment should the nurse next perform?
A) Inspect the palpebral conjunctiva.
B) Assess the nasolacrimal sac.
C) Perform the eye positions test.
D) Test pupillary reaction to light.
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2. When performing a client's ophthalmoscopic exam, the nurse observes a round shape
with distinct margins. The nurse would document this as which of the following?
A) Physiologic cup
B) Optic disc
C) Retinal vessels
D) Fovea
3. A nurse shines a light into one of the client's eyes during an ocular exam and the pupil
of the other eye constricts. The nurse interprets this as which of the following?
A) Direct reflex
B) Optic chiasm
C) Consensual response
D) Accommodation
N
4. The nurse is preparing to test a client's eyes for accommodation. The nurse would have
the client focus on an object in which sequence for this test?
A) Far, then near
B) Lateral, then near
C) Near, then far
D) Lateral, then far
sh
Th
5. During a health history, a 62-year-old male client reveals that he occasionally sees 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
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6. A nurse who works at an outpatient ophthalmic clinic has a large number of clients.
Which client would be at the highest risk for developing cataracts?
A) A 55-year-old female client
B) A 40-year-old with arteriosclerosis
C) A client who has severe environmental allergies
D) A male client who is obese
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7. A nurse is assessing an adult client's eyes and vision. When performing the cover test,
the nurse would cover one of the client's eyes and then do which of the following?
A) Ask the client to focus on a distant object, looking for movement in the other eye.
B) Ask the client to close the other eye then open that eye quickly.
C) Ask the client to follow the nurse's finger with the other eye.
D) Ask the client to look directly at a light with the other eye.
8. The nurse is assessing a client whose electronic health record notes a diagnosis of
esotropia. When examining this client, the nurse should expect what finding?
A) Eye turning outward
B) Eye malalignment
C) Eye turning inward
D) Eye oscillating
N
9. A client's history suggests a need to assess eye muscle strength and cranial nerve
function. What assessment should the nurse consequently perform?
A) Corneal light reflex test
B) Eye positions test
C) Cover test
D) Visual fields test
sh
Th
10. A nurse is performing an eye assessment of an 81-year-old male client. Which of the
following would the nurse document as a normal finding?
A) Ectropion
B) Episcleritis
C) Chalazion
D) Exophthalmos
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11. Which of the following 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
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12. During a client's eye assessment, the nurse is testing for consensual pupillary
constriction. Which technique should the nurse implement?
A) Hold a pencil about 12 inches from the tip of the nose.
B) Use an ophthalmoscope to inspect the inner eye.
C) Shine a light directly into one eye of the client.
D) Place a barrier between the client's eyes.
13. A nurse is assessing the eyes of a 3-year-old child. Which finding would the nurse
document as normal?
A) Pseudostrabismus
B) Tropia
C) Nystagmus
D) Exotropia
N
14. A review of a client's history reveals cranial nerve IV paralysis. Which of the following
findings 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.
sh
Th
15. A nurse is observing the red reflex in a client during an eye assessment. During this
component of the assessment, the client states, ìI hope you can see it because I have
cataracts.î What finding should the nurse expect?
A) Black spokes pointing inward
B) White arc around the limbus
C) Thickened bulbar conjunctiva
D) A red spot on the retina
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16. A nurse in the emergency department assesses a client's pupillary reaction and observes
pinpoint pupils. The nurse interprets this finding as suggesting which of the following?
A) Recent eye trauma
B) Narcotic use
C) Macular degeneration
D) Recent peripheral nervous system injury
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17. A nurse is assessing a client who is suspected to have optic atrophy. Which of the
following assessment findings is most consistent with this diagnosis?
A) Obscured retinal vessels
B) No visible physiologic cup
C) Increased appearance of the disc vessels
D) A white appearance of the optic disc
18. A nurse is performing an eye and vision assessment on a client who has an inner ear
disorder. This disorder may contribute to what finding during the client's eye positions
test?
A) Strabismus
B) Phoria
C) Tropia
D) Nystagmus
N
19. After teaching a group of students about the external and internal structures of the eye,
the instructor determines that the teaching was successful when the students identify
which of the following as external structures? Select all that apply.
A) Lacrimal apparatus
B) Conjunctiva
C) Lens
D) Iris
E) Sclera
F) Caruncle
sh
Th
20. A nurse is presenting a class to a local community group about vision and eye health. As
part of the presentation, the nurse explains how visual perception occurs. Which of the
following would the nurse include in the explanation?
A) It refers to a client's subjective appraisal of his or her vision.
B) It begins with light rays striking the retina.
C) It primarily involves the lens of the eye.
D) It allows the eyes to focus on near objects.
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21. A nurse is completing a comprehensive health history of a 69-year-old woman who is a
new client of the clinic. Which of the nurse's interview questions most directly
addresses the client's risk for developing cataracts?
A) ìDo you exercise regularly?î
B) ìHave you ever been tested for diabetes?î
C) ìDo you ever take over-the-counter pain medications?î
D) ìAt what age did you first start wearing glasses?î
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22. A client has sought care because she states that she has begun to see halos around
headlights and streetlights when she is out at night. The nurse should recognize the need
to refer the client for further assessment related to what health problem?
A) Episcleritis
B) Strabismus
C) Macular degeneration
D) Glaucoma
23. A factory worker has presented to the occupational health nurse with a small wood
splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm
tap water, but the splinter remains in place. What should the nurse do next?
A) Attempt to remove the splinter using sterile forceps.
B) Irrigate the eye with dilute hydrogen peroxide.
C) Arrange for worker to beNpromptly assessed by an eye specialist.
D) Encourage the worker to see an optometrist as soon as possible.
sh
Th
24. During an eye assessment, the nurse is testing a client's visual acuity using a Snellen
chart. In order to prepare the client for this component of assessment, what instruction
should the nurse provide?
A) ìI'm going to ask you to slowly walk forward until the last line of the chart become
clear.î
B) ìPlease stand at a comfortable distance from the chart and I'll get you to read each
of the letters.î
C) ìHold this chart and start to read out the letters after covering one of your eyes.î
D) ìCover one of your eyes and then read out the letters on the chart, starting from the
top.î
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25. A nurse is conducting an assessment of a client's eyes and vision and has completed the
positions test. Following this test, the nurse will be able to document data that address
what aspects of eye health? Select all that apply.
A) Distant visual acuity
B) Near visual acuity
C) Accommodation
D) Eye muscle strength
E) Cranial nerve function
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26. A nurse has completed the assessment of a client's direct pupillary response and is now
assessing consensual response. This aspect of assessment should include which of the
following actions?
A) Observing the eye's reaction when a light is shone into the opposite eye
B) Shining a light into one eye while covering the other eye with an opaque card
C) Moving a finger into the client's peripheral vision field and asking the client to
state when he or she sees the finger
D) Comparing the difference between the client's dilated pupil and a constricted pupil
27. The nurse is using an ophthalmoscope to examine a client's inner eye structures. What
action should the nurse perform in order to accurately examine the client's optic disc?
A) Slowly approach the client's eye from a 90-degree angle, maintaining a focus on
N
the pupil.
B) Position the scope close to the client's eye and look through the pupil at a 15degree angle.
C) From a distance of 3 to 5 cm, examine the pupil from a 45- to 50-degree angle.
D) While looking through the ophthalmoscope, approach the client's eye slowly from
the side.
sh
Th
28. A nurse is collecting subjective data during a client's eye and vision assessment. When
asking the question, ìDo you wear sunglasses during exposure to the sun?î the nurse is
addressing a known risk factor for what health problem?
A) Presbyopia
B) Cataracts
C) Nystagmus
D) Glaucoma
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29. A nurse has taught a group of older adults about the high incidence and prevalence of
macular degeneration. What health promotion and prevention activity should the nurse
encourage these clients to perform?
A) Obtain a home version of the Snellen chart and test their vision weekly
B) Rinse their eyes with a warmed, normal saline solution three to four times per week
C) Maintain a low-sodium diet
D) Post an Amsler grid in their home and perform the test on a regular basis
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30. A nurse has performed the corneal light reflex test during a client's eye examination.
During this test, the nurse held a penlight 1 foot from the client's eyes and appraised the
client's eye alignment in which of the following ways?
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
sh
Th
N
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Answer Key
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B
B
C
A
C
A
A
C
B
A
C
D
A
C
A
B
D
D
A, B, F
B
B
D
C
D
D, E
A
B
B
D
A
N
sh
Th
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2.
3.
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5.
6.
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8.
9.
10.
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12.
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15.
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29.
30.
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1. The nurse is reviewing a client's electronic health record before assessing her mouth.
Which of the following diagnoses would the nurse recognize as an indication for
immediate medical follow-up?
A) Thrush
B) Leukoplakia
C) Gingivitis
D) Canker sore
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2. In the course of the nurse's health interview, a client reports an occasional blockage in
the upper portion of his nasal passage. What is the most pronounced effect that this will
have on the client?
A) Decreased sense of taste
B) Difficulty hearing
C) Impaired sense of smell
D) Occasional dizziness
3. A client presents with a cluster of upper airway complaints that include rhinorrhea.
Which area of assessment would yield the most pertinent information to the etiology of
rhinorrhea?
A) History of allergies
B) Incomplete immunization record
N
C) History of epistaxis (nosebleeds)
D) Prolonged tonsillar enlargement
4. The nurse is providing health education to an elderly client with dysphagia following a
recent ischemic stroke. Which of the following would be most appropriate for the nurse
to include?
A) Sit with the head of the bed at 45 degrees during meals.
B) Be aware of the possibility of temporomandibular joint pain.
C) Thoroughly chew small amounts of food with each mouthful.
D) Drink fluids before and after, but not during, meals.
sh
Th
5. When examining the mouth of an adult client with recent cognitive changes, the nurse
notes a distinct bluish-black line along the client's gum line. Which action should be the
nurse's priority?
A) Determining whether the client is receiving phenytoin therapy
B) Referring the client for further evaluation
C) Encouraging the client to enroll in a smoking cessation program
D) Providing the client with information on proper mouth care
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6. While examining a client's mouth, the nurse notes the presence of fasciculations (fine
tremors) of the client's tongue. How should the nurse best respond to this assessment
finding?
A) Have the client provide 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 nerve function.
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7. A client has just been diagnosed with a sinus infection accompanied by large amounts of
exudate. Which of the following assessment findings should the nurse anticipate along
with this condition?
A) Crepitus over the maxillary sinuses
B) Frontal sinuses nontender to palpation
C) Red, tender tympanic membrane
D) Increased amounts of saliva production
8. The nurse is inspecting a client's tonsils and notes that they make contact with the
client's uvula. The nurse would document this finding as which of the following?
A) 1+
B) 2+
C) 3+
N
D) 4+
9. A decrease in tongue strength is noted on examination of a client. The nurse interprets
this as indicating a problem with which cranial nerve?
A) III
B) VI
C) VIII
D) XII
sh
Th
10. When 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
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11. The nurse is assessing an older adult client whose health problems include receding
gums. The nurse notes gum ischemia and worn tooth surfaces. Which question would be
most important for the nurse to ask?
A) ìHave you lost any teeth recently?î
B) ìHow would you describe your typical diet?î
C) ìHas your dentist screened you for oral cancer recently?î
D) ìAre you able to taste the food you eat?î
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12. During the health interview, the nurse notes that a client is a mouth breather. The client
denies nasal congestion and has a healthy body mass index. Which of the following
would be most important for the nurse to assess?
A) Asking if the client experiences dry mouth often
B) Inspecting for inflammation of the tonsils
C) Checking for a deviated nasal septum
D) Performing a focused respiratory assessment
13. While performing an elderly client's admission assessment, the nurse notes the presence
of deep tongue fissures. Which of the following responses should take priority?
A) Anterior-posterior and lateral chest x-ray
B) Complete blood count with differential
C) Dietitian referral
N
D) Intravenous fluid replacement
14. The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of
the following nursing actions should the nurse do next?
A) Facilitate blood testing for human immunodeficiency virus (HIV).
B) Refer the client to a primary care provider for medication.
C) Asses the client's laboratory values for zinc deficiency.
D) Assess the client for signs of jaundice.
sh
Th
15. The nurse inspects a client's mouth and notes the presence of 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
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16. On inspection, the nurse observes a line across the tip of an 8-year-old client's nose. The
nurse should consequently focus on which area of assessment?
A) History of abuse
B) Chronic nose picking
C) Mucosal polyps
D) Chronic allergies
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17. A client has presented for care because of frequent sinus headaches. During
transillumination of the frontal sinuses, a red glow is noted. The nurse should anticipate
which of the following?
A) The physician will write a prescription for antibiotics.
B) The drainage will need to be cultured.
C) A repeat procedure will be done in 1 week to compare findings.
D) The headaches are most likely not from a sinus infection.
18. A group of students is reviewing information about the salivary glands and their
secretions. The students demonstrate understanding of the information when they
identify which of the following as components of saliva? Select all that apply.
A) Salts
B) Proteins
C) Fats
N
D) Mucus
E) Amylase
19. The nurse has completed a focused assessment of a client's mouth, nose, and throat.
Which of the following findings would a nurse interpret as being normal?
A) Absence of red glow on transillumination of sinuses
B) Nasal mucosa pale pink and swollen
C) Tonsils 2+
D) Pinkish, spongy soft palate
sh
Th
20. When 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
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21. A nurse is integrating health promotion education into the assessment of a client's
mouth, nose, and throat. What interview question is most likely to identify a risk factor
for oral cancer?
A) ìWould you say that you're prone to getting mouth ulcers?î
B) ìDo you brush and floss daily?î
C) ìDo you use tobacco, whether smoking or chewing?î
D) ìHow often do you usually go to the dentist in a year?î
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22. The nurse is assessing a client who enjoys good health overall but who has brought a
complaint of chronic nasal congestion and recurrent nosebleeds. What interview
question should the nurse prioritize?
A) ìHow often do you use over-the-counter nasal sprays?î
B) ìHow often do you take Tylenol?î
C) ìHow many drinks of alcohol do you have in a typical day?î
D) ìWould you say that you eat a balanced diet?î
23. The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus,
and throat assessment. After asking the client about his history of environmental
allergies, the client states, ìI'm pretty sure that I'm allergic to something, but I'm not
exactly sure what triggers my allergies.î How can the nurse begin to identify the specific
allergens that cause the man's symptoms?
N respond to OTC antihistamines.
A) Ask the client if his allergies
B) Ask the client about the timing of his allergy symptoms.
C) Perform a detailed inspection of the client's ears and throat using an otoscope.
D) Perform transillumination of the client's sinuses.
sh
Th
24. An experienced nurse is aware that receding gums are an expected finding in some
clients whereas in other clients this finding is abnormal. In which of the following
clients 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
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25. Assessment of a client's mouth reveals a lesion on the client's buccal membrane that is
approximately 0.5 cm in diameter. On further questioning, the client states that the
lesion has been present for 3 months and that it bleeds intermittently. How should the
nurse follow up this assessment finding?
A) Swab the lesion to obtain a sample for culture and sensitivity testing.
B) Recommend that the client gargle with saltwater twice daily for several days.
C) Refer the client to her primary care provider promptly.
D) Determine whether the lesion can be removed with a sterile cotton-tipped
applicator.
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26. A client has presented with ìa terrible head cold,î and the nurse is assessing for signs
and symptoms of sinusitis. The nurse should utilize what assessment techniques? Select
all that apply.
A) Inspection
B) Palpation
C) Auscultation
D) Percussion
E) Transillumination
27. The 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
N
finding would most strongly suggest
sinusitis?
A) Resonance on percussion
B) Dull sounds
C) Tympanic sounds
D) Pain on percussion
Th
28. The nurse is caring for a client who has been experiencing dysphagia secondary to a
stroke. What risk nursing diagnosis should the nurse associate with this health problem?
A) Risk for injury related to potential esophageal trauma
B) Risk for oral infection related to dysphagia
C) Risk for aspiration related to decreased swallowing ability
D) Risk for excess fluid volume related to decreased peristalsis
sh
29. A medical nurse is preparing to administer a topical antifungal medication to a client
who has just been diagnosed with an oral candida infection (thrush). On inspection of
the patient's tongue, the nurse should anticipate what appearance?
A) Thick, white plaques on the tongue surface
B) Dry appearance with fissures present
C) Diffuse reddened lesions that bleed easily
D) Firm, raised nodules that are pink or red
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30. The nurse is assessing the characteristics and positioning of the client's uvula, which
deviates asymmetrically when the nurse has the client say ìaaah.î This finding should
prompt the nurse to focus on which of the following during subsequent assessment?
A) The client's nutritional status
B) The client's neurological status
C) The client's immune function
D) The client's respiratory function
sh
Th
N
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Answer Key
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B
C
A
C
B
D
A
C
D
B
A
C
D
B
B
D
D
A, D, E
D
C
C
A
B
D
C
B, D, E
D
C
A
B
N
sh
Th
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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1. When assessing whispered pectoriloquy, the nurse should instruct a client to do which
of the following?
A) Softly repeat the words ìone-two-three.î
B) Say the number ìninety-nine.î
C) Cough each time the stethoscope is moved.
D) Say the letter ìeî until instructed to stop.
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2. When preparing to assess a client's thoracic cage, the nurse should locate which
landmark when determining where to begin the assessment of the ribs and intercostal
spaces?
A) Scapula
B) Suprasternal notch
C) Sternal angle
D) Sternal border
3. The nurse is assessing a client who has been admitted for the treatment of severe
dehydration. What might the nurse expect to hear when auscultating the lungs of a client
with this fluid volume deficit?
A) Friction rub
B) Decreased breath sounds
C) Sibilant wheeze
N
D) Stridor
4. A client has sustained a brain stem injury and is being treated in the intensive care unit.
Which of the following would the nurse need to consider when assessing this client's
respiratory status?
A) The client will have a loss of involuntary respiratory control.
B) The client will respond negatively to increased stimuli.
C) The client will have greatly increased respiratory effort.
D) The client will exhibit Cheyne-Stokes respirations.
sh
Th
5. During the health interview, a client tells the nurse that he ìcan't breathe all that wellî at
night when he is lying down and that this significantly disrupts his sleep. The nurse
should assess this client further for which of the following health problems?
A) Pneumonia
B) Tuberculosis
C) Bronchitis
D) Heart failure
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6. A client is diagnosed with pulmonary edema, and the nurse is performing a rapid
assessment prior to treatment. The nurse would be most concerned about which of the
following assessment findings related to the client's sputum?
A) White or cream-colored
B) Yellowish and foul-smelling
C) Pink and frothy
D) Rust-tinged
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7. Upon entering the examination room, the nurse observes that the client is leaning
forward with his arms supporting his body weight. The nurse would recognize this as a
tripod position and suspect the presence of which of the following medical problems?
A) Pleural effusion
B) Heart failure
C) Chronic obstructive pulmonary disease
D) Pneumonia
8. The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. The
nurse should document this as which of the following?
A) Limited expansion
B) Normal expansion
C) Hypoexpansion
N
D) Hyperexpansion
9. A client has a history of emphysema. During the respiratory assessment, the nurse
percusses the client's chest, expecting to find which of the following?
A) Hyperresonance
B) Dullness
C) Resonance
D) Tympany
sh
Th
10. While auscultating a client's lungs, the nurse notes the presence of adventitious sounds.
Which of the following actions should the nurse do first?
A) Refer the client for further medical evaluation.
B) Auscultate for egophony.
C) Perform bronchophony.
D) Have the client cough, then listen again.
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11. The nurse is preparing to auscultate the client's thorax. Which of the following actions is
the priority during this component of assessment?
A) Listen at each site for at least one complete respiratory cycle.
B) Have the client breathe deeply through his or her nose.
C) Encourage the client to cough before auscultating each site.
D) Have the client hold the breath for a few seconds after auscultating each site.
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12. An adult client has been diagnosed with bronchitis. Which of the following would the
nurse most likely hear on auscultation?
A) Sibilant wheezes
B) Fine crackles
C) Sonorous wheezes
D) Coarse crackles
13. The nurse is performing a respiratory assessment of a client who is palliative due to
severe, uncompensated heart failure. What type of respiratory pattern should the nurse
anticipate?
A) Biot's
B) Bradypnea
C) Kussmaul's
D) Cheyne-Stokes
N
14. The school nurse assesses unequal shoulder and scapula height in an adolescent. Which
of the following should the nurse assess next?
A) Lateral aspect of the thorax
B) Lung volume
C) Hip levels
D) Spinal column
sh
Th
15. While auscultating a client's trachea, the nurse hears a high, harsh sound with short
inspiration and long expiration. The nurse would document which of the following?
A) Vesicular breath sounds
B) Bronchovesicular breath sounds
C) Adventitious breath sounds
D) Bronchial breath sounds
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16. When percussing the scapula of a client, which of the following would the nurse expect
to hear?
A) Resonance
B) Dullness
C) Flatness
D) Hyperresonance
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17. A group of students is reviewing the vertical reference lines of the thorax. They
demonstrate understanding when they identify which line as a reference line for the
posterior thorax?
A) Midaxillary line
B) Vertebral line
C) Right midclavicular line
D) Sternal line
18. The nurse is assessing the apices of the client's lungs. The nurse should 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
N
19. The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the
nurse must assess which lobe anteriorly?
A) Left upper lobe
B) Left lower lobe
C) Right upper lobe
D) Right middle lobe
sh
Th
20. A nursing instructor is discussing cultural variations in the size of the thorax and impact
on lung capacity. Which group would the instructor identify as typically having a larger
thorax?
A) African Americans
B) Asian Americans
C) Native Americans
D) Caucasians
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21. The nurse is preparing to perform a focused respiratory assessment on a client. The
nurse should be cognizant of what anatomical characteristic of the lungs?
A) The right lung has three lobes, while the left lung has two lobes.
B) The lungs are structurally symmetrical but functionally differently.
C) The right lung is approximately one-third larger than the left lung.
D) The lower lobes of both lungs are primarily located toward the anterior chest wall.
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22. The nurse is conducting the health interview of an adult client who has sought care
because of a ìwicked coughî leading to dyspnea. When trying to differentiate between
pathologic lung changes and an infection as the etiology of the client's cough and
resultant dyspnea, what interview question should the nurse ask?
A) ìDoes your cough often cause you to be short of breath?î
B) ìDo you experience chest pain when you cough?î
C) ìHow long have you been experiencing your cough?î
D) ìAre you now or have you ever been a smoker?î
23. During a health screening event, the nurse is assessing a client's risk factors for lung
cancer. When addressing the most significant risk factor for lung cancer, the nurse
should question the client about which of the following?
A) Childhood exposure to air pollution
B) History of tobacco use
N
C) History of working in a factory
or smelter
D) History of recurrent lung infections
Th
24. The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states,
ìIt shouldn't be a problem for me. My husband smokes quite heavily but I've been a
lifelong nonsmoker.î The nurse should recognize the need to teach the client about what
topic?
A) Strategies for making her husband quit smoking
B) Genetic causes of lung cancer
C) Age-related changes to respiratory function
D) Health risks of secondhand smoke
sh
25. The nurse is assessing a 79-year-old client's posterior thorax during a focused
respiratory assessment. The nurse should attribute what assessment finding to agerelated changes?
A) Slight kyphosis
B) Inaudible posterior lung sounds
C) Audible wheeze
D) Asymmetrical chest expansion
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26. While assessing the health of a client's respiratory system, the nurse is palpating for
fremitus. What instruction should the nurse provide to the client during this component
of assessment?
A) ìWhen I say so, please exhale forcefully and hold the breath.î
B) ìSay the letter 'e' and keep saying it until I tell you to stop.î
C) ìBreathe in as deeply as you can and hold your breath until I say.î
D) ìPlease say the number 'ninety-nine' for me.î
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27. The nurse is assessing a client's respiratory rate and rhythm during the beginning of a
shift. The nurse knows that a normal breathing rate is between approximately 10 and 20
breaths per minute, but 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.
28. A nurse is caring for a patient whose diagnosis of cystic fibrosis results in the
production of large amounts of sticky mucus. The client has a history of repeated
hospital admissions for complications of his disease and receives daily treatments to
mobilize the secretions. When planning the care of this client, what nursing diagnosis is
N
most plausible?
A) Readiness for Enhanced Breathing Patterns
B) Risk for Impaired Oral Mucous Membranes related to mouth breathing
C) Ineffective Airway Clearance related to respiratory secretions
D) Ineffective Breathing Pattern: Hyperventilation related to cystic fibrosis
sh
Th
29. The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The
nurse should recognize that this adventitious sound results from what
pathophysiological process?
A) Air leaking from the alveoli into the pleural space
B) Air being diverted from the trachea to the bronchi
C) Air increasing in turbulence in a wide passage
D) Air passing through constricted passageways
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30. The 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.
sh
Th
N
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A
C
A
A
D
C
C
B
A
D
A
C
D
D
D
C
B
C
D
D
A
C
B
D
A
D
A
C
D
D
N
sh
Th
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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Answer Key
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Chapter 20: Assessing Breasts and Lymphatic System
1. When should a woman conduct self-breast examination with respect to her menses?

5 to 7 days following her menses
Explanation:
The breast examination should be conducted during the time with the least estrogen stimulation
of the breast tissue. This corresponds to 5 to 7 days following menses.
2. Nurse G. is conducting a teaching session on breast self-examination to a group of
women at a health fair sponsored by the local community center. Which of the following
instructions is most accurate?

“Remember that doing BSE regularly is not a replacement for regularly-scheduled
mammograms or clinical examinations.”
Explanation:
BSE should be coupled with mammography and clinical examination on a schedule congruent
with current guidelines and the client's risk factors. It should be performed 5 to 7 days after the
beginning of the woman's period and all lumps or changes should be followed up. A standing
position in the shower is appropriate for palpation.
3. During the breast examination of a client, the nurse notes red, scaly, and crusty areas over
the areola. The nurse understands that this appearance of the skin is due to what type of
breast condition?

Paget disease
Explanation:
Paget disease causes red, scaly, and crusty areas over the areola. A pigskin-like or orange-peel
appearance is found in metastatic disease of the breast. It results from edema caused by blocked
lymphatic drainage. A fibroadenoma is a round, firm, and well-defined mass, is seldom tender,
and is usually singular and mobile. Fibrocystic lesions are benign and firm but rubbery lesions
that tend to be bilateral and may become tender just before menses.
4. A nurse is examining the breasts of a woman who has had a mastectomy. Which of the
following should the nurse do?

Palpate the scar for redness, lesions, lumps, swelling, or tenderness
Explanation:
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Chapter 20: Assessing Breasts and Lymphatic System
If the client has had a mastectomy or lumpectomy, it is still important to perform a thorough
examination. Palpate the scar and any remaining breast or axillary tissue for redness, lesions,
lumps, swelling, or tenderness. White scar tissue in a client who underwent a mastectomy or
lumpectomy is a normal finding and need not be referred.
5. Which technique is appropriate for the nurse to use to palpate a client's breast?

Flat pads of three fingers
Explanation:
The nurse should use the flat pads of three fingers to palpate the breast of the client for accurate
assessment. The tips of four fingers, palms of both hands, or palm and fingers of one hand are
not used for assessing the breasts as they may not give accurate results on examination.
6. The nurse is assessing a 15-year-old male and finds soft, fatty enlargement of breast
tissue. The nurse would document this as what?

Gynecomastia
Explanation:
Gynecomastia is breast enlargement. Cysts are lumps that may be found in the breasts. Abscesses
are an infection. Fibroadenoma s a well-defined, usually single or multiple, nontender, fi rm or
rubbery, round or lobular mass that is freely movable.
7. A client has been found to have a breast lump and an ultrasound has been ordered. The
client voices concerns to the nurse she is afraid of the painful testing she is going to
endure. How should the nurse best respond?

"This noninvasive test uses high frequency waves to determine if the mass is solid or
cystic."
Explanation:
An ultrasound is a noninvasive test that uses sound waves. An MRI uses a magnetic field and
mammography uses x-ray. A fine needle biopsy is an invasive procedure.
8. The nurse is performing teaching on breast health at a community center. The nurse
would identify what risk factors related to breast cancer? Select all that apply.


Obesity
Physical inactivity
Explanation:
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Chapter 20: Assessing Breasts and Lymphatic System
Modifiable risk factors assoicated with breast cancer include obesity and and physical inactivity.
Trauma, tobacco use and chest radiation are not risk factors of breast cancer.
9. The size and shape of the breasts in females are related to the amount of

fatty tissue.
Explanation:
Fatty tissue is the third component of the breast. The glandular tissue is embedded in the fatty
tissue. This subcutaneous and retromammary fat provides most of the substance to the breast,
determining the size and shape of the breasts.
10. A client has had a recent mastectomy and visits the clinic for postoperative evaluation.
The client tells the nurse that she has been depressed and feels as if she is less of a
woman. The most appropriate nursing diagnosis for this client is

disturbed body image related to mastectomy.
Explanation:
When interviewing clients—especially females—about the breasts, keep in mind that this topic
may evoke a wide spectrum of emotions from the client. Explore your own feelings regarding
body image, fear of breast cancer, and the influence of the breasts on self-esteem. Disturbed body
image is the most appropriate nursing diagnosis.
1. Which factors should the nurse include in a discussion with a young female to assist the
client to reduce her risk for breast cancer? Select all that apply.



Engage in regular, strenuous physical activity
Pregnancy is beneficial before 30 years of age
Breast-feed if possible
Explanation:
Strenuous exercise, pregnancy before 30 years of age, and breast-feeding are factors that help to
reduce the risk for breast cancer. Intake of a high fat diet is a possible risk factor for breast cancer
and intake of two to five drinks daily is a risk factor for the development of breast cancer.
2. A 23-year-old computer programmer comes to the office for an annual examination. She
has recently become sexually active and wants to start oral contraception. Her only
complaint is that the skin in her armpits has become darker. She states it looks like dirt;
she scrubs her skin nightly with soap and water, but the colour stays. Her past medical
symptoms consist of acne and mild obesity. Her periods have been irregular for 3 years.
Her mother has type 2 diabetes and her father has high blood pressure. The client denies
tobacco but drinks four to five drinks on Friday and Saturday nights. She denies any
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Chapter 20: Assessing Breasts and Lymphatic System
illegal drug use. Examination shows a mildly obese woman breathing comfortably. Her
vital signs are unremarkable. Inspection of the axillae reveals dark velvet-like skin. Her
annual examination is otherwise unremarkable. What disorder of the breast or axilla is
she most likely to have?

Acanthosis nigricans
Explanation:
Acanthosis nigricans can be associated with an internal malignancy, but in most cases it is a
benign dermatological condition associated with polycystic ovarian syndrome, a syndrome
consisting of acne, hirsutism, obesity, irregular periods, infertility, ovarian cysts, and early onset
type 2 diabetes. It is also known to correlate with insulin resistance.
3. A 43-year-old store clerk comes to the office upset because she has found an enlarged
lymph node under her left arm. She states she found it yesterday when she was feeling
pain under her arm during movement. She states the lymph node is about an inch long
and is very painful. She checks her breasts monthly and gets a yearly mammogram (her
last was 2 months ago); until now everything has been normal. She states she is so upset
because her mother died in her 50s of breast cancer. The client does not smoke, drink, or
use illegal drugs. Her father is in good health. Examination shows a tense woman
appearing her stated age. Visual inspection of her left axilla reveals a tense red area with
no surrounding scarring. On palpation, the examiner feels a 2-cm tender movable lymph
node underlying hot skin. Other shoddy nodes are also in the area. Visualization of both
breasts is normal. Palpation of her right axilla and both breasts is unremarkable.
Examination of the left arm reveals a scabbed-over superficial laceration over her left
hand. Upon questioning, the client remembers that she cut her hand gardening last week.
What disorder of the axilla is most likely responsible for her symptoms?

Lymphadenopathy of infectious origin
Explanation:
An enlarged lymph node resulting from infection is generally hot, tender, and red. Close
examination of the skin that drains to that lymph node region is advised. Often there will be a cut
or scratch over the involved arm that has an infectious agent. An example is cat scratch disease.
4. Which of the following assessment findings is most likely benign on breast examination?

One breast larger than the other
Explanation:
Asymmetry in size of the breasts is a common benign finding. The others are concerning for
underlying malignancy.
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5. Screening measures for breast cancer include all of the following except:

Breast x-rays
Explanation:
There are significant roles in breast cancer screening for BSE, mammography, and clinical
examination. The low-density character of the breasts makes radiography less sensitive.
6. When palpating the female breast for masses, the nurse distinguishes which of the
following characteristics as a potentially cancerous mass?

Single, firm, fixed nodule
Explanation:
Any mass that is firm, fixed, poorly circumscribed, and qualitatively different from surrounding
tissue strongly suggests cancer.
7. Mrs. Ash, a client in her 50s, has told the nurse during her most recent visit to the clinic
that she and her circle of friends have discontinued breast self-examination (BSE) since
hearing and reading that the practice is now considered ineffective. How can the nurse
best respond to Mrs. Ash?

“BSE is certainly not a replacement for other screening methods, but a high proportion of
breast masses are in fact detected by women themselves.”
Explanation:
While BSE does not reduce breast cancer mortality, the fact remains that a high proportion of
breast masses are detected by women themselves. BSE should be coupled with mammography
and clinical examination.
8. During the physical examination, a nurse palpates the breasts of a client for masses. The
nurse knows that if the client has benign breast disease, masses with which characteristics
will be present? (Select all that apply.)


Rubbery and mobile
Well-demarcated borders
Explanation:
Multiple rubbery mobile nodules with well-demarcated borders are found in benign breast
disease. Malignant tumors are hard and nontender and fixed to underlying tissues. They are
usually unilateral with irregular and poorly delineated borders.
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Chapter 20: Assessing Breasts and Lymphatic System
9. While interviewing a client, the nurse asks her what her typical daily diet consists of.
Which of the following is associated with an increased risk for breast cancer?

High-fat diet
Explanation:
A high-fat diet may increase the risk for breast cancer. Alcohol intake exceeding two drinks per
day and tobacco use has been associated with a higher risk for breast cancer. Caffeine can
aggravate fibrocystic breast disease, but is not associated with breast cancer. A high-sugar diet is
not associated with breast cancer.
10. A nurse is inspecting a client's breasts. The nurse notices that one breast is larger than the
other. Which action should the nurse take next?

Ask the client whether the larger breast has increased in size recently
Explanation:
Breasts can be a variety of sizes and are somewhat round and pendulous. One breast may
normally be larger than the other. However, a recent increase in the size of one breast may
indicate inflammation or an abnormal growth; it thus would be best for the nurse to inquire about
any recent changes in breast size. There is no need to inform the physician immediately.
Inquiring about the client's family history of breast cancer should have occurred earlier, during
the interview.
11. The parents of a newborn express concern upon seeing the pediatrician palpate and gently
express a small amount of whitish, milk-like liquid from the baby's nipples. They
anxiously ask, “What can be done to fix this problem?” What is the nurse's best response?

"Nothing is wrong with your baby. This liquid will clear up spontaneously."
Explanation:
Enlarged breast tissue and white discharge (commonly called witch's milk) in newborns of either
gender may occur for the first few weeks of life, secondary to the effects of maternal estrogens.
If breast enlargement, witch's milk, or both are present, it is important to reassure the newborn's
parents/caregivers that nothing is wrong and the conditions will resolve spontaneously. The baby
does not need further evaluation, hormone therapy, or a change in diet since this condition is
considered normal for the first few weeks after birth.
12. During a breast assessment the nurse finds scaly lesions at the nipple with a lump behind
the nipple. The nurse suspects what?

Paget disease
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Explanation:
A rash or ulceration may occur in Paget disease. Peau d’orange has an orange peel appearance
and is caused by breast edema from blocked lymph drainage and indicates advanced cancer.
Erythema is redness and hyperpigmentation is a darker area.
13. At puberty, the female breasts enlarge in response to estrogen and

progesterone.
Explanation:
The male and female breasts are similar until puberty, when female breast tissue enlarges in
response to the hormone’s estrogen and progesterone, which are released from the ovaries.
14. The nurse has discussed the risks for breast cancer with a group of high school seniors.
The nurse determines that one of the students’ needs further instructions when the student
says that one risk factor is

having a baby before the age of 20 years.
Explanation:
Having a baby before 20 years of age does not increase the risk of breast cancer. The risk of
breast cancer is greater for women who have never given birth or for those who had their first
child after age 30. A family history of breast cancer, consumption of a high-fat diet, and late
menopause are all factors that increase the risk of breast cancer.
15. The nurse is preparing to examine the breasts of a female client who had a left radical
mastectomy 3 years ago. When examining the client, the nurse observes redness at the
scar area. The nurse should explain to the client that this may be indicative of

an infectious process.
Explanation:
Redness and inflammation of the scar area may indicate infection.
16. The lymph nodes that are responsible for drainage from the arms are the

lateral lymph nodes.
Explanation:
The lateral nodes drain most of the arms.
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17. Benign conditions of the breast include

fibrocystic changes
Explanation:
Cysts (due to BBD) are common lumps that are usually elliptical or round, soft, and mobile. Size
may vary, and they often occur in multiple numbers, usually in both breasts, and frequently in the
upper outer quadrants.
18. What information would the nurse include when educating a client concerning magnetic
resonance imaging (MRI) as a screening for breast cancer?

Specificity is such that false positive readings can occur.
Explanation:
Studies have investigated the use of screening MRIs in women with a high risk for breast cancer
who personally have a BRCA1 or BRCA2 gene mutation. However, the cost is high, and
specificity is 77%, resulting in more false positives, recalls, and biopsies. MRIs should not be
done in isolation but in conjunction with a mammogram.
19. What instruction should the nurse provide to a client to assess for dimpling or retraction
of breast tissue?

raise arms over the head
Explanation:
To bring out dimpling or retraction that may otherwise be invisible, ask the client to raise the
arms over the head. Shrugging the shoulders, bending the arms at the elbows, and extending the
arms out to the side are not actions to bring out breast dimpling or retractions.
20. The nurse instructs a female client on breast self-examination. Why does the nurse
recommend the pattern shown for the client to use?

It is the best technique to detect masses
Explanation:
The vertical stripping pattern is currently the best validated technique for detecting breast
masses. It is not recommended because it takes the least amount of time, is the easiest for the
client to learn, or because it causes the least amount of pain.
1. A client comes to the clinic with reports of a reddened, tender lump on the left breast.
What would the nurse document about this lump?
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
Size
Explanation:
When palpating a breast lump, the nurse documents the lump's location, size, shape, consistency,
mobility, tenderness, and distinctness. The nurse would not note pallor of the lump—that finding
relates to the skin over the lump. Nipple size and chest symmetry are not directly related to the
lump in question.
2. While assessing an adult woman new to the clinic, the nurse should perform a subjective
assessment of what risk factors?

Bottle fed all three children
Explanation:
Some risk factors that the nurse assesses during subjective data collection are a family history of
breast cancer in first-degree relatives (client's mother and grandmother), early onset of
menstruation (age 11 years), bottle feeding of children, obesity, high-fat diet, and lack of
exercise.
3. The nurse encourages a client to perform a monthly self-breast examination between
what days of the menstrual cycle?

4 to 7
Explanation:
The best time to examine the breasts is when they are least congested and smallest (in adult
women, days 4 to 7 of the menstrual cycle). The other options suggest times when the breasts are
congested or enlarged.
4. The nurse is preparing to conduct a clinical breast examination of a patient. Current
recommendation suggest that which pattern should be followed when assessing the breast
tissue?

Vertical strip
Explanation:
The vertical strip pattern is currently the best validated technique for detecting breast masses.
The circular or wedge pattern can be used but it is not the best validated technique for detecting
breast masses. The concentric circle pattern is used to palpate at each examination point during
the breast examination.
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5. A 72-year-old retired saleswoman comes to the office with a bloody discharge from her
left breast for 3 months. She denies any trauma to her breast. Her past medical history
includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of
ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The
client denies tobacco, alcohol, or drug use. She is a widow and has three healthy children.
On examination her breasts are symmetrical with no skin changes. The nurse can express
bloody discharge from the client's left nipple. No discrete masses are palpable, but her
left axilla has a hard 1-cm fixed node. The remainder or her heart, lung, abdominal, and
pelvic examinations are unremarkable. What is the most likely cause of nipple discharge
in her circumstance?

Breast cancer
Explanation:
Nipple discharge in breast cancer is usually unilateral and can be clear or bloody. Although a
breast mass is not palpated, in this case a fixed lymph node is palpated. Other forms of breast
cancer can present as a chronic rash on the breast.
6. When inspecting the nipples, which of the following findings is unexpected?

Retraction of the left nipple
Explanation:
Longstanding nipple inversion and supranumerary nipples do not constitute threats to health. A
downward point of the nipples, provided symmetry exists, is not necessarily pathological, while
retraction can indicate underlying cancer.
7. A nurse is examining the breasts of a 75-year-old woman. Which of the following are
normal findings in the breasts of an older adult?



Smaller, flatter nipples
Nipples that are less erectile on stimulation
Pendulous breasts
Explanation:
The older client often has more pendulous, less firm, and saggy breasts and smaller, flatter
nipples that are less erectile on stimulation. Peau d’orange skin, associated with carcinoma, and
spontaneous discharge are not normal findings in the breasts of older adults and should be
referred for further evaluation.
8. When examining the breasts of a client, the nurse finds a collection of fatty tissue that
appears as a lump. The nurse knows that this is which of the following conditions?
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
Lipoma
Explanation:
Lipomas are a collection of fatty tissue that may also appear as a lump. Milk cysts are sacs filled
with milk. Fibroadenomas are usually 1–5 cm, round or oval, mobile, firm, solid, elastic,
nontender, single or multiple benign masses found in one or both breasts. Malignant tumors, or
carcinomas, are most often found in the upper outer quadrant of the breast. They are usually
unilateral, with irregular, poorly delineated borders. They are hard and nontender and fixed to
underlying tissues.
9. During the physical examination of a female client, the nurse notes that the client's
axillary lymph nodes are enlarged, hard, and fixed. The nurse recognizes that these
findings are consistent with what disease process?

Malignancy
Explanation:
Enlarged, hard, and fixed axillary lymph nodes indicate malignancy. Infection may cause
swelling of the lymph nodes but does make them hard and fixed. Lactation does not cause a
change in lymph nodes. Inflammation does not cause the lymph nodes to harden and get fixed.
10. A nonpregnant female presents to the health care facility and reports new onset of breast
discharge. The nurse assesses the discharge to be milky in appearance without breast
tenderness or masses. What additional data should the nurse obtain from this client?

Prescribed medications such as antipsychotic agents
Explanation:
A persistent milk secretion (galactorrhea) from the breasts in a nonpregnant, nonlactating woman
can be caused by the intake of hormones, contraceptives, and some antipsychotic agents, such as
haloperidol (Haldol). Recent surgeries or trauma and exposure to chemicals are not known to
cause persistent milk discharge. Excessive alcohol intake is a risk factor for the development of
breast cancer.
11. How should a nurse instruct a client to perform a breast self-examination to most
effectively cover the entire breast?

Up-and-down pattern starting at the underarm and moving across the breast
Explanation:
There is some evidence that the up-and-down pattern, also referred to as the vertical pattern, is
the best method to most effectively cover the breast tissue. It is important to teach the client that
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breast tissue covers the entire upper chest, thus the exam should be performed from the underarm
and move across the breast to the middle of the chest bone (sternum). Hands should go up and
down the breast until the client feels the ribs and up to the neck area.
12. A nurse is discussing breast self-examination (BSE) with a 60-year-old woman. Which of
the following should the nurse recommend?

Picking a set day of the month that the client will remember on which to perform BSE
Explanation:
Older clients and others who no longer menstruate may find it helpful to pick a set day of the
month for BSE, a date that they will remember each month such as the day of the month they
were born. Although BSE is not required, the nurse should not encourage the client to
discontinue it if she is already performing it. It is unlikely that the client is still menstruating at
her age. The BSE, if performed, should be done monthly, not annually.
13. A mother brings her adolescent son into the clinic because she is concerned about his
development of breast tissue. Her son denies use of any medications and is slender in
appearance. What should be the nurse's next action?

Palpate for any irregular or hard masses.
Explanation:
Gynecomastia (firm, glandular tissue in the breasts) in males may occur when there is an
imbalance of estrogen and androgen. An ulcer or hard, irregular mass suggests cancer and should
be palpated for upon initial assessment. Gynecomastia also occurs with use of anabolic steroids,
diseases, and as an adverse effect of some medications; however this boy denies any medication
use. Gynecomastia also occurs in overweight or obese males; however this client is slender;
therefore dietary teaching is not the next, best action. These hormonal changes can be expected;
but first the nurse should assess for a serious condition such as cancer by palpating for hard or
irregular masses. Uncomplicated gynecomastia does tend to resolve with time; but the nurse
must assess for signs of abnormalities such as cancer first.
14. The functional part of the breast that allows for milk production consists of tissue termed

glandular.
Explanation:
Glandular tissue constitutes the functional part of the breast, allowing for milk production.
Glandular tissue is arranged in 15 to 20 lobes that radiate in a circular fashion from the nipple.
Each lobe contains several lobules in which the secreting alveoli (acini cells) are embedded in
grape-like clusters.
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15. The nurse is assessing a 50-year-old client’s breasts and observes a spontaneous
discharge of fluid from the left nipple. The nurse should

refer the client for a cytology examination.
Explanation:
Any type of spontaneous discharge should be referred for cytologic study and further evaluation.
16. Montgomery glands secrete

protective lubricant
Explanation:
Within the areola are small sebaceous glands called Montgomery glands. During lactation, these
glands secrete a protective lubricant.
17. The nurse is concerned that a client has undiagnosed cancer of the breast. What
assessment finding is most likely related to this clinical determination?

dimpling of the breast
Explanation:
Dimpling could indicate an underlying lesion that causes the tissue to pucker with movement.
Uneven breast size is not an indication of breast cancer. Retracted nipples do not indicate breast
cancer unless it is a new finding and occurs in one breast. Uneven areola size is not an indication
of breast cancer.
18. A client denies performing breast self-examination however practices breast awareness.
What is this client focusing on when following this practice?

Appearance, feel, and shape of the breasts and nipples
Explanation:
Because breast self-examination has been met with controversy, an alternative called breast selfawareness may be practiced. This is the act of becoming familiar with the appearance, feel, and
shape of one’s breasts and nipples. Breast self-awareness does not focus on the size of the chest
and bra or the amount of breast discomfort with menstruation. Discharge from the nipples should
be reported to the health care provider for evaluation.
19. The nurse instructs a client on breast self-examination techniques. Which observation
indicates that teaching has been effective?
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
Palpates the breasts using an up and down approach
Explanation:
When performing a breast self-examination, the client should be supine with the arm of the
breast being examined under the head. The breasts should be palpated with the fingertips. The
arms should be placed on the hips or extended above the head. One approach to palpate the
breasts is to use an up and down approach.
Reference:
20. The nurse instructs a female client on breast self-examination. Which part of the breast
should the nurse explain as being the area where most cancers occur? Select the part on
the diagram.
You Selected:

Explanation:
The upper outer quadrant or the Tail of Spence is the area most targeted by breast cancer.
1. The nurse is examining the breast of a clinic client and palpates a lump. What would the
nurse be sure to document about this lump? Select all that apply.



Consistency
Distinctness
Mobility
Explanation:
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If a lump is palpated, the nurse documents the location, size, shape, consistency, mobility,
tenderness, and distinctness. Additionally, the nurse notes the skin over the lump, the nipple, and
any lymphadenopathy. The nurse would not note erythema or pallor of the lump, because these
are notations about the skin over the lump.
2. When performing a breast assessment on a clinic patient, the nurse practitioner notes
scaly lesions that begin at the nipple and move toward a lump behind the nipple well. The
NP would know that further assessment for what would be necessary?

Paget's disease
Explanation:
Paget's disease produces scaly lesions that begin at the nipple and progress to a lump behind the
nipple well. Severe pain (mastalgia) is more likely to result from trauma or infection. Single
breast masses can indicate benign conditions (e.g., cysts, fibroadenoma, fat necrosis, lipoma) or
more serious conditions (e.g., cancer).
3. A nurse palpates the breasts of a client for masses during the physical examination. The
nurse knows that if a tumor if malignant, which characteristics will be present? Select all
that apply.



hard and nontender
fixed to underlying tissues
irregular in shape
Explanation:
Malignant tumors are hard and nontender and fixed to underlying tissues. They are usually
unilateral with irregular poorly delineated borders. Multiple rubbery mobile nodules with welldemarcated borders are found in benign breast disease.
4. A 63-year-old nurse comes to the office upset because she has found an enlarged lymph
node under her right arm. She states she found it last week while taking a shower. She
isn't sure if she has any breast lumps because she doesn't know how to do self-breast
examinations. She states her last mammogram was 5 years ago and it was normal. Her
past medical history is significant for high blood pressure and chronic obstructive
pulmonary disease. She quit smoking 2 years ago after a 55-pack a year history. She
denies any illegal drugs and drinks alcohol rarely. Her mother died of a heart attack and
her father died of a stroke. She has no children. Examination shows an older woman
appearing her stated age. Visual inspection of her right axilla reveals nothing unusual.
Palpation reveals a 2-cm hard fixed lymph node. She denies any tenderness. Visualization
of both breasts is normal. Palpation of her left axilla and breast is unremarkable. On
palpation of the right breast, the nurse detects a nontender 1-cm lump in the tail of
Spence. What disorder of the axilla is most likely responsible for her symptoms?
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
Breast cancer
Explanation:
Metastatic lymph nodes tend to be hard, nontender, and fixed, often to the rib cage. Although the
client has no family history of breast cancer, she is at a slightly increased risk because she never
had children.
5. The client reports to the nurse that she is concerned she has cancer as she has been
experiencing clear discharge from her breasts. What is the best response of the nurse?

"Do you take any medications?"
Explanation:
Some medications such as steroids, calcium channel blockers, oral contraceptives. or
tranquilizers may also cause nipple discharge. Stress, family history and early pregnancy do not
cause clear discharge.
6. What pattern of palpation is currently the best validated technique for detecting breast
masses?

Vertical strip pattern
Explanation:
Although a circular or wedge pattern can be used, the vertical strip pattern is currently the best
validated technique for detecting breast masses.
7. Elevated sebaceous glands, known as Montgomery glands, are located in the breast’s

areolas.
Explanation:
The areola surrounds the nipple (generally 1 to 2 cm radius) and contains elevated sebaceous
glands (Montgomery glands) that secrete a protective lipid substance during lactation.
8. The nurse plans to instruct an adult female client with regular menstrual cycles, who is
not taking oral contraceptives, about breast self-examination. The nurse should plan to
instruct the client to perform breast self-examination

right after menstruation.
Explanation:
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BSE is usually performed monthly after the period.
9. The nurse plans to instruct an adult female client with regular menstrual cycles, who is
not taking oral contraceptives, about breast self-examination. The nurse should plan to
instruct the client to perform breast self-examination

right after menstruation.
Explanation:
BSE is usually performed monthly after the period.
10. Which statement made by a student nurse about fibrocystic changes to the the breast
indicates the nurse needs further teaching?

"Fibrocystic changes are considered a risk factor for breast cancer."
Explanation:
Fibrocystic changes are commonly palpable as nodular, rope-like densities in women ages 25 to
50. They may be tender or painful. They are considered benign and are not viewed as a risk
factor for breast cancer.
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1. While auscultating the client's heart at the third intercostal space and on the left sternal
border, the nurse notes a high-pitched, scratchy sound that increases with exhalation
with the client leaning forward. The nurse should document which of the following?
A) Pericardial friction rub
B) Midsystolic click
C) Summation gallop
D) Aortic ejection click
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2. During chest auscultation, the nurse hears a quiet murmur immediately upon placing the
stethoscope on the client's chest. The nurse interprets this as which grade?
A) 1
B) 2
C) 3
D) 4
3. A group of students is reviewing the structures of the heart, noting that the thickest layer
of the heart is made up of contractile muscle cells. The students are correct in
identifying this layer as which of the following?
A) Myocardium
B) Epicardium
C) Endocardium
N
D) Pericardium
4. A nurse is reviewing the electrical conduction system of the heart in preparation for
assessing a client with a conduction problem. The nurse should be aware that the
electrical signal originates in which of the following locations?
A) Bundle of His
B) Purkinje fibers
C) Sinoatrial node
D) AV node
sh
Th
5. The nurse is analyzing the data from the assessment of a client's heart and neck vessels.
The client's first heart sound corresponds with what event in the cardiac cycle?
A) Isometric contraction
B) Closure of the semilunar valves
C) Beginning of diastole
D) Closure of the atrioventricular valves
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6. The nurse is assessing a client who is in uncompensated right-sided heart failure. What
assessment finding should the nurse anticipate?
A) Increased jugular venous pressure
B) Bradycardia
C) Decreased blood pressure
D) Dysrhythmias
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7. The nurse is assessing a client with a cardiac condition who complains of not sleeping
well and of having to get up frequently at night to urinate. The nurse should recognize
what implication of this statement?
A) The client may have developed a cardiac conduction problem.
B) The client may be experiencing symptoms of heart failure.
C) The client's cardiac problem is being adequately compensated for.
D) The client may be at increased risk for myocardial infarction.
8. The 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.
N
9. The nurse is preparing to assess a client's apical impulse. The nurse should palpate at
which location?
A) Second intercostal space, left sternal border
B) Third intercostal space, left axillary line
C) Fourth intercostal space, left sternal border
D) Fifth intercostal space, left midclavicular line
sh
Th
10. A nurse is preparing a health education session for a local community group. When
addressing the relationship between coronary artery disease (CAD) and culture, which
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.
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11. The nurse is assessing a client with mitral insufficiency. Which characteristic of the first
heart sound should the nurse expect to hear?
A) Split
B) Diminished
C) Accentuated
D) Varying
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12. The 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.
13. A nurse is auscultating a client's heart sounds. What action should the nurse perform
during this assessment?
A) Start by auscultating the client's breath sounds.
B) Auscultate prior to inspection and palpation.
C) Use the bell rather than the diaphragm.
D) Systematically listen to the entire precordium.
N
14. After teaching a group of students about the traditional areas of auscultation of heart
sounds, the instructor determines that the teaching was successful when the students
identify which of the following as Erb's point?
A) Fifth intercostal space near the left midclavicular line
B) Third to fifth intercostal space at the left sternal border
C) Second intercostal space at the right sternal border
D) Second or third intercostal space at the left sternal border
sh
Th
15. A nurse is reviewing a client's electrocardiogram (ECG). The nurse should identify
which component as indicating ventricular repolarization?
A) P wave
B) QRS complex
C) ST segment
D) T wave
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16. The nurse is preparing to assess a client's carotid arteries. Which of the following
actions 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.
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17. A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular.
Which of the following should the nurse do next?
A) Inspect for a lift.
B) Palpate for a thrill.
C) Auscultate for pulse rate deficit.
D) Listen for a ventricular gallop.
18. The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The
nurse would document this as which of the following?
A) 1+
B) 2+
C) 3+
D) 4+
N
19. A nurse is having difficulty identifying a client's heart sounds, specifically S1 and S2.
Which of the following 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.
sh
Th
20. A nurse is preparing a class for a local community group on coronary heart disease.
Which of the following recommendations should the nurse include as appropriate for
reducing a person's risk? Select all that apply.
A) Avoid eating carbohydrates.
B) Eat foods low in sodium.
C) Walk for at least 30 minutes/day.
D) Limit alcohol intake to 3 drinks per day.
E) Use relaxation techniques to manage stress.
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21. A client has sought care with complaints of increasing swelling in her feet and ankles,
and the nurse's assessment confirms the presence of bilateral edema. The nurse's
subsequent assessments should focus on the signs and symptoms of what health
problem?
A) Myocardial infarction
B) Heart failure
C) Atherosclerosis
D) Heart block
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22. The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain.
What interview question addresses the ìAî in this assessment model?
A) ìDo you have any other symptoms together with your chest pain, such as nausea,
sweating?î
B) ìIn your experience, what kinds of activities tend to cause your chest pain?î
C) ìWould you describe your chest pain as being acute, or is it chronic?î
D) ìWhat changes do you have to make in order to accommodate your chest pain?î
23. The nurse has begun the objective assessment of a client's heart and neck vessels and is
assessing the client's jugular veins. What finding would the nurse consider to be normal
in a healthy client?
A) The jugular venous pulse is not visible when the client is sitting upright.
N distended when the client is in a high Fowler's position.
B) The jugular veins are fully
C) The jugular veins are distended when the client sits at 45 degrees.
D) The jugular venous pulse is visible when the client lies supine.
24. The nurse is assessing the carotid arteries of a client with a history of heart disease.
What action should the nurse perform during this assessment?
A) Palpate the client's left and right carotid arteries simultaneously.
B) Palpate the client's carotid arteries prior to auscultation.
C) Instruct the client to inhale and exhale forcefully during auscultation.
D) Palpate the client's carotid arteries gently if an occlusion is audible.
sh
Th
25. The 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.
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26. The 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 ìbear downî (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.
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27. The nurse is assessing an older adult client's heart and neck vessels. When attempting to
palpate the client's apical impulse, what principle should guide the nurse's actions?
A) The apical impulse will be irregular due to normal, age-related physiological
changes.
B) The apical impulse may be more difficult to palpate than in a younger client.
C) The apical impulse will be found in a more medial location than in a younger
client.
D) The apical impulse will be easier to palpate if the client is in a standing position.
28. The 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.
N hypertrophy.
C) The client has left ventricular
D) The client's atria are not synchronized with the ventricles.
sh
Th
29. The nurse is integrating health promotion education into the assessment of a client's
heart and neck vessels. What teaching point addresses the most significant risk factor for
coronary artery disease?
A) ìIf you can eliminate red meat from your diet, your risk of heart disease will drop
significantly.î
B) ìTry to ensure that you're screened for heart disease at least once every six months.î
C) ìAnything that you can do to reduce stress in your life will benefit your heart
health.î
D) ìYour risk for heart disease will drop greatly if you're able to stop smoking.î
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30. The nurse has assessed a client's neck vessels and is now preparing to auscultate the
client's heart sounds. What action should the nurse perform during this phase of
assessment?
A) Rapidly auscultate all areas of the precordium and then repeat the assessments in
greater detail.
B) Stand on the client's left side, nearest the heart.
C) Elevate the head of the client's bed to 30 degrees.
D) Begin by auscultating the entire precordium with the bell of the stethoscope.
sh
Th
N
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Answer Key
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A
B
A
C
D
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D
B
B
B
D
B
D
A
C
B
B
B, C, E
B
A
A
D
D
D
B
A
D
C
N
sh
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2.
3.
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5.
6.
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8.
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30.
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1. During a client's vascular assessment, the nurse is palpating the pulse just under the
client's inguinal ligament. The nurse is assessing which pulse?
A) Temporal
B) Brachial
C) Popliteal
D) Femoral
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2. During a health visit, a client says, ìI know that arteries and veins are both blood
vessels, but what's the difference?î Which of the following would the nurse include in
the response?
A) Arteries have thicker walls than veins.
B) Arteries carry 70% of the body's blood volume.
C) Arteries have a lower pressure than veins.
D) Arteries carry waste from the tissues.
3. A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area?
A) Posterior neck
B) Axillary area
C) Inguinal area
D) Upper arm
N
4. An older adult client presents with cramping-type leg pain when walking, which is
relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to
6 seconds. Which of the following would the nurse suspect?
A) Arterial insufficiency
B) Musculoskeletal weakness
C) Venous insufficiency
D) Diabetic neuropathy
sh
Th
5. The nurse refers an older adult client for further evaluation after the nurse assesses
warm skin and brown pigmentation around the ankles. The nurse should note the
possibility of what health problem when making the referral?
A) Venous insufficiency
B) Stasis ulceration
C) Arterial occlusion
D) Dependent edema
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6. Which question would be most important to ask when obtaining the nursing health
history of a male client with extensive peripheral vascular disease?
A) ìWhat dietary supplements do you take?î
B) ìWhen was your last prostate exam for cancer?î
C) ìHave you experienced a change in your usual sexual activity?î
D) ìHave you had an electrocardiogram recently?î
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7. When analyzing the nursing history recently taken on a client, which factor would most
strongly alert the nurse to a significantly increased risk for chronic arterial
insufficiency?
A) Sedentary lifestyle
B) A family history of arterial insufficiency
C) Intake of 1 to 2 alcoholic drinks per day
D) 14-year history of smoking a pack a day
8. The clinic nurse is reviewing the medication history of a 39-year-old woman. Which
medication would the nurse identify as a potential risk factor for thrombophlebitis?
A) A beta-adrenergic blocker
B) A selective serotonin reuptake inhibitor (SSRI)
C) An oral contraceptive
D) An antilipid agent
N
9. The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. Which of
the following would be most appropriate for the nurse to do next?
A) Document ìabsence of dorsalis pedis pulse.î
B) Auscultate the anatomic area with a stethoscope.
C) Use Doppler ultrasonography to locate the pulse.
D) Apply a tourniquet for 2 minutes and then reassess.
sh
Th
10. A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of
the following should the nurse do next?
A) Document this finding as normal.
B) Recheck in 5 minutes after elevating the arm.
C) Reassess after applying warm compresses.
D) Refer the client for medical follow-up.
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11. A nurse is unable to palpate a client's radial and ulnar pulses. What is the nurse's most
appropriate action?
A) Refer the client for medical follow-up.
B) Document the finding and proceed with the assessment.
C) Palpate the brachial pulse.
D) Auscultate the apical pulse.
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12. A nurse assesses a client's epitrochlear nodes and finds them to be enlarged and tender.
Which of the following would the nurse do next?
A) Ask the client about any recent ear and throat infections.
B) Carefully assess the cervical lymph nodes for enlargement.
C) Examine the lower arm and hand for infection sites.
D) Assess both legs for Homans' sign.
13. Assessment of a client's lower extremities reveals unilateral edema of the right foot and
ankle. Which of the following would be most appropriate for the nurse to do next?
A) Compare measurements of both extremities.
B) Perform the Allen test.
C) Check for bilateral varicosities.
D) Palpate the femoral pulses.
N
14. When assessing a client for possible varicose veins, the nurse should do which of the
following actions?
A) Have the client stand for the exam.
B) Tell the client to raise his or her leg.
C) Dorsiflex the client's foot.
D) Obtain the ankle-brachial index.
sh
Th
15. A group of nursing students is reviewing information about the lymph nodes of the
lower extremity and the areas drained by them. The students demonstrate the need for
additional teaching when they identify which area as being drained by the superficial
inguinal nodes?
A) Legs
B) External genitalia
C) Upper abdomen
D) Buttocks
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16. A nurse instructor is observing a nursing student assess a client's capillary refill. Which
action by the student indicates the proper technique?
A) Student gently compresses the wrist area on the side of the thumb.
B) Student compresses the client's nail bed until it blanches.
C) Student applies firm pressure to the hand, noting any indentation.
D) Student asks client to turn hands slowly over and back.
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17. A nurse is determining a client's ankle-brachial index. Which result would indicate to
the nurse that the client's circulation is normal and free of arterial occlusion?
A) 0.5
B) 0.8
C) 1.1
D) 1.4
18. Assessment of a client's radial pulse reveals that it is bounding and does not disappear
with moderate pressure. The nurse documents the pulse amplitude as which of the
following?
A) 1+
B) 2+
C) 3+
D) 4+
N
19. A nurse obtains the following information: right arm brachial pressure, 160 mm Hg; left
arm brachial pressure, 150 mm Hg; right ankle pressure, 80 mm Hg; left ankle pressure,
94 mm Hg. The nurse determines that the right ankle-brachial index would be which of
the following?
A) 0.50
B) 0.53
C) 0.59
D) 0.63
sh
Th
20. While inspecting the lower extremities of a client, the nurse observes an ulcer. Which of
the following would lead the nurse to suspect that the ulcer is the result of arterial
insufficiency? Select all that apply.
A) Irregular border
B) Deep
C) Circular in shape
D) Moderate leg edema
E) Client report of severe pain
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21. The nurse is assessing a client who has been referred to the clinic because of possible
arterial insufficiency. What assessment finding should the nurse identify as most
consistent with this diagnosis?
A) Dry, shiny, hairless shins and feet
B) Pitting edema to the feet and ankles
C) Numbness and tingling of the lower extremities
D) Reddish-blue coloration of the shins and feet
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22. The nurse is assessing an 81-year-old client's peripheral vascular function. What
principle should guide the nurse's analysis of assessment data?
A) Leg pain that is relieved by rest is the result of normal physiological changes.
B) Hair loss on the legs may be an age-related change rather than a sign of arterial
insufficiency.
C) Venous ulcers and arterial ulcers have a similar appearance and course in older
adults.
D) Non-palpable peripheral pulses are expected in clients over the age of 80.
23. The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on
the client's great toe. What should the nurse suspect as the etiology of the client's
wound?
A) Blood is returning from the client's toe more slowly than normal.
N
B) There is a blockage or infection
in the client's lymphatic system.
C) There is a disruption in osmotic pressure in the client's extremities.
D) The client's toe is receiving an inadequate supply of blood.
Th
24. The nurse has attempted to palpate the client's popliteal pulses but is unable to feel
them, despite confirming appropriate landmarking and client positioning. What is the
nurse's best response?
A) Advocate for a referral to a vascular surgeon.
B) Have the client perform light physical activity to promote circulation and then
reattempt.
C) Document the finding and proceed with the assessment.
D) Palpate the client's brachial pulse.
sh
25. The nurse is using Doppler ultrasound to auscultate the peripheral pulses of a client with
peripheral vascular disease. What action should the nurse perform during this
assessment?
A) Gently cool the client's extremities to aid auscultation.
B) Apply a small amount of petroleum gel to the Doppler probe.
C) Hold the probe at a 60- to 90-degree angle to the client's skin.
D) Push the probe firmly against the skin to enhance audibility.
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26. The nurse is performing a peripheral vascular assessment of an adult client. The nurse is
palpating the client's peripheral pulses but knows that some are not palpable, even in
healthy clients. What pulse is not palpable in a large proportion of healthy clients?
A) Ulnar
B) Radial
C) Brachial
D) Femoral
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27. The nurse is performing the Allen test on a client who has a diagnosis of peripheral
vascular disease. What action should the nurse take after a positive Allen test?
A) Document the absence of dorsalis pedis or posterior tibial pulses.
B) Document the lack of patency in the ulnar and/or radial arteries.
C) Attempt to palpate the popliteal pulse with the client's leg in a dependent position.
D) Corroborate the finding by assessing capillary refill in the client's great toes.
28. The nurse's inspection of a Caucasian client's lower extremities reveals a brownish
coloration to the client's ankles and shins. The nurse should perform further assessments
that address what health problem?
A) Venous insufficiency
B) Peripheral edema
C) Coronary artery disease N
D) Raynaud's phenomenon
Th
29. The nurse reads in a client's electronic health record that her most recent ankle-brachial
index (ABI) was 0.42. How should this assessment finding inform the nurse's care?
A) The nurse should inspect the client's feet and ankles for venous ulcers once per
shift.
B) The nurse should implement interventions to address severe arterial insufficiency.
C) The nurse should assess the client's extremities for pitting edema at least once per
shift.
D) The nurse should position the client to promote venous return.
sh
30. The presence of faint pedal pulses in a client has prompted the nurse to perform a
position change test for arterial insufficiency. What finding would suggest that the client
may have arterial insufficiency?
A) The client's legs are tender on palpation when in a dependent position.
B) The client's legs are visibly pale when elevated above the examination table.
C) The client's legs return to a pink color in 5 seconds.
D) The client's legs develop pitting edema when he or she dangles them over the
bedside.
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N
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Answer Key
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D
A
D
A
A
C
D
C
C
A
C
C
A
A
C
B
C
C
A
B, C, E
A
B
D
C
C
A
B
A
B
B
N
sh
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
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21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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1. During 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 of the following
actions 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.
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2. When 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
3. A group of students is preparing for their clinical experience, during which they are
required to demonstrate the techniques for assessing the abdomen. The students
demonstrate understanding of the proper sequence when they demonstrate the
techniques in which order?
A) Palpate, percuss, inspect, auscultate
N percuss
B) Auscultate, inspect, palpate,
C) Inspect, auscultate, percuss, palpate
D) Percuss, inspect, auscultate, palpate
4. To promote relaxation of the client's abdominal muscles, which of the following would
be most appropriate for the nurse to do?
A) Encourage the client to hold his or her breath.
B) Cover the client in a warm blanket.
C) Place a pillow under both of the client's knees.
D) Assure the client that painful areas will not be examined.
sh
Th
5. A 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's sign
D) Tympany on percussion
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6. A 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. The nurse
auscultates the client's bowel sounds, noting them to be which of the following?
A) Normoactive
B) Hyperactive
C) Hypoactive
D) Absent
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7. The nurse is percussing a client's liver and is assessing liver descent. The nurse should
have the client do which of the following?
A) Cough forcefully
B) Hold the breath
C) Breathe in and out deeply
D) Perform the Valsalva maneuver
8. A nurse determines that the liver span of an older adult male client measures 6 cm. The
nurse would interpret this as indicating which of the following?
A) It is a normal-sized liver.
B) The liver is larger than normal.
C) It is a smaller-than-normal liver.
D) The liver has atrophied.
N
9. Which of the following should a nurse suspect if dullness is percussed at the last left
interspace at the anterior axillary line on deep inspiration?
A) Hepatomegaly
B) Splenomegaly
C) Abdominal mass
D) Intestinal air
sh
Th
10. While assessing a client's abdomen, the nurse observes involuntary reflex guarding on
expiration. The nurse would interpret this as most likely indicating which of the
following?
A) Hernia
B) Malignancy
C) Infection
D) Aneurysm
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11. The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at
which location?
A) Midline at the umbilicus
B) Deep epigastrium to the left of midline
C) Slightly above the suprapubic area
D) Between the umbilicus and the symphysis pubis
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12. During palpation of the client's abdomen, the nurse feels a prominent, nontender,
pulsating 6-cm mass above the umbilicus. What action should the nurse take?
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.
13. A nurse is preparing to palpate a client's spleen. Which position should the nurse use to
best facilitate palpation?
A) Sitting upright
B) Prone
C) Semi-Fowler's
D) Right side-lying
N
14. A client's bladder is found to be distended. At which location should the nurse begin
palpating?
A) At the umbilicus
B) At the symphysis pubis
C) In the right lower quadrant
D) In the left lower quadrant
sh
Th
15. The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness
test for suspected appendicitis. The nurse identifies correct technique when the new
graduate is observed pressing deeply at which abdominal location?
A) Right upper quadrant
B) Left upper quadrant
C) Right lower quadrant
D) Left lower quadrant
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16. The nurse demonstrates the correct technique for assessing the psoas sign by which
action?
A) Applying deep palpation pressure to the client's right lower quadrant, then
suddenly releasing
B) Tapping fingerpads over the client's abdominal wall, feeling for a floating mass
C) Percussing over the client's symphysis pubis with the client supine and then sitting
upright
D) Flexing the client's right hip, applying downward pressure on the right thigh
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17. The nurse is assessing a client who is in liver failure and who has developed ascites.
When measuring the client's abdominal girth, the nurse should place the client in which
position?
A) Sitting
B) Standing
C) Supine
D) Prone
18. A nurse is reviewing the various causes associated with abdominal distention. Which of
the following should the nurse identify? Select all that apply.
A) Fat
B) Stool
N
C) Gas
D) Hernia
E) Fibroid tumors
sh
Th
19. A 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. The nurse
should document which of the following?
A) Positive Rovsing's sign
B) Psoas sign present
C) Obturator sign positive
D) Positive skin hypersensitivity test
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20. The 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) ìI'm going to examine the area where you're having pain first to get a better picture
of what's going on.î
B) ìBefore I get ready to examine the painful area, I will let you know in plenty of
time.î
C) ìYou don't need to worry about anything. I will make sure to be very gentle during
the exam.î
D) ìSince you're having pain in a certain area, I won't have to do a very detailed exam
there.î
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21. The 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
22. A client exhibits many of the most common signs and symptoms of peptic ulcer disease.
What interview question addresses the most plausible cause of the client's health
problem?
A) ìDo you feel like you're N
able to adequately address the stress in your life?î
B) ìDo you take painkillers like aspirin on a regular basis?î
C) ìDo you tend to eat foods that are quite high in fat?î
D) ìAre you currently taking vitamin supplements?î
Th
23. An adult client states that his mother has been living with peptic ulcer disease, and he is
motivated to ensure that he does not develop the disease as he ages. What health
promotion advice should the nurse provide?
A) Quit smoking as soon as possible.
B) Exercise for at least 30 minutes, three times per week.
C) Eat several small meals a day rather than three larger meals.
D) Attend screening clinics at least twice per year.
sh
24. A 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
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25. The 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. How should the
nurse proceed with assessment?
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.
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26. The nurse is assessing the gastrointestinal system of an 81-year-old client. What agerelated 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.
27. The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds.
How should the nurse proceed with assessment?
A) Repeat auscultation in four to six hours.
B) Palpate the client's abdomen to stimulate bowel motility.
N
C) Perform abdominal percussion,
wait three to five minutes and then repeat
auscultation.
D) Listen for at least five minutes before documenting an absence of bowel sounds.
28. The nurse is percussing a client's abdomen. What predominant sound should the nurse
expect to hear over the majority of the abdomen?
A) Accentuated tympany
B) Hyperresonance
C) Tympany
D) Dullness
sh
Th
29. The nurse is performing blunt percussion of a client's kidneys. For what abnormal
finding is the nurse primarily assessing?
A) Dullness
B) Tympany
C) Tenderness
D) Hyperresonance
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30. The 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.
sh
Th
N
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Answer Key
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D
A
C
C
C
D
B
A
B
C
B
D
D
B
C
D
B
A, B, C, E
A
B
C
B
A
B
D
A
D
C
C
A
N
sh
Th
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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1. A client has suffered a suspected 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
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2. After teaching a group of students about the bones and their functions, the instructor
determines that the teaching was successful when the students state that blood cells are
produced in which of the following?
A) Compact bone
B) Red marrow
C) Yellow marrow
D) Spongy bone
3. A client complains of temporomandibular joint (TMJ) pain. Which of the following
would the nurse most likely assess?
A) Joint dislocation
B) History of fracture
C) History of dental abscess
D) Difficulty chewing
N
4. Assessment reveals that an older adult client has osteomalacia. Which of the following
would be most important to include in the client's teaching plan?
A) Practice risk prevention for fractures.
B) Keep exercise to a minimum to decrease pain.
C) Minimize movements to maintain joint stability.
D) Treat secondary arthritis proactively.
sh
Th
5. Which of the following 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
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6. The nurse is assessing an adolescent client and notes 45-degree flexion of the cervical
spine. What is the nurse's most appropriate action?
A) Facilitate a referral for medical follow up.
B) Palpate the spinous processes.
C) Perform the LasËgue test.
D) Continue the exam because this curve is normal.
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7. When asked to touch her ear to her shoulder, a client reports pain. Which of the
following should 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 paravertebral muscles for pain.
8. Which test would be most appropriate for the nurse to perform when a client complains
of low back pain?
A) Straight leg test
B) Muscle leg strength
C) Lateral bending of cervical spine
D) Internal rotation of the shoulders
N
9. A nurse asks a client to bring his hands together behind his head with his elbows flexed.
The nurse is testing which of the following?
A) Abduction
B) Adduction
C) Internal rotation
D) External rotation
sh
Th
10. Which of the following would the nurse interpret as a positive response to the Phalen
test for a client suspected of having carpal tunnel syndrome?
A) Numbness
B) Atrophy of the thenar prominence
C) No tingling
D) Hard, painless Bouchard nodes
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11. A nurse is preparing a program on osteoporosis for a local women's group. Which of the
following should the nurse cite as a risk factor?
A) Obesity
B) Multiparity (multiple pregnancies)
C) History of smoking
D) African-American ethnicity
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12. Which of the following would be most appropriate when the nurse notes limitation in
active range of motion of a client's right shoulder?
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.
13. When testing muscle strength, a client has difficulty moving her right arm against
resistance. Which of the following should the nurse 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
N
14. Assessment reveals that a client has slight weakness with active range of motion against
some resistance. The nurse would document this as which of the following?
A) 2/5
B) 3/5
C) 4/5
D) 5/5
sh
Th
15. While assessing the knee joint of a client, a nurse also explains about the typical
motions associated with that joint. Which of the following would the nurse include?
A) Circumduction
B) Flexion
C) Abduction
D) Internal rotation
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16. When testing the range of motion of the cervical spine, the nurse notes impaired range
of motion and neck pain. A review of the client's history reveals fever, chills, and
headache. Which of the following would the nurse suspect?
A) Meningitis
B) Cervical strain
C) Compression fracture
D) Cervical disc degeneration
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17. A nurse is testing the range of motion of the thoracic and lumbar spine. Which of the
following would the nurse document as an abnormal finding?
A) Flexion of 80 degrees
B) Lateral bending of 35 degrees
C) Hyperextension of 15 degrees
D) Rotation of 30 degrees
18. The nurse is preparing to palpate the anatomic snuffbox. At which location 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
N
19. Inspection of a client's knee reveals swelling, and the nurse suspects that there is
significant fluid in the knee. Which of the following would the nurse use to confirm the
suspicion?
A) Phalen's test
B) Tinel's test
C) Ballottement test
D) Leg raising test
sh
Th
20. During the physical exam, the nurse notes a very tender and painful, reddened, hot, and
swollen metatarsophalangeal joint of the client's great toe. Which of the following
would the nurse suspect?
A) Gouty arthritis
B) Rheumatoid arthritis
C) Degenerative joint disease
D) Plantar fasciitis
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21. The nurse is conducting a focused musculoskeletal assessment of an older adult client.
When analyzing assessment data, the nurse should be aware of what age-related
physiological changes? Select all that apply
A) Absence of knee flexion
B) Decreased bone density
C) Decreased joint flexibility
D) Joint capsule calcification
E) Reduced muscle strength
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22. A 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
23. During 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
N
C) Nonsteroidal anti-inflammatories
(NSAIDs)
D) Calcium channel blockers
24. The nurse is performing an assessment of a client's musculoskeletal system. The nurse
should begin the assessment by examining which of the following?
A) The client's leg length
B) The client's lateral bending ability
C) The client's cervical ROM
D) The client's gait
sh
Th
25. The nurse has had a client place the backs of both her hands against each other while
flexing her wrists 90 degrees with fingers pointed downward and wrists dangling. The
presence of pain or tingling during this test suggests what health problem to the nurse?
A) Osteoarthritis
B) Diabetic neuropathy
C) Carpal tunnel syndrome
D) Gouty arthritis
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26. The 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.
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27. The 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
28. Inspection of a client's foot reveals an enlarged, painful, inflamed bursa (bunion) on the
medial side of the foot. The nurse should make a referral for what health problem?
A) Osteomalacia
B) Hallux valgus
N
C) Pes planus
D) Gouty arthritis
Th
29. The 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
sh
30. A 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
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Answer Key
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C
B
D
A
C
D
B
A
D
A
C
C
B
C
B
A
C
D
C
A
B, C, D, E
A
B
D
C
D
A
B
A, C, D
B
N
sh
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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1. The nurse is assessing the eyes of a client who has a lesion of the sympathetic nervous
system. What assessment finding should the nurse anticipate?
A) Bilateral dilated pupils
B) Nystagmus (involuntary eye movement)
C) Argyll-Robertson pupils
D) Constricted pupils, unresponsive to light
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2. A client has sustained an injury to the cerebellum. Which area should be the nurse's
primary focus for assessment?
A) Vital signs
B) Respiratory status
C) Cardiac function
D) Coordination
3. Which of the following 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
N
4. A client complains of headaches each morning that resolve after getting out of bed.
Which of the following would be most appropriate for the nurse to do?
A) Assess the client's level of consciousness.
B) Assess the client's deep tendon reflexes.
C) Refer the client for immediate medical follow-up.
D) Refer the client for physical therapy and occupational therapy.
sh
Th
5. A nurse is preparing to assess a client's cerebellar function. Which of the following
aspects of neurological function should the nurse address?
A) Remote memory
B) Sensation
C) Judgment
D) Balance
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6. The nurse assesses brisk reflexes in a client during a neurological assessment. The nurse
should document this finding as which of the following?
A) 1+
B) 2+
C) 3+
D) 4+
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7. A nurse is having difficulty eliciting a patellar reflex during a client's neurological
assessment. Which of the following 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.
8. Which of the following tests would be most appropriate for the nurse to use 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.
N
9. A client has presented with signs and symptoms that are suggestive of Bell's palsy.
What assessment finding is most consistent with this diagnosis?
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
sh
Th
10. When assessing cranial nerves IX and X, which of the following would the nurse
consider as a normal finding?
A) Stationary soft palate on phonation
B) Deviation of uvula when client says ìahî
C) Asymmetrical soft palate
D) Uvula and soft palate rising bilaterally
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11. The nurse is planning to assess a client for graphesthesia. How will the nurse perform
this phase of assessment?
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 nurse will briefly touch the client, and the client will identify where the touch
occurred.
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12. During the Romberg test, a client is unable to stand with the feet together and
demonstrates a wide-based, staggering, unsteady gait. The nurse would interpret this
finding as suggestive of which of the following?
A) Spastic hemiparesis
B) Parkinsonian gait
C) Scissors gait
D) Cerebellar ataxia
13. When 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 N
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.
Th
14. When preparing to test a client for meningeal irritation, which of the following would be
most important for the nurse to do first?
A) Check for evidence of fever and chills.
B) Ensure there is no injury to the cervical spine.
C) Position the client prone.
D) Check for a Babinski reflex.
sh
15. During 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
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16. When evaluating a client's risk for cerebrovascular accident, which client should the
nurse identify as being at highest risk?
A) A 42-year-old Caucasian female who smokes
B) A 68-year-old African-American male with hypertension
C) A 70-year-old Caucasian male who has one to two beers a day
D) A 35-year-old African-American male who has sleep apnea
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17. After teaching a group of students about the brain and spinal cord, the instructor
determines that the students demonstrate the need for additional teaching when they
identify which of the following as being controlled by the brain stem?
A) Respiratory function
B) Heart rate
C) Equilibrium
D) Reflex actions
18. A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test
CN I. Which of the following should the nurse do?
A) Use a Snellen chart to test visual acuity.
B) Ask a client to identify scents.
C) Test extraocular eye movements.
D) Perform the Weber test.
N
19. When reviewing the neural pathways, a group of students is identifying sensations that
travel via the spinothalamic tract. Select all the sensations that are carried by this tract.
A) Pain
B) Temperature
C) Position
D) Vibration
E) Light touch
sh
Th
20. A 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
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Material
21. The nurse is assessing a 39-year-old woman who has a 20 pack-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
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22. An adult client has asked the nurse about actions that she can take to reduce her future
risk of stroke. What health promotion activity should the nurse prioritize?
A) Smoking cessation
B) Annual MRI screening
C) Nutritional supplementation
D) Improved coping skills
23. The nurse is obtaining the health history of a young adult client. During the interview,
the client tells the nurse, ìI banged my head pretty good when I was snowboarding last
weekend.î The client states that he did not subsequently seek care. What is the nurse's
most appropriate action?
A) Promptly assess the client's balance and coordination.
B) Teach the client about the warning signs of increased intracranial pressure.
N assessment and possible treatment.
C) Refer the client for medical
D) Teach the client about the importance of wearing head protection during sports.
24. The 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
sh
Th
25. The 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
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26. The 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's palsy
D) Brain stem lesion
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27. The 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.
28. The 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 N
D) Cerebellar lesion
29. The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What
instruction should the nurse provide to the client during this phase of assessment?
A) ìClench your teeth together tightly.î
B) ìClose your left eye and look at me with your right.î
C) ìLook straight at me while I shine this light in your eye.î
D) ìOpen your mouth wide and say 'ah.'î
sh
Th
30. Examination 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) Footdrop
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Answer Key
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D
D
C
C
D
C
A
C
B
D
A
D
C
B
A
B
C
B
A, B, E
B
D
A
C
B
A
B
A
A
A
B
N
sh
Th
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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1. When examining a newborn male infant, the nurse notes that neither testicle is
descended. The nurse documents this finding as which of the following?
A) Epididymitis
B) Orchitis
C) Cryptorchidism
D) Varicocele
2. During the health history, a young male client asks the nurse why his scrotum rises and
relaxes. The nurse would incorporate knowledge of which of the following when
responding to this client?
A) When the temperature is warm, the scrotum rises.
B) The cremasteric reflex controls the rise and relaxation of the scrotum.
C) When the scrotum relaxes, it has many rugae.
D) If the temperature is colder, the scrotum relaxes.
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Chapter 26 Assessing Male Genitalia and Rectum
3. While interviewing a teenage male client, the nurse reviews the various structures of the
male genitalia. The client asks, ìSo what does this epididymis do?î Which of the
following 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.
N sex hormones.
D) It produces sperm and male
4. An adult male client reports hesitancy when urinating. The nurse would further assess
this client for which of the following?
A) Scrotal hernia
B) Sexually transmitted infection
C) Prostate enlargement
D) Testicular tumor
sh
Th
5. The nurse is presenting a program about sexually transmitted infections, including HIV,
to a group of young men. The nurse would include which of the following as the having
the highest incidence of HIV infection in the United States?
A) Men having sex with men
B) Heterosexual partners
C) Bisexual individuals
D) Intravenous drug users
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6. When the nurse is examining a male client's genitalia, the client experiences an erection.
Which of the following would be most appropriate for the nurse to do?
A) Remain silent but continue the examination.
B) Stop the exam and leave the room for a few minutes.
C) Ask the client whether continuing the exam will embarrass him.
D) Reassure the client that this is not unusual.
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7. The nurse is beginning the physical exam of a male client's genitals. The nurse is sitting
on a stool in front of the client. In which position would be best to place the client?
A) Lying supine
B) Kneeling
C) Standing
D) Sitting
8. A male client is receiving chemotherapy for the treatment of cancer. Which finding
should the nurse anticipate during examination of the client's genitalia?
A) Sparse pubic hair
B) Hardness along the ventral surface of the penis
C) Cyanosis to the glans
D) Tenderness on scrotal palpation
N
9. A nurse is planning to assess a male client for urethral discharge. Which technique
would be best for the nurse to use?
A) Have the client hold the penis while the examiner looks for discharge.
B) Gently squeeze the glans between the thumb and index finger.
C) Inspect the scrotal skin while holding the penis aside.
D) Observe the glans of the penis for signs of abnormal discharge.
sh
Th
10. While assessing the scrotum of an adult client, the nurse notes thin and rugated scrotal
skin with little hair dispersion. The nurse interprets this finding as which of the
following?
A) Reiter's syndrome
B) Normal findings
C) Effects of chemotherapy
D) Gonorrhea
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11. During a client's genitourinary exam, the nurse notes that the client's scrotum is enlarged
and easily transilluminates. Which of the following should the nurse suspect?
A) Tumor
B) Hernia
C) Varicocele
D) Hydrocele
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12. A client complains of scrotal pain, and the nurse elicits a positive Prehn sign, in which
passive elevation of the testes relieves the scrotal pain. The nurse should refer the client
for treatment of which of the following?
A) Strangulated hernia
B) Tortuous varicocele
C) Epididymitis
D) Scrotal mass
13. The nurse is assessing a client who is suspected of having an incarcerated scrotal hernia.
Which finding would help confirm this suspicion?
A) The mass cannot be pushed up into the abdomen.
B) The area around the hernia is ecchymotic.
C) The client complains of tenderness and nausea.
D) A scrotal bulge disappears when the client lies down.
N
14. While inspecting the penis of a client, the nurse suspects herpes progenitalis based on
which assessment finding?
A) Red, oval ulcerations
B) Hardened nodules on the glans
C) Clear vesicles that erupt
D) Painless, fleshy papules
sh
Th
15. Assessment findings reveal that a client has herpes progenitalis. Which of the following
would be most important to include in the teaching related to after the initial lesions
disappear?
A) The disease will spontaneously regress.
B) The client is at increased risk for cancer of the glans.
C) Recurrence can happen with varying frequency.
D) The next outbreak will include moist, fleshy papules.
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16. A nurse is preparing to examine a client's inguinal area. The nurse understands that this
area is contained by which structure laterally?
A) Symphysis pubis
B) Inguinal ligament
C) Inguinal canal
D) Anterior superior iliac spine
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17. When inspecting a client's inguinal area for bulging, which of the following would be
most appropriate for the nurse to have the client do?
A) Bend forward from the waist
B) Bear down as if having a bowel movement
C) Hold his breath after exhaling
D) Lie supine and draw his knees to his chest
18. A 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 which of the following?
A) Epispadias
B) Hypospadias
C) Paraphimosis
D) Phimosis
N
19. The nurse is assessing the genitalia of an older adult client. Which of the following
would the nurse document as a normal finding?
A) Decrease in size of the testes
B) Testes hanging lower in the scrotum
C) Abundant pubic hair
D) Bulging in the inguinal area
sh
Th
20. A nurse teaches a male client how to perform testicular self-examination when the
client's history reveals that he does not do it. The nurse should instruct the client to
perform the self-examination at which frequency?
A) Weekly
B) Bimonthly
C) Monthly
D) Quarterly
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21. A client has a family history of prostate cancer and is committed to regular screening.
What should the nurse teach the client about prostate-specific antigen (PSA) blood
testing?
A) Annual PSA blood testing should begin at age 50.
B) PSA blood testing is not recommended for most clients.
C) PSA blood testing should only be performed on men who reject digital rectal
exams.
D) PSA blood tests should be performed biannually between ages 45 and 60 and then
annually thereafter.
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22. An adult client has sought care because he has a two-day history of stool that is ìblack
like road tar.î How should the nurse best respond to this aspect of the client's history?
A) Promptly refer the client for treatment of a possible gastrointestinal bleed.
B) Refer the client to a dietitian for treatment of a possible vitamin deficiency.
C) Encourage the client to increase his intake of fluids and soluble fiber.
D) Encourage the client to use an over-the-counter laxative for the next 2 to 3 days.
23. A client has admitted to the nurse that he has been having difficulty obtaining and
maintaining erections for many months. Which of the nurse's assessment questions most
clearly addresses a potential cause for the client's problem?
A) ìHow would you describe a typical day's food intake?î
N currently taking?î
B) ìWhat medications are you
C) ìHave you ever been screened for prostate cancer?î
D) ìDo you ever experience pain when you urinate?î
24. A nurse is a preparing to assess a male client's anus and rectum. How should the nurse
best prepare the client for this assessment?
A) Ask the client if he is feeling anxious or fearful about the exam.
B) Assist the client into the supine position.
C) Administer a dose of analgesia 15 minutes before the exam.
D) Position the client in a left side-lying position.
sh
Th
25. A nurse is aware of the need to protect against false allegations of inappropriate physical
touch during a client's genitourinary assessment. How can the nurse best address this
risk?
A) Thoroughly explain the rationale for each aspect of the assessment.
B) Ensure that a chaperone is present in the room during the exam.
C) Perform the assessment as quickly and efficiently as possible.
D) Ask for the client's permission prior to starting the assessment.
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26. Palpation 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.
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27. 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.
28. A client has sought care because of a sudden increase in the size of his scrotum. The
nurse's assessment reveals the presence of a large scrotal mass. How can the nurse best
assess for a scrotal hernia?
A) Palpate the mass for pain.
B) Auscultate the mass for bowel sounds.
C) Percuss the mass for dullness.
D) See if the mass disappears when the client stands.
N
29. A 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
sh
Th
30. A teenage boy has been diagnosed with orchitis. When reviewing the child's health
history, the nurse should expect that the client may have recently been treated for what
health problem?
A) Measles
B) Varicella
C) Phimosis
D) Influenza A
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C
B
A
C
A
D
C
A
B
B
D
C
A
C
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D
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B
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C
B
A
B
D
B
B
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Answer Key
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1. To examine the Bartholin's glands of a female client, the nurse would palpate at which
anatomic location?
A) On both sides of the clitoris
B) Just inside the urethral orifice
C) Between the vaginal opening and labia minora
D) Inside the vaginal orifice
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2. During the health history, a postmenopausal client mentions that she is experiencing
vaginal dryness. When explaining the most likely reason to the client, the nurse should
explain the role of which hormone?
A) Estrogen
B) Progesterone
C) Follicle-stimulating hormone (FSH)
D) Oxytocin
3. A client's health history reveals that she had a total hysterectomy at age 33 to treat
severe endometriosis. She says that the surgeon also removed both ovaries and fallopian
tubes. The nurse would interpret this as which of the following?
A) Natural menopause
B) Delayed menopause
C) Premature menopause
D) Artificial menopause N
4. An older adult client states, ìSometimes when I sneeze, I notice that I wet my pants.î
The nurse interprets this as which of the following?
A) Reflex incontinence
B) Stress incontinence
C) Urge incontinence
D) Total incontinence
sh
Th
5. A postmenopausal woman tells the nurse that she experiences discomfort during sexual
intercourse. Which of the following should the nurse suggest?
A) Use of a lubricant
B) Abstinence from intercourse
C) Use of a condom by the partner
D) Kegel exercises
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6. A young female client refuses treatment for a sexually transmitted infection. The nurse
explains that lack of treatment may put her at risk for which condition?
A) Endometriosis
B) Urinary tract infection
C) Cervical cancer
D) Pelvic inflammatory disease
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7. A 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
8. During the health history, the nurse teaches a client about toxic shock syndrome and
ways to reduce her risks. The nurse determines that the teaching was successful when
the client states which of the following?
A) ìI will get a Pap smear regularly.î
B) ìIt is important to use latex condoms.î
C) ìI should change tampons at least every 4 to 6 hours.î
D) ìI should stop using oralNcontraceptives.î
9. When assessing the vaginal orifice of a young female client who has never been
sexually active, the nurse notes a fold of fibrous tissue at the introitus. The nurse
recognizes this as which structure?
A) Labia
B) Urethra
C) Hymen
D) Clitoris
sh
Th
10. When palpating the Bartholin's glands, the nurse expresses a purulent discharge. Which
of the following would be most appropriate for the nurse to do next?
A) Recommend sitz baths.
B) Palpate the uterus.
C) Obtain a culture.
D) Perform a rectal exam.
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11. The nurse notes a malodorous, yellow discharge upon inserting the speculum into the
client's vagina. Which of the following should the nurse do next?
A) Obtain a urine specimen.
B) Obtain a wet mount slide.
C) Procure a Papanicolaou (Pap) smear.
D) Perform a bimanual exam.
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12. The nurse is presenting a class to a group of high school students about sexually
transmitted infections. Which of the following should the nurse include as a major risk
factor for cervical cancer?
A) Gonorrhea
B) Chlamydia
C) Syphilis
D) Human papilloma virus
13. When obtaining a cervical specimen for a Neisseria gonorrhoeae culture, which of the
following would be most appropriate?
A) Wipe the cotton-tipped applicator onto a slide.
B) Spread the specimen in a ìZî pattern on a special culture plate.
C) Immerse the swab in a liquid medium and refrigerate.
D) Roll the endocervical brush onto a slide.
N
14. The nurse is inspecting the client's vaginal musculature and asks the client to bear down.
Which finding would lead the nurse to suspect that the client has a cystocele?
A) Bulging of the anterior vaginal wall
B) Protrusion of the cervix
C) Urine leakage
D) Protrusion at the back of the vaginal wall
sh
Th
15. The nurse is preparing to perform a speculum examination on a client. The nurse
lubricates the speculum with which of the following?
A) Petroleum jelly
B) Water-soluble lubricant
C) Client's vaginal secretions
D) Antimicrobial ointment
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16. The nurse is inspecting the cervix of a client who has two children. The nurse would
expect the cervical os to appear as which of the following?
A) Round
B) Slit-like
C) Transverse
D) Stellate
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17. When assessing the cervix of an older postmenopausal woman, which of the following
would the nurse document as a normal finding?
A) Bluish color
B) Bright red
C) Pale pink
D) White patches
18. The nurse is assessing a female client's genitourinary system. Which of the following
findings 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
N
19. The nurse is preparing to perform a rectovaginal examination on a client. Which
statement by the nurse would be most appropriate?
A) ìI have to do this exam to make sure everything is okay, so just bear with me.î
B) ìYou might feel uncomfortable, almost like you have to move your bowels.î
C) ìJust relax, it will only take a minute and then I'll be all finished.î
D) ìI want you to hold your breath as I insert my fingers into the openings.î
sh
Th
20. While inspecting the vagina, the nurse observes a thin, grayish-white vaginal discharge
with a fishy odor. Which of the following would the nurse suspect?
A) Moniliasis
B) Trichomoniasis
C) Bacterial vaginosis
D) Atrophic vaginitis
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21. A 49-year-old woman has sought care because of severe perimenopausal symptoms.
The client has asked the nurse if she should talk to her doctor about beginning hormone
replacement therapy (HRT). How should the nurse best respond?
A) ìThe most recent research suggests that the benefits of HRT have been greatly
overstated.î
B) ìHRT often relieves many of the symptoms of menopause, but it's not without
some risks.î
C) ìHRT is a good option for many women, mostly because it's a naturally occurring
substance.î
D) ìYour doctor will likely recommend HRT because you're beginning menopause
quite young.î
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22. A 52-year-old woman's current medication regimen includes estrogen-progestin therapy
(EPT). In addition to reduced symptoms of menopause, the nurse should be aware that
this therapy confers what secondary benefit?
A) Weight loss
B) Reduced risk of colorectal cancer
C) Protection against stroke
D) Increased libido
23. A female client has presented for a Pap smear test, and the nurse is discussing risk
N risk factor should the nurse describe?
factors for cervical cancer. What
A) Having multiple sexual partners
B) Previous treatment for chlamydial infection
C) Pregnancy before age 21
D) African-American ethnicity
Th
24. The nurse is completing a client's genitourinary assessment and is preparing to assess
the client's cervix. What finding would most clearly warrant referral?
A) The cervix is firm on palpation.
B) The cervix is immobile on palpation.
C) The cervix is smooth and pink on inspection.
D) The cervix projects 2 cm into the client's vagina.
sh
25. Scar tissue is visible on the perineum of an adult female client. The nurse should
consequently question the client about which of the following?
A) Surgical correction of a rectocele
B) History of sexually transmitted infections
C) History of sexual abuse
D) Tearing during vaginal delivery
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26. In which of the following clients would the nurse consider a bluish tint to the cervix an
expected assessment finding?
A) A client who is 17 years old and sexually active.
B) A client who is 10 weeks' pregnant.
C) A 71-year-old multiparous client
D) A client who has a 24 pack-year smoking history.
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27. The 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
28. A 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) ìStop taking any antibiotics for 24 hours before your examination.î
B) ìMake sure not to douche for 48 hours before the examination.î
C) ìDon't bathe or shower on the morning of the appointment.î
D) ìDrink at least 48 ouncesNof fluid the morning before the appointment.î
29. The nurse is preparing a client for an assessment of her genitalia and rectum. What
action should the nurse perform when preparing the client?
A) Assist the client into a prone position.
B) Explain the rationale for using foot stirrups.
C) Reassure the client that no one other than the nurse will be in the room.
D) Obtain written, informed consent for the examination.
sh
Th
30. An adult client has sought care at the clinic, stating that she believes she has ìa raging
yeast infection.î 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
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C
A
D
B
A
D
D
C
C
C
B
D
B
A
C
B
C
C
B
C
B
B
A
B
D
B
D
B
B
A
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2.
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7.
8.
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Answer Key
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1. A nurse is performing an assessment within the legal parameters of assessment and
diagnosis. These legal guidelines would be specified in which of the following?
A) The state's Nurse Practice Act
B) The client's informed consent documents
C) The nurse's terms of license
D) The institution's policies and procedures guidelines
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2. When preparing to do a comprehensive health assessment, the nurse obtains the client's
permission based on an understanding of which of the following principles?
A) The client has the right to refuse the assessment.
B) Obtaining permission enhances therapeutic rapport.
C) The client will be more willing to disclose after giving permission.
D) The client's level of comfort will be increased by granting explicit consent.
3. The 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
N
4. A novice nurse is practicing how to complete a comprehensive assessment to gain
confidence and skill. Which of the following would be most important for the nurse to
remember?
A) Always gather objective data before subjective data.
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.
sh
Th
5. When analyzing data related to a client's behavior, the nurse should compare the
observations with which of the following?
A) The client's developmental stage
B) The client's motivation for change
C) The client's body mass index
D) The client's vital signs
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6. When performing a client's head-to-toe assessment, during which part would the nurse
assess the motor function of cranial nerve VII?
A) Mental status examination
B) Head and face assessment
C) Ears assessment
D) Examination of mouth and throat
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7. When documenting a comprehensive assessment, which statement would the nurse
record as the reason for seeking health care?
A) ìI try not to let the pain affect my life.î
B) ìI haven't had a checkup in over 5 years.î
C) ìI had my appendix removed when I was 14 years old.î
D) ìI have an aunt who had breast cancer.î
8. The nurse would test for stereognosis during which part of the comprehensive exam?
A) Posterior and lateral chest
B) Nose and sinuses
C) Arms, hands, and fingers
D) Legs, feet, and toes
N a client's nose and sinuses and is about to examine the
9. A nurse has finished examining
client's mouth and throat. Which of the following would be most important for the nurse
to do?
A) Warm the hands
B) Put on gloves
C) Obtain a tuning fork
D) Collect a saliva specimen
sh
Th
10. When assessing a client's mental status, which of the following would the nurse assess?
Select all that apply.
A) Remote memory
B) Coping skills
C) Speech
D) Abstract reasoning
E) Judgment
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11. The nurse is performing a head-to-toe assessment of a client. Which of the following
would be an example of information obtained during the review of the client's body
systems?
A) Wears dentures; denies problems with eating, chewing, and swallowing.
B) States her father died of a heart attack at age 70.
C) Uses over-the-counter antacid for occasional heartburn.
D) Vaginal delivery of two children without complications.
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12. A nurse is preparing to complete a comprehensive health assessment on a female client.
Prior to beginning the assessment, the client states, ìI'm really having a good deal of
pain in my hip now.î Which of the following would be most appropriate for the nurse to
do?
A) Begin the comprehensive assessment and aim to complete it efficiently.
B) Explain the reason for the client's assessment.
C) Delay the full exam until the client's pain has been addressed.
D) Provide education on pain control.
13. A nurse is performing a head-to-toe assessment and is preparing to examine the client's
ears. Which equipment would the nurse need to have readily available?
A) Ophthalmoscope
B) Tuning fork
N
C) Facial tissues
D) Stethoscope
14. A nurse should assess the client's epitrochlear lymph nodes when assessing which of the
following?
A) Neck
B) Arms
C) Posterior chest
D) Sinuses
sh
Th
15. The nurse will palpate a client's axillae during a head-to-toe assessment. The nurse
should combine this with examination of which area?
A) Neck
B) Anterior chest
C) Heart
D) Breasts
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16. The nurse is palpating the client's tonsillar, submandibular, and submental lymph nodes.
The nurse is most likely examining which area during a comprehensive assessment?
A) Nose and sinuses
B) Abdomen
C) Neck
D) Face
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17. During which part of the comprehensive assessment would the nurse auscultate after
inspecting but before percussing?
A) Abdomen
B) Anterior chest
C) Neck
D) Heart
18. When assessing the client's legs, feet, and toes, which pulses would the nurse expect to
palpate? Select all that apply.
A) Femoral
B) Brachial
C) Temporal
D) Dorsalis pedis
E) Popliteal
N
F) Posterior tibial
19. The nurse is documenting findings of a comprehensive assessment. Which statement
would be categorized as part of the general survey?
A) Hair neat and clean with white and gray streaks; no scalp lesions noted
B) Sclera white; conjunctiva slightly reddened without lesions
C) Client alert and cooperative; sitting comfortably on chair with hands in lap
D) Head symmetrically round; neck nontender with full range of motion
sh
Th
20. A nurse is preparing to complete a comprehensive assessment on a client. When
collecting objective data, which of the following should the nurse do first?
A) Assess the client's vital signs.
B) Take the client's body measurements.
C) Assess the client's mental status.
D) Observe the client's overall appearance.
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21. The 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) Obtain the client's history from the electronic health record and proceed with
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.
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22. The nurse is preparing to gather equipment prior to a client's head-to-toe assessment.
The nurse's selection of equipment should be based primarily on what variable?
A) The nurse's time allowance
B) The nurse's level of expertise
C) The client's health needs
D) The client's level of participation
23. The nurse is performing an abbreviated head-to-toe assessment of a hospital client.
What question should the nurse ask when assessing the client's level of consciousness?
A) ìIf there were a fire in your house, what would you do?î
N your overall level of stress?î
B) ìHow would you describe
C) ìCan you tell me the current month and year?î
D) ìCan you tell me what you ate for breakfast this morning?î
Th
24. The nurse is performing an abbreviated head-to-toe assessment of a client. When the
nurse asks the client about his pain, the client states, ìMy stomach's really killing me
right now.î How should the nurse first respond to this client's statement?
A) Offer analgesia to the client
B) Ask the client to rate his pain on a 0-to-10 scale
C) Assess the client's level of consciousness
D) Assure the client that his pain will be addressed immediately following the
assessment
sh
25. The nurse is completing an abbreviated head-to-toe assessment of a client. Which of the
following should 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.
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26. A client has been recovering from surgery in the hospital, and the nurse is beginning a
shift by conducting an abbreviated head-to-toe assessment. How should the nurse assess
the client's bowel sounds?
A) Auscultate for 2 to 3 minutes in the client's right upper abdominal quadrant.
B) Auscultate for bowel sounds in each of the client's four abdominal quadrants.
C) Auscultate for 5 minutes to confirm the presence of consistent bowel sounds.
D) Auscultate to determine which quadrant contains the most active bowel sounds.
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27. The 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
28. The nurse is using the COLDSPA mnemonic during the client's head-to-toe assessment.
This tool will allow the nurse to address what component of assessment?
A) The client's present health concern
B) The review of the client's body systems
C) The client's personal health history
D) The client's health practices profile
N
29. The nurse is assessing a client's judgment during a comprehensive head-to-toe
assessment. How can the nurse best appraise this aspect of cognitive function?
A) ìWhat would you do if you found a stamped, addressed envelope on the ground?î
B) ìWhat kinds of activities do you do to improve your health?î
C) ìWho is the most important person in your life, and why?î
D) ìWhat is your idea of the ideal vacation?î
sh
Th
30. The nurse should ensure that a Doppler ultrasound is available when performing which
of the following assessments?
A) Respiratory assessment
B) Peripheral vascular assessment
C) Abdominal assessment
D) Musculoskeletal assessment
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Answer Key
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A
A
C
C
A
B
B
C
B
A, C, D, E
A
C
B
B
D
C
A
A, D, E, F
C
D
D
C
C
B
A
B
B
A
A
B
N
sh
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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1. A client at 22 weeks' gestation comes to the clinic complaining of earache and
decreased hearing. Otoscopic examination of the ear is normal. The nurse explains to
the client that her symptoms are pregnancy-induced as a result of what physiologic
change?
A) Thickened, dry cerumen
B) Infection of the inner ear
C) Vascularity of the eardrum
D) Auditory nerve compression
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2. A pregnant client asks the clinic nurse what she can use to relieve her nasal “stuffiness.”
The nurse bases the answer on the most likely cause of the congestion, which is
attributable to which hormone?
A) Estrogen
B) Progesterone
C) Thyroxine
D) Relaxin
3. A client who is at 23 weeks' gestation tells the nurse, “I just burn up all the time. I can't
even sleep with any covers on me!” The nurse explains to the client that heat intolerance
during pregnancy is primarily due to which physiologic change?
A) Increased basal metabolic rate
N
B) Decreased sweat gland activity
C) Increase in maternal blood volume
D) Stretching of abdominal muscles
Th
4. A newly pregnant client says that she has heard that her nipples will leak milk during
the pregnancy. The nurse should tell the client that she should expect to be able to
express colostrum from her nipples beginning at how many weeks' gestation?
A) 6 to 8
B) 12 to 14
C) 24 to 28
D) 34 to 36
sh
5. The nurse is completing a head-to-toe assessment of a pregnant client. What anatomic
area should be examined when assessing the Montgomery tubercles?
A) Thorax
B) Abdomen
C) Breasts
D) Perineum
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6. The pregnant client tells the nurse she has a history of mitral valve stenosis as a sequela
of rheumatic fever. The nurse plans to closely monitor the client based on the
understanding that which physiologic change in pregnancy increases this client's risk for
complications?
A) Physiologic anemia
B) Altered carbohydrate metabolism
C) Increased blood volume
D) Hormonal changes
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7. The nurse assesses the uterine fundus and finds it to be halfway between the symphysis
pubis and the umbilicus. The nurse knows that this is an expected finding at how many
gestational weeks?
A) 6
B) 12
C) 16
D) 20
8. A client at 32 weeks' gestation has been placed on complete bed rest due to premature
labor contractions. The nurse should prioritize assessments for which of the following
complications?
A) Hyperglycemia
B) Urinary tract infection N
C) Thrombophlebitis
D) Leg cramps
Th
9. A client at 34 weeks' gestation is lying on an examination table while the nurse asks
questions. The client says she is feeling dizzy. What intervention by the nurse would be
most appropriate?
A) Measure orthostatic blood pressures.
B) Have her get up and walk around.
C) Provide her with a glass of juice.
D) Turn her on her left side.
sh
10. A client at 26 weeks' gestation appears at the clinic for her first prenatal visit. During the
health interview, she states that she has been a habitual cocaine user. The nurse
understands that this client is at risk for which of the following?
A) Abruptio placenta
B) Thrombophlebitis
C) Placenta previa
D) Gestational diabetes
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11. A woman comes to the clinic for an exam and says that she is considering trying to
become pregnant in the next few months. Which of the following would the nurse
encourage the client to begin taking now?
A) Iron
B) Folic acid
C) Calcium
D) Magnesium
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12. During the first prenatal examination, a woman is found to have inverted nipples. Which
suggestion would be most appropriate if the woman desires to breast-feed her infant?
A) Wear a supportive nursing bra during the pregnancy.
B) Insert breast shields in the bra during the third trimester.
C) Apply a lanolin cream to the nipples twice daily.
D) Rub the nipples frequently with a rough towel.
13. A nurse is attempting to auscultate fetal heart tones after determining that the fetus is in
a longitudinal lie, cephalic presentation, and left occiput anterior position. The nurse
would auscultate them at which area?
A) Left upper quadrant
B) Right upper quadrant
C) Left lower quadrant
D) Right lower quadrant N
14. A client at 32 weeks' gestation, who has had regular prenatal care, is found to have
gained 6 pounds in 1 week. Which of the following would be most appropriate for the
nurse to do next?
A) Ask for 24-hour diet recall.
B) Assess the legs for edema.
C) Collect a urine culture.
D) Check fundal height.
sh
Th
15. The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32
weeks' gestation. Which action would be most appropriate?
A) Refer her for cardiac evaluation.
B) Ask another nurse to assess the heart.
C) Inquire if the client has chest pain.
D) Document this and continue to follow at future visits.
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16. During a prenatal class, a nurse teaches a client how to measure the frequency of
contractions. The client demonstrates understanding with which statement?
A) “I should time from when I feel the contraction to the end of the contraction.”
B) “I'll start timing when I feel one starting until I feel another one starting.”
C) “I should start timing when the contraction is the strongest until it subsides.”
D) “I should time from when one contraction ends and another one starts.”
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17. The nurse is preparing to perform Leopold's maneuvers. During the first maneuver, the
nurse palpates a soft mass in the upper quadrant of the abdomen. The nurse interprets
this as which fetal part?
A) Back
B) Head
C) Buttocks
D) Feet
18. The nurse is measuring the fundal height of a woman who is at 28 weeks' gestation.
Which measurement would the nurse expect?
A) 12 cm
B) 18 cm
C) 28 cm
D) 32 cm
N
19. During a prenatal visit, the nurse inspects the skin of the client's abdomen. Which of the
following would the nurse identify as an abnormal finding?
A) Superficial bruising
B) Linea nigra
C) Striae
D) Darkening of the umbilicus
sh
Th
20. A client comes to the prenatal clinic for a follow-up examination. When assessing the
client's breasts, which of the following should the nurse expect to find? Select all that
apply.
A) Pallor of the areolae
B) Prominent veins
C) Nodular breasts
D) Warmth
E) Increased sensitivity
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21. A client reports that she has been pregnant four times, had two babies born at term, no
preterm births, two spontaneous abortions, and has two living children. The nurse
should document the client's gravida and para status as which of the following?
A) G2 P4202
B) G4 P2022
C) G2 P4044
D) G4 P4220
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22. During the health interview of a client who has just learned that she is pregnant, the
nurse is assessing the client's health history. What assessment question most directly
addresses a known risk for congenital malformations?
A) “Do you ever experience severe premenstrual symptoms?”
B) “Do your menstrual periods tend to be irregular?”
C) “Do you exercise on a regular basis?”
D) “Do you have diabetes?”
23. A client who is in her first trimester states, “I've always been a fairly inactive person,
but I'm determined to start going to exercise classes every day so my baby's as healthy
as possible.” How should the nurse respond to the client's statement?
A) “Usually, your doctor will recommend against starting brand new exercise
programs while you're pregnant.”
B) “Good for you. Regular N
physical activity tends to make labor and delivery go much
smoother.”
C) “That's an excellent idea, and it really reduces your risk of developing high blood
sugar during pregnancy.”
D) “Remember to start low and go slow to avoid putting stress on your baby.”
sh
Th
24. A client has just received a positive pregnancy test and is now discussing health
promotion activities with the nurse. The client states, “I know I'm supposed to start
gaining weight, but how much is healthy?” The nurse should tell the client that she
should aim to gain how much weight during the first trimester?
A) Two to four pounds
B) Six to ten pounds
C) Eight to twelve pounds
D) Five percent of her normal body weight
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25. The nurse is completing the assessment of a client who is 26 weeks pregnant.
Assessment reveals a fundal height of 21 cm. How should the nurse follow up this
assessment finding?
A) Have the client reassessed for gestational diabetes.
B) Obtain a 24-hour food recall.
C) Refer the client due to possible intrauterine growth retardation.
D) Order a repeat ultrasound due to possible multiple gestation.
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26. The nurse is assessing a pregnant client and is performing Leopold's maneuvers. For the
first two maneuvers, the nurse will perform which of the following actions?
A) Palpate the client's midline abdomen and then the region of the symphysis pubis.
B) Palpate the client's abdomen beginning with the left flank and then moving to the
right flank.
C) Palpate the client's floating ribs and then gradually palpate to the level of the
ischial spines.
D) Palpate the client's fundal region and then the lateral sides of the abdomen.
27. The clinic nurse is assessing a client who is pregnant at 18 weeks' gestation. The nurse
is obtaining a fetal heart rate using Doppler ultrasound. What fetal heart rate represents
an expected finding?
A) 90 beats per minute
B) 130 beats per minute N
C) 175 beats per minute
D) 225 beats per minute
28. The nurse is palpating a pregnant client's left and right adnexa. The presence of a
palpable mass should prompt the nurse to refer the client promptly for what problem?
A) Abruptio placentae
B) Placenta previa
C) Ectopic pregnancy
D) Incompetent cervix
sh
Th
29. The nurse is measuring a pregnant client's fundal height during a scheduled prenatal
visit. The nurse should measure with reference to what anatomical landmarks?
A) The edge of the fundus and the umbilicus
B) The symphysis pubis and the fundus
C) The fundus and the abdomen
D) The xiphoid process and the symphysis pubis
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30. The nurse is inspecting a pregnant client's cervix during a prenatal clinic visit. What is
an expected assessment finding?
A) Smooth cervix with a bluish tint
B) Slightly rough cervix with dark pink coloration
C) Pink or red cervix with small, visible nodes
D) Smooth cervix with small amounts of creamy white discharge
sh
Th
N
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Answer Key
N
sh
Th
!
C
A
A
C
C
C
C
C
D
A
B
B
C
B
D
B
C
C
A
B, C, E
B
D
A
A
C
D
B
C
B
A
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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1. When assessing a newborn, the nurse observes that the infant's hands and feet are bluish
in color. The nurse interprets this finding as being suggestive of which of the following?
A) Cardiopulmonary dysfunction
B) Peripheral vascular disease
C) Acidñbase imbalance
D) Ineffective temperature regulation
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2. A new mother asks the nurse, ìWhat are those small white spots on my baby's nose?î
Which response by the nurse would be most appropriate?
A) ìThose are small glands that look like whiteheads but will disappear soon.î
B) ìThose white spots are lesions containing pus and are caused by a minor skin
infection.î
C) ìNewborns retain sweat, which causes those white bumps on their skin.î
D) ìOften newborns have a rash of this type, which fades in a few days.î
3. The nurse completes the initial newborn assessment and notes the presence of fine,
downy hair on the infant's shoulders and back. The nurse documents the presence of
which of the following?
A) Vernix
B) Milia
C) Lanugo
N
D) Nevi
4. The nurse is assessing the anterior fontanelle of a 4-month-old infant brought to the
clinic for a well-child exam. Which of the following would the nurse expect to assess?
A) Sunken fontanelles
B) Closed fontanelles
C) Bulging fontanelles
D) Flat fontanelles
sh
Th
5. The nurse is performing an otoscopic examination of an infant's ears. Which of the
following actions should the nurse do?
A) Pull the pinna forward and down.
B) Pull the pinna up and back.
C) Pull the pinna straight back.
D) Pull the pinna down and back.
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6. A nurse assesses the pulses of an infant and notes that the femoral pulses are weak.
Which of the following health problems should the nurse suspect?
A) Right ventricular enlargement
B) Sinus arrhythmia
C) Coarctation of the aorta
D) Patent ductus arteriosus
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7. Which action would be most appropriate when a nurse assesses the umbilical cord of a
4-day-old infant and finds it to be dried and black?
A) Notify the newborn's physician.
B) Apply warm compresses.
C) Apply an antibiotic ointment.
D) Recognize this as normal.
8. A parent of an ill infant states, ìWe've gave him ibuprofen for a fever, and he had an
allergic reaction.î Which response would be most appropriate?
A) ìIs he allergic to any other drugs?î
B) ìI will write that on his chart so he won't be given any.î
C) ìHow often has he received ibuprofen?î
D) ìDescribe what happens to him when he takes ibuprofen.î
N
9. Which child should the pediatric nurse suspect of having a developmental delay?
A) A 5-month-old who does not sit unsupported
B) An 11-month-old who does not pull himself to a standing position
C) A 3-month-old who cannot grasp an object voluntarily
D) A 12-month-old who cannot build a tower of eight blocks
sh
Th
10. A nurse is presenting a class for new parents about infant care. To decrease the risk of
sudden infant death syndrome, the nurse should encourage parents to place their
sleeping infants in what position?
A) Prone
B) Supine
C) High Fowler's
D) Low Fowler's
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11. The nurse assesses the respirations of a 2-week-old infant and identifies periods of
apnea lasting longer than 20 seconds. What should the nurse do next?
A) Assess the apical heart rate.
B) Percuss the lungs for consolidation.
C) Auscultate the lungs for adventitious sounds.
D) Inspect the shape of the thorax.
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12. The nurse is assessing the skin of a 12-hour-old infant. Which assessment finding would
be cause for concern?
A) Milia
B) Jaundice
C) Erythema toxicum
D) Mongolian spot
13. The nurse is preparing to measure the head circumference of a newborn. In a healthy
newborn, the nurse should expect the circumference of the infant's head to be within
what range?
A) 33 to 35.5 cm
B) 35 to 37.5 cm
C) 37 to 39.5 cm
D) 39 to 41.5 cm
N
14. A nurse is reviewing an infant's Apgar score. Which of the following areas was assessed
during the calculation of the score?
A) Temperature
B) Reflex irritability
C) Head circumference
D) Weight
sh
Th
15. The nurse is preparing to measure the chest circumference of a 2-day-old newborn. The
nurse would place the tape measure at which area?
A) High up under the axillary area
B) At the level of the umbilicus
C) At the level of the nipple line
D) Midway between the nipple line and umbilicus
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16. The nurse is assessing a newborn's neuromuscular maturity in light of the infant's known
gestational age. Which of the following would the nurse expect to find if the newborn
was premature?
A) Flexed arms and legs
B) Elbow position less than midline
C) Heel distant from ear
D) Delayed arm recoil
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17. The nurse is assessing a newborn's rooting reflex. What action should the nurse perform
during this assessment?
A) Touch the infant's lip or cheek with a gloved finger.
B) Place a gloved finger in the newborn's mouth.
C) Touch the ball of the newborn's foot.
D) Hit the surface near where the newborn is lying.
18. A nurse is assessing a 9-month-old infant. Which reflexes would the nurse expect to
assess? Select all that apply.
A) Rooting
B) Sucking
C) Tonic neck
D) Moro
N
E) Palmar grasp
F) Babinski
19. When the nurse palpates the neck of an infant, he notes the presence of crepitus at the
right shoulder area. The infant also exhibits decreased movement in the right arm.
Which of the following should the nurse suspect?
A) Osteomyelitis
B) Down syndrome
C) Fractured humerus
D) Fractured clavicle
sh
Th
20. While assessing an infant's abdomen, which finding would the nurse interpret as
necessitating immediate evaluation and treatment?
A) Palpable mass
B) Tenderness
C) Rigidity
D) Gurgling sounds
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21. A clinic nurse is assessing a 6-month-old infant prior to the administration of scheduled
immunizations. The nurse should anticipate that the infant's resting heart rate will be
nearest to what value?
A) 80 beats per minute
B) 100 beats per minute
C) 120 beats per minute
D) 140 beats per minute
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22. The nurse is assessing a 2-day-old infant prior to discharge home from the hospital with
his mother. When assessing the infant's eyes, what finding would the nurse consider to
be abnormal?
A) The infant is unable to follow a moving object or light.
B) The infant's periorbital area is slightly edematous.
C) The infant's pupils react to light.
D) The infant's sclerae have a yellowish tint.
23. The nurse is assessing a newborn infant who currently has nasal congestion and
rhinorrhea (runny nose). When analyzing these data, the nurse should consider which of
the following?
A) Nasal congestion in an infant is indicative of infection.
B) Nasal mucus in infants should be treated with an inhaled vasoconstrictor.
N oxygenation because infants are nose breathers.
C) Nasal congestion can impair
D) Nasal congestion in infants is an expected finding for the first 6 weeks of life.
Th
24. A new mother rings her call bell after giving birth to a healthy infant 18 hours earlier.
The client states that her infant ìlooks like she has milk coming out of her nipples.î How
should the nurse best interpret this phenomenon?
A) The infant is showing signs of postnatal mastitis.
B) This is a normal finding that results from hormonal stimulation.
C) This is an expected finding in female infants but an unexpected finding in male
infants.
D) The nurse should plan to manually express the liquid from the infant's breasts.
sh
25. During the assessments of infants' genitalia, what finding most clearly warrants referral
for further assessment?
A) A newborn male has an undescended testicle.
B) A newborn female has bloody vaginal discharge.
C) A newborn female has engorged labia.
D) A newborn male has intact foreskin.
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26. The nurse is completing a head-to-toe assessment of a newborn infant. How should the
nurse determine if the infant's anus is patent?
A) Spread the infant's buttocks to facilitate inspection.
B) Observe for the passage of meconium.
C) Insert a gloved finger 0.5 to 1 cm into the rectum.
D) Auscultate for bowel sounds to all four abdominal quadrants.
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27. The nurse is performing Ortolani's maneuver to test for congenital hip dysplasia in a
newborn infant. What finding would suggest the presence of hip dysplasia?
A) The infant expresses no signs of pain or discomfort during manipulation of the hip.
B) The nurse is unable to perform passive range of motion of the infant's hip joint.
C) The nurse hears a click from the site of the infant's hip joint.
D) The nurse is unable to bring the infant's knees into alignment.
28. The nurse's assessment of an infant reveals a positive Barlow's sign. What collaborative
problem should the nurse consequently identify?
A) RC: Failure to thrive
B) RC: Jaundice
C) RC: Patent ductus arteriosus
D) RC: Hip displacement
N
29. The nurse is auscultating the bowels of an infant who was born 10 hours ago. What
principle should guide the nurse's assessment and data analysis?
A) Bowel sounds are not normally audible until 48 to 72 hours postpartum.
B) Bowel sounds are not normally audible until 24 to 48 hours postpartum.
C) Bowel sounds should be audible every 10 to 30 seconds.
D) Bowel sounds should be absent at rest and audible after palpation.
sh
Th
30. In preparation for discharge, the nurse is assessing a newborn infant's hearing acuity.
How should the nurse best perform this assessment?
A) Determine whether the infant turns his or her head toward verbal stimuli.
B) Determine whether the infant makes eye contact in response to a loud voice.
C) Determine whether a loud noise near the infant evokes a startle response.
D) Determine whether the infant appears to recognize the mother's voice.
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D
A
C
D
D
C
D
D
B
B
A
B
A
B
C
D
A
B, F
D
C
C
D
C
B
A
B
C
D
C
C
N
sh
Th
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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Answer Key
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1. A preadolescent girl comes to the clinic for a sports physical exam. The nurse notes
beginning breast development and documents which of the following?
A) Gynecomastia
B) Thelarche
C) Menarche
D) Adolescence
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2. When assessing adolescent girls, the nurse should know that which of the following
usually appears first?
A) Pubic hair
B) Breast buds
C) Axillary hair
D) Menses onset
3. When describing cultural differences related to tooth eruption, the nurse explains that
permanent teeth typically appear earlier in which group?
A) Caucasians
B) Hispanics
C) African Americans
D) Native Americans
N
4. Which finding would require further evaluation or referral when auscultating heart
sounds on an 8-year-old client during a routine physical exam?
A) Audible S3
B) Soft systolic murmur
C) Sinus arrhythmia
D) Pulse rate 120 beats per minute
sh
Th
5. During palpation of a young child's abdomen, the nurse assesses the liver. Which of the
following would the nurse expect to find?
A) The liver can be palpated 4 cm below the right costal margin.
B) The liver is not palpable.
C) The liver is found at the left costal margin.
D) The liver is located 2 cm below the right costal margin.
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6. The nurse has identified a need to discuss sexuality with a 15-year-old client. How
should the nurse best plan this aspect of the health interview?
A) Obtain informed consent for the health interview.
B) Begin by explaining appropriate and acceptable sexual behavior.
C) Discuss the matter when a parent is not present.
D) Ensure that a chaperone is in the room during the interview.
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7. A 4-year-old boy is brought to the emergency department by his parents, who state that
he has been crying and saying his ìtummy hurts.î Which method would be most
appropriate for the nurse to initially assess the problem?
A) Ask the child to point with one finger where it hurts.
B) Inspect, palpate, percuss, and then auscultate the abdomen.
C) Determine the time and character of the child's last bowel movement.
D) Ask the child to describe the character of his pain.
8. A nurse is conducting a workshop with a group of adults who are enrolled in a parenting
class. Which of the following would the nurse emphasize as important in helping the
school-age child achieve the psychosocial task of industry and avoid inferiority?
A) Allow independence
B) Encourage competition
C) Increase socialization
N
D) Acknowledge accomplishments
9. A school nurse plans to test hearing acuity in students who range between kindergarten
and sixth grade. Which of the following would be most appropriate method?
A) Loud noise screening
B) Audiometry
C) Whisper test
D) Weber test
sh
Th
10. Which technique should the nurse use to perform scoliosis screening in a school-age
child?
A) Have the child bend forward at the waist.
B) Measure the length of each of the child's legs.
C) Measure the distance between the child's knees and ankles.
D) Ask the child to walk across the room.
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11. During the health history, a nurse asks a mother to describe the play activities of her
school-age son. The mother reports activities that are typical for this age group. The
nurse would document this as which type of play?
A) Imitative
B) Associative
C) Parallel
D) Competitive
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12. A mother voices concern about the amount of time her school-age child sleeps. When
responding to the mother, the nurse understands that this age group sleeps an average of
how many hours each night?
A) 11 to 12
B) 9 to 10
C) 8 to 9.5
D) 7 to 8
13. The nurse is teaching a group of parents of children of various ages how to best measure
a child's temperature. The nurse instructs the parents that rectal temperature
measurement is indicated in which situation?
A) During the newborn period
B) When a child is dehydrated
N
C) When no other route is feasible
D) When rapid temperature changes occur
14. During a well-child visit, a parent asks the nurse the best way to manage negativism in
her toddler. Which suggestions by the nurse would be most appropriate?
A) Implement punishment appropriate for the child's age.
B) Spend more quality time with the child.
C) Repeatedly tell the child not to always say ìno.î
D) Reduce the opportunities for a ìnoî answer.
sh
Th
15. When the nurse palpates the abdomen of a preschool boy, he begins to giggle and draw
his legs up onto his abdomen. Which of the following would be most appropriate for the
nurse to do?
A) Omit the entire abdominal exam.
B) Palpate with the child's hand under the nurse's hand.
C) Ask the parent to discipline the child.
D) Explain the purpose of the exam to the child.
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16. The nurse is participating in a vision-screening program for children age 3 to 10 years.
The nurse would expect a child to have 20/20 vision at what age?
A) 3 to 4
B) 4 to 5
C) 5 to 6
D) 6 to 7
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17. The nurse assesses the respiratory rate of a 5-year-old boy. Which finding would
indicate to the nurse that his rate is within the age-appropriate range for this child?
A) 16 breaths/minute
B) 24 breaths/minute
C) 32 breaths/minute
D) 40 breaths/minute
18. A nurse is providing an in-service presentation to a group of new pediatric nurses and
reviewing differences in assessment of children and adults. When describing the heart
sound typically auscultated in children in comparison to an adult, which characteristic
would the nurse describe?
A) Children typically have softer heart sounds.
B) Children typically have less harsh heart sounds.
C) Children typically have higher pitched heart sounds.
N sounds of longer duration.
D) Children typically have heart
Th
19. A nurse has completed an assessment of a school-age child. The nurse has identified
several ìsoft signsî of potential neurologic impairment. How should the nurse best
interpret these findings?
A) Recognize that the findings are related to developmental tasks rather than
neurologic pathology
B) Recognize the need for an emergency neurological assessment
C) Recognize that the findings may or may not indicate the presence of a neurologic
problem
D) Recognize that the findings need to be interpreting in light of the child's education
level
sh
20. After inspecting an adolescent male's genitalia, the nurse documents the findings as
Tanner stage 3. Which of the following findings would be most likely?
A) Scrotum and testes slightly enlarged; sparse, long, downy pubic hair
B) Penis elongated; pubic hair sparse over pubis, coarse and curly
C) Penis increased in width; abundant pubic hair not extending to thighs
D) Penis of adult size; dark curly abundant pubic hair to thighs
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21. The pediatric nurse is obtaining the nursing history of a 4-year-old girl who is
accompanied by her mother. What question should the nurse pose to the child's mother?
A) ìIs your daughter able to pick out her name from a page of writing?î
B) ìDo you think your daughter can see others' points of view?î
C) ìDoes your daughter often ask 'why'?î
D) ìDoes your daughter like to collect things?î
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22. The nurse has assessed the head circumference (HC) of an 18-month-old during a
regular checkup. The nurse should compare the percentile of the child's HC to which of
the following?
A) The child's body mass index
B) The child's height and weight percentiles
C) The child's chest circumference percentile
D) The child's developmental stage
23. The nurse's assessment of a child's hair reveals that it is clean and neatly trimmed but
exceptionally dry and brittle. What is the nurse's best response to this finding?
A) Assess the child for signs and symptoms of impaired nutrition.
B) Assess the child for indications of abuse or neglect.
C) Facilitate a referral to a dermatologist.
D) Encourage the child's mother to ensure that the child gets adequate exposure to
N
sunlight.
24. The nurse's inspection of a young child's anus reveals the presence of hemorrhoids. How
should the nurse best interpret this assessment finding?
A) Hemorrhoids are unusual in children and warrant further assessment.
B) Hemorrhoids are a common indication of deficient fluid intake in children.
C) Hemorrhoids are common in children until they attain bowel continence.
D) Hemorrhoids in a child younger than 10 are suggestive of colorectal cancer.
sh
Th
25. The nurse inspects a 10-day-old infant's umbilicus and notes that it is reddened with the
presence of slight discharge. What nursing diagnosis is suggested by these data?
A) Risk for contamination
B) Ineffective peripheral tissue perfusion
C) Infection
D) Risk for injury
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26. The nurse is assessing a 6-year-old child. While auscultating the child's apical heart rate,
the nurse notes that the child's heart rate increases during inspiration. What is the nurse's
most appropriate action?
A) Arrange for a STAT electrocardiogram.
B) Document this as an expected assessment finding.
C) Facilitate a referral for medical assessment.
D) Reposition the child and then reassess.
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27. The school nurse is assessing a 15-year-old client. The nurse should understand that this
child's current priorities will most likely reflect what developmental task?
A) Exerting influence
B) Learning new information
C) Becoming productive
D) Developing a personal identity
28. The nurse is meeting the parents of an ill child for the first time and is preparing to
perform the health interview. In addition to gathering health data, what additional goal
should the nurse prioritize during this interaction?
A) Gauge the parents' own levels of health.
B) Emphasize the importance of adherence to treatment.
C) Identify the family's socioeconomic status.
N parents.
D) Foster trust with the child's
29. The nurse is experiencing challenges in eliciting information during the health interview
of a 4-year-old boy. How can the nurse best foster communication with the child?
A) Set a time limit for completing the interview.
B) Ask the child to talk about himself in the third person.
C) Explain the purpose of the interview in simple terms.
D) Engage the child in play.
sh
Th
30. A nurse is having difficulty getting a 14-year-old child to ìopen upî during the health
interview. What strategy is most likely to enhance the nurse's communication with this
child?
A) Give the child some control over the course and content of the interview.
B) Teach the child about the negative consequences of an inadequate interview.
C) Arrange for one of the child's parents to speak with him or her privately.
D) Promise the child a reward for participating in the interview.
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B
B
C
D
D
C
A
D
B
A
D
C
C
D
B
D
B
C
C
B
C
B
A
A
C
B
D
D
D
A
N
sh
Th
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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Answer Key
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1. The nurse is conducting a functional assessment of an older adult client. The nurse
should focus questions on which area?
A) Feelings about aging
B) Quality of life
C) Recent personal losses
D) Activities of daily living
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2. A nurse assesses the skin of an older adult's forearms and observes purpura. The nurse
interprets this finding as indicative of which of the following?
A) Elder abuse
B) Vascular fragility
C) Poor circulation
D) Herpes zoster
3. When 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
N
4. When examining the eyes of an elderly client, the nurse observes a brownish
discoloration of the lens. The nurse interprets this finding as being suggestive of what
health problem?
A) Conjunctivitis
B) Presbyopia
C) Glaucoma
D) Cataracts
sh
Th
5. During 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, which of the following 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
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6. A nurse is preparing a health education 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 cite as a common cause of infection-related deaths in the
elderly?
A) Pyelonephritis
B) Cellulitis
C) Pneumonia
D) Meningitis
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7. When auscultating the heart of an elderly client, the nurse detects a soft systolic murmur
at the base of the heart. The nurse understands that this is most likely the result of which
of the following?
A) Calcification of the aortic and mitral valves
B) Accumulation of amyloid in the pacemaker cells
C) Enlargement of the heart muscle
D) Regurgitation through a stenotic valve
8. 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 of the following age-related changes?
A) Decreased ventricular compliance
N
B) Peripheral vascular disease
C) Widening pulse pressure
D) Collagen deposits around pacemaker cells
9. A nurse assesses a client's blood pressure and the findings suggest orthostatic
hypotension. Which area should the nurse emphasize during client education?
A) Daily exercise routine
B) Prevention of falls
C) Diet high in iron
D) Vitamin supplementation
sh
Th
10. The children of an elderly client tell the nurse, ìHe has lost his appetite. He eats very
small amounts, and only twice a day.î 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.
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11. The nurse is assessing an elderly client who is receiving tube feedings via a nasogastric
tube. The nurse should assess the client for signs and symptoms of which of the
following?
A) Gingivitis
B) Sinusitis
C) Epiglottitis
D) Cellulitis
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12. The advanced practice nurse is preparing to perform a pelvic examination on an elderly
female client. Which of the following would the nurse expect to find?
A) Elongation of the vagina
B) Thick, pale epithelium
C) Decreased vaginal secretions
D) Palpable ovaries
13. When assessing an elderly client's hip joint after a fall, which of the following 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) Thigh pain
N
14. After teaching a group of students about geriatric syndromes, the instructor determines
that the teaching was successful when the students identify which of the following as an
example?
A) Confusion
B) Pneumonia
C) Heart failure
D) Renal failure
sh
Th
15. A nurse has assessed an elderly client and is preparing to analyze the assessment data.
Which of the following would the nurse need in order to accurately perform data
comparison?
A) Client's major complaints
B) Client's usual daily patterns
C) Client's adherence to treatment
D) Client's underlying pathology
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16. A home care nurse is assessing an older adult's functional status. The nurse should
identify which of the following as an instrumental activity of daily living?
A) Bathing
B) Cooking
C) Toileting
D) Eating
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17. A nurse is interviewing an elderly client and begins the interview by evaluating the
client's mental status. The nurse does this based on an understanding of which of the
following?
A) The aging brain is more easily affected by pathology.
B) Older clients have decreased intellectual capacity.
C) The brain is the last organ to experience an age-related decline.
D) The client is always the most reliable person to provide the data.
18. An elderly client's history reveals the use of antihistamines. When inspecting the client's
mouth, which of the following would the nurse expect to find?
A) Resorption of the gum ridge
B) Swollen, red tongue
C) Decreased saliva production
D) Pocketing of food
N
19. An elderly client with a history of sinusitis has been taking antibiotics for this condition.
The nurse should assess for what potential adverse effect of treatment?
A) Exacerbation of cardiac dysrhythmias
B) Candidal infection
C) Overdrying of nasal passages
D) Exacerbation of hypertension
sh
Th
20. The nurse has assessed the thorax and lungs of an elderly client, as well as reviewing the
results of lung function testing. Which of the following findings should the nurse
attribute to possible pathology rather than expected, age-related changes?
A) Respiratory rate of 30 breaths per minute
B) Decreased vital capacity
C) Increased residual volume
D) Presence of a slight barrel chest
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21. The nurse is interviewing an 82-year-old client who is accompanied by her daughter.
The daughter states that her mother is ìunable to hold her urine,î and the client attests
that this is true. What question should the nurse prioritize when assessing the client's
urinary incontinence?
A) ìDid you deliver your children vaginally or by cesarean section?î
B) ìHave you been prone to urinary tract infections in the past?î
C) ìIs this something that has begun to happen just recently?î
D) ìHave you noticed any change in your bowel function?î
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22. An 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.
23. The 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.
N
A) Sleep disturbances
B) Infection
C) Poor nutrition
D) Falls
E) Pain
Th
24. A 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) ìWho generally prepares your meals and snacks?î
B) ìDo you require any assistance when showering or bathing?î
C) ìDo you feel like you have enough support from your family?î
D) ìAre you able to shop for your own groceries?î
sh
25. The nurse is assessing an older adult client's vaccination history. This aspect of the
client's history will have a significant bearing on her risk for what health problem?
A) Pneumonia
B) Urinary tract infections
C) Cellulitis
D) Tuberculosis
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26. An 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.
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27. An older adult client has received a diagnosis of stress incontinence, and the nurse is
planning the client's subsequent care. What health education is most relevant to this
client's needs?
A) Pelvic floor strength training and activity management
B) Appropriate use of incontinence pads and dietary modifications
C) Management of fluid and electrolyte intake
D) Aseptic technique for intermittent catheterization and fluid restriction
28. The nurse is reviewing an older adult's recent laboratory values prior to performing a
physical assessment. What value would most clearly indicate the need for further
nutritional assessment?
A) Hemoglobin 12.2 g/dL
B) Hematocrit 40%
C) Serum albumin 3.9 g/dLN
D) Vitamin B12 91 µg/ml
29. An older adult client has come to the clinic with new complaints of fatigue,
constipation, and cold intolerance. This client may benefit from referral for which of the
following purposes?
A) Liver function testing
B) Cognitive testing
C) Lung function testing
D) Assessment of thyroid function
sh
Th
30. An 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.
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Answer Key
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D
B
B
D
C
C
A
D
B
C
B
C
D
A
B
B
A
C
B
A
C
B
A, C, D
B
A
C
A
D
D
B
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
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1. A nurse is preparing to assess a family. The nurse best adopts the view of the family unit
as being a system by using which approach?
A) Focusing on each individual member's health problems
B) Identifying strengths and problem areas within the family structure
C) Educating the sick client about methods to maintain independence
D) Fostering emotional support for each family member
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2. When doing a family assessment, what components are most essential for the nurse to
include?
A) Structure, development, and function
B) Development, boundaries, and culture
C) Communication, expectations, and strengths
D) Socialization, development, and problems
3. A nurse is attempting to view a whole family as a unit to obtain a view of the family
composition. How can the nurse best achieve this goal?
A) Compile a list of family members.
B) Construct a family genogram.
C) Determine the internal power structure.
D) Identify communication patterns.
N
4. After creating a family genogram, the nurse evaluates it, usually prioritizing which of
the following components?
A) Psychosocial interaction problems between family members
B) Communication patterns between generations
C) Power structure within the family configuration
D) Health-illness patterns through the generations
sh
Th
5. When assessing a family that is known to be highly functional, the nurse would most
likely find which type of boundaries?
A) Clearly defined
B) Diffuse
C) Rigid
D) Hierarchical
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6. A nurse is creating a family attachment diagram. The nurse is assessing which area of
family structure and function?
A) Composition
B) Interaction patterns
C) Power structure
D) Socialization
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7. The nurse wants to assess a family's interactions with the systems outside of the family.
Which tool would be most appropriate to use?
A) Genogram
B) Family attachment diagram
C) Ecomap
D) Calgary Family Assessment Model
8. A nurse is planning to assess the instrumental functioning of a family. The nurse
develops questions to focus on which of the following?
A) Intimacy needs
B) Communication patterns
C) Beliefs about health
D) Activities of daily living
N
9. After teaching a group of students about systems theory and family, the instructor
determines that the teaching was successful when the students state which of the
following as a major principle of the systems theory?
A) Parts are independent of one another.
B) Each system has the same characteristics.
C) The whole is greater than the sum of the parts.
D) Information is isolated within each part the system.
sh
Th
10. When describing circular communication to a group of students, which of the following
would the instructor explain as the basis for the circular communication feedback loop?
A) Perceptions and reactions
B) Symmetry and complementarily
C) Content and relationships
D) Listening and observation
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11. A family has just admitted their grandmother to a long-term care facility after caring for
her in the home for several years. Which statement by the nurse would best demonstrate
purposeful therapeutic conversation?
A) ìIf possible, it would be best to visit her every day.î
B) ìTell me about her morning routine at home.î
C) ìHow do you plan to finance her medications?î
D) ìHow independent is she with dressing and bathing?î
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12. During a family assessment, the nurse closely observes family interactions for which
main reason?
A) To determine if members support and nurture one another
B) To analyze each family member's response to stress
C) To provide feedback on the family's communication problems
D) To determine the transmission of beliefs and values
13. After assessing a family, the nurse determines that the family has permeable boundaries.
The nurse interprets this as leading to what outcome?
A) Restricting self-differentiation
B) Encouraging emotional development
C) Discouraging family cohesiveness
D) Inhibiting emotional communication
N
14. When counseling a family regarding verbal communication patterns, the nurse should
encourage which type of messages to foster open communication?
A) Metaphorical
B) Displaced
C) Clear
D) Obtainable
sh
Th
15. After teaching a group of students about families and family assessment, the instructor
determines that the teaching was successful when the students describe family as which
of the following?
A) Two individuals who are related by marriage
B) Whoever the family says they are
C) Two or more individuals residing together
D) Individuals connected by time and blood
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16. When assessing a family's structure, the nurse should gather information about which of
the following? Select all that apply.
A) Gender roles
B) Rank order
C) Religion
D) Stage of growth
E) Beliefs about an illness
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17. A nurse is constructing a genogram of a family. Assessment reveals that the maternal
grandmother died at age 69. The nurse would depict this person on the genogram using
which symbol?
A) Triangle with a line through it
B) Square with a line surrounding it
C) Circle with an ìxî through it
D) Connecting line with two small lines through it
18. An instructor is describing the stages of family growth and development using a twoparent nuclear family as an example. Which tasks would the instructor include as the
likely priority for the childbearing family?
A) Establishing a mutually satisfying marriage
B) Expanding relationships with extended family
N the kin network
C) Relating harmoniously to
D) Socializing the children
19. While interviewing a family, the nurse questions the family about external systems. The
nurse would collect information about which of the following?
A) Patterns of affection
B) Shared activities
C) Decision-making patterns
D) Recreational organizations
sh
Th
20. While interviewing a family, the mother says that she does the cooking and takes the
children to and from school and to their after-school activities during the week. The
father reports that he drives the children to their activities and does the cooking on the
weekends. The nurse interprets this information as reflecting which family function?
A) Instrumental
B) Affective
C) Expressive
D) Health care
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21. A workplace injury has caused a man to be on long-term disability compensation. His
wife has returned to paid employment after many years absence in order to ìmake ends
meet.î The clients both agree that this family transition has been challenging, with the
wife stating, ìHe says that he feels he's unproductive, even though there's nothing that
can be done about it.î What nursing diagnosis may possibly apply to the husband?
A) Ineffective role performance related to loss of employment
B) Impaired Home Maintenance related to loss of employment
C) Caregiver role strain related to injury
D) Risk for Impaired Parenting related to family changes
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22. A nurse is completing a detailed assessment of a family who is receiving care. When
assessing the context of the family, the nurse should include what assessment questions?
Select all that apply.
A) ìAre there any ways that you think your family could be happier?î
B) ìHow would you describe your family's ethnicity?î
C) ìWould you characterize your family as being religious?î
D) ìWhen were each of you born?î
E) ìHow do you interact within the neighborhood around you?î
23. The nurse is assessing a family's function within the domain of health care. What
assessment question best addresses this area of function?
N best improve your health?î
A) ìWhat do you think would
B) ìWho is your regular family doctor?î
C) ìIs anyone in your family a health professional?î
D) ìWhen was your father first diagnosed with heart disease?î
Th
24. The nurse is integrating the principles of Bowen Family System theory during
interactions with a family. What principle underlies this theory?
A) The role of younger family members supersedes that of older members.
B) Every family is equally functional, although in different ways.
C) Family identity is inseparable from ethnicity.
D) Patterns of relating tend to repeat over generations.
sh
25. The nurse has completed the assessment of a family. What phenomenon would the nurse
identify as a triangle?
A) The youngest child in the family has been estranged from his siblings for many
years.
B) The father was married and divorced as a young adult, before remarrying.
C) Two sisters have been in conflict and each attempts to elicit support from their
mother.
D) There is a total of three children in the family.
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26. A nurse is consciously implementing the principles of therapeutic conversation during
interactions with a family. Which of the following should characterize the nurse's
communication?
A) The nurse should improve the family's structure and function.
B) The nurse's statements should be purposeful.
C) The nurse should gather as much information as possible.
D) The nurse should be motivated by a need to educate.
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27. A nurse is beginning a scheduled follow-up meeting with a family by providing a
commendation. What is the best example of a commendation?
A) ìEveryone in your family is kind and considerate.î
B) ìYour family shows great strength by caring for your grandmother in her own
home.î
C) ìYour family is much more compassionate than most of the families with which I
have contact.î
D) ìYour family definitely chose the best plan to improve your grandmother's health
outcomes.î
28. The data obtained during a nurse's family assessment suggest that the mother in the
family is enmeshed with the youngest son, who is a middle-aged adult. The nurse should
recognize what implication ofNthis fact?
A) The son and the mother have the highest priority relationship in the family.
B) The son is inferior to the mother.
C) The son and mother cannot form relationships with others.
D) The son and the mother cannot self-differentiate.
Th
29. The nurse's assessment reveals that a family possesses a high level of affective
functioning. What observation would most likely lead the nurse to this conclusion?
A) Family members appear to be close to each other and considerate of each other.
B) Family members communicate frequently and clearly.
C) Family members agree that conflict is unacceptable.
D) Family communication is characterized by direct statements.
sh
30. The nurse is assessing a client's differentiation of self within the context of a broader
family assessment. When assessing the client's differentiation of self, the nurse must
determine which of the following?
A) The client's rank order and communication style
B) The client's emotional function and intellectual function
C) The client's self-esteem and family responsibilities
D) The client's strengths and weaknesses
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Th
N
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Answer Key
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B
A
B
D
A
B
C
D
C
A
B
A
B
C
B
A, B, C
C
B
D
A
A
B, C, E
A
D
C
B
B
D
A
B
N
sh
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1. The nurse is planning a community assessment using the Community as a Partner
model. The nurse understands that the key to this model is which of the following?
A) People of the community
B) History of the community
C) Demographics of the community
D) Health of the community
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2. Which of the following would be the best way for the nurse to implement the process of
"participant observation" when conducting a community assessment?
A) Interview the key leaders of the community.
B) Review the census data and health records.
C) Participate in the daily life of the community.
D) Conduct a survey of the health problems.
3. The nurse is planning to assess a community. Which of the following would be most
appropriate for the nurse to do when collecting objective data about a community?
A) Interview the residents
B) Talk to key leaders
C) Observe lifestyles
D) Analyze census data
4. After assessing the health care needs of a Native American community, what health care
problem would most likely need addressing?
A) Cardiovascular
B) Tuberculosis
C) Diabetes mellitus
D) Hypertension
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5. Which of the following would be most important to plan and implement when a nurse
notes a higher-than-expected teen birth rate in a particular community?
A) Childbirth education classes
B) Infant care education
C) Parenting education classes
D) Family planning education
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6. When assessing a community, the nurse is reviewing statistics related to adult mortality
in clients who are 65 years of age and older. The nurse would assess the community for
health programs to address which of the following as the major cause of death in this
age group?
A) Unintentional injuries
B) Chronic lower respiratory diseases
C) Heart disease
D) Diabetes
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7. A nurse is assessing a community to determine if it can provide appropriate services
related to the fastest-growing aspect of the health care system? Which area is the nurse
evaluating?
A) Emergency services
B) Ambulatory clinics
C) Health departments
D) Home health care
8. The nurse is assessing the economic stability of a community. Which assessment would
the nurse do first?
A) Mortality statistics
B) Hospital facilities
C) Tax base
D) Neighborhoods
9. A nurse is assessing a community's environmental protection. The nurse would focus on
which of the following?
A) Drug Abuse Resistance Education program
B) Neighborhood Watch programs
C) Sewage treatment facilities
D) Domestic violence shelters
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10. When assessing a rural community, the nurse would most likely identify which of the
following as a major factor hindering access to health care?
A) Social service agencies
B) Police protection
C) Low -income housing
D) Public transportation
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11. The nurse appears before a community governance committee and encourages them to
respond to the views of the citizens to prevent which likely reaction?
A) Apathetic response
B) Hostile response
C) Reactive response
D) Proactive response
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12. A nurse is planning a health fair for a local community. When advertising about this fair,
which method would be most appropriate for the nurse to use as an open channel of
communication?
A) Newsletter
B) Fliers
C) Bulletin boards
D) Television
13. A nurse is planning a program to address measures to reduce the leading cause of
mortality in children age 1 to 14 years. Which of the following would the nurse include?
A) Gun control
B) Prenatal care
C) Accident prevention
D) Substance abuse
14. A nurse determines that a community lacks adequate recreational activities and
facilities. Which nursing diagnosis would the nurse most likely identify?
A) Ineffective health maintenance
B) Risk for other-directed violence
C) Risk for social isolation
D) Ineffective community coping
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15. A group of students is reviewing information about community assessment and the
physical environment of the community. The students demonstrate a need for additional
study when they identify which of the following as an element of the physical
environment?
A) Geographic boundaries
B) Housing
C) Access to health services
D) Climate
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16. An instructor is preparing a class for a group of students about communities. Which of
the following would the instructor use as an example of a geopolitical community?
Select all that apply.
A) States
B) School districts
C) Alzheimer's association
D) State student nurse organization
E) Census tract
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17. A nurse is preparing to conduct a community assessment. Upon completing the
assessment, which of the following would the nurse expect as the primary outcome?
A) Development of a common bond
B) Identification of health-related concerns
C) Creation of a health partnership
D) Increase in the number of services provided
18. A nursing instructor is describing the various models used for community assessment.
The instructor determines that the teaching was successful when the students identify
which model as being used to assist community agencies in meeting challenges of
providing care to clients with declining resources?
A) Partners in Caring Model
B) Mobilizing for Action through Planning and Partnerships
C) Partnership Model
D) Community Readiness Model
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19. When reviewing the demographics of various communities, the nurse would identify a
community with a large percentage of which age as most likely to have health-related
concerns?
A) Teenagers
B) Young adults
C) Middle-age individuals
D) Elderly
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20. Assessment of a community reveals that the community has experienced frequent
episodes of racial violence leading to many individuals moving to other areas. The nurse
interprets this information as reflecting which of the following?
A) Demographics
B) Community history
C) Physical Environment
D) Health and social services
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21. The nurse is gathering data about home health services of a community. The nurse
would evaluate the community for which types of services? Select all that apply.
A) Diagnostic services
B) Homemaker services
C) Nutritional consultation
D) Substance abuse services
E) Skilled care
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22. After assessing a community, the nurse plans programs to address the community's
government. Which of the following would be most appropriate?
A) Encouraging the view of the majority
B) Limiting the number of differing views
C) Using open forum community meetings
D) Maintaining the status quo
23. A nursing instructor is describing formal and informal channels of communication that
occur within a community. The instructor determines that the teaching was successful
when the students identify which of the following as an example of informal
communication?
A) Newspaper
B) Television
C) Radio
D) Fliers
24. When evaluating a community's education, which of the following would the nurse use
to identify the effectiveness of the community's school system?
A) Number of libraries
B) Scores on standardized tests
C) School health programs
D) Extracurricular activities
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25. A nurse is planning to address a community's problem of childhood obesity. Which
framework might be most helpful?
A) Community Readiness Model
B) Partners in Caring Model
C) Mobilizing for Action through Planning and Partnerships
D) Community as a Partner Model
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Answer Key
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A
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D
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A, B, E
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A
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B, C, E
C
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B
A
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Page 6
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