Essential Health Assessment 2nd Edition Thompson Test Bank
Chapter 1. Understanding Health Assessment
Question 1
Type: MCSA
The nurse is obtaining a health history from a client who reports that he is healthy and has no
health concerns. As part of the health history, the nurse documents that the client reported that he
has high blood pressure and suffers from a leg ulcer that remains unhealed after 6 months. Which
3. Do you understand what hypertension is?
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4. Is there anything else you are not telling me?
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2. Tell me about your definition of being healthy.
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1. I feel that you may be in denial about your health status.
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interview?
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of the following statements would be the best choice for the nurse to use at this point in the
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Correct Answer: 2
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Rationale 1: More information would be needed before the nurse could attribute the clients
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viewpoint as denial or lack of knowledge.
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Rationale 2: A client will have his or her own definition of health, illness, and wellness. The
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individuals concept of health and wellness is influenced by many factors, including age, gender,
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race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and
self-expectations.
Rationale 3: The clients history of hypertension is a valid area requiring further investigation but
the nurse must first ascertain the clients definition of healthy.
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Rationale 4: There is not enough information to determine the clients withholding of
information to the nurse.
Global Rationale: A client will have his or her own definition of health, illness, and wellness.
The individuals concept of health and wellness is influenced by many factors, including age,
gender, race, family, culture, religion, socioeconomic conditions, environment, previous
experiences, and self-expectations. More information would be needed before the nurse could
attribute the clients viewpoint as denial or lack of knowledge. The clients history of hypertension
is a valid area requiring further investigation but the nurse must first ascertain the clients
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definition of healthy. There is also not enough information to determine the clients withholding
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
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Client Need Sub:
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of information to the nurse.
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 1.4: Identify the factors to consider in health assessment
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Question 2
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Type: MCSA
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The nurse is documenting in the clients medical record and wishes to use SOAP charting. The
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nurse includes which of the following under the assessment category?
1. The clients blood pressure was 177/93.
2. The recent loss of employment and insurance have prevented the client from being able to
afford prescription medications.
3. The client reports having lost her job and insurance 3 months ago.
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4. Referrals have been made to social services to determine financial assistance programs
available.
Correct Answer: 2
Rationale 1: This is the O component, objective data.
Rationale 2: The A component of the SOAP note refers to conclusions drawn from the
subjective and objective data obtained.
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Rationale 3: This is subjective data.
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Rationale 4: This is the P component, plan.
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Global Rationale: The A component of the SOAP note refers to conclusions drawn from the
subjective and objective data obtained. The clients recent loss of employment and the potential
that this was a contributing factor in the inability to afford medications is an example of a
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conclusion. The clients reported blood pressure would be an example of objective data.
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Objective data is information that can be measured by the examiner. Blood pressure is not an
example of subjective information nor is it a conclusion. The clients reported loss of employment
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and insurance is an example of subjective data. The statement does not include conclusions as to
the results of these events. Making referrals to social services is an example of an intervention. It
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is not a conclusion.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the factors to consider in health assessment.
Question 3
Type: MCSA
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The nurse is presenting a workshop on wellness and health promotion and the initiatives of
Healthy People 2020 as a resource for this topic. After the session, which of the following
statements by a participant indicates an understanding concerning the initiatives proposed?
1. It will allow health care providers to lobby legislators for more funding.
2. The primary goal of Healthy People 2020 is to assist health care providers in determining risk
factors for premature birth.
3. Healthy People 2020 seeks to promotes health, prevent illness, disability, and premature death.
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4. The initiatives will outline standards of care for providers in managing diseases.
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Correct Answer: 3
Rationale 1: Health care providers and other persons interested in programs to promote health
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have found the document to be a useful source of information in their efforts to gain funding.
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Rationale 2: The Healthy People 2020 initiative is a 10-year strategy intended to promote
health, prevent illness, disability, and premature death. The document identifies leading health
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indicators that reflect public health concerns. Risk factors for premature birth may be part of
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those health indicators, but the scope of the document covers broad areas of concern.
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Rationale 3: The Healthy People 2020 initiative is a 10-year strategy intended to promote
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health, prevent illness, disability, and premature death.
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Rationale 4: Standards of care in disease management is not a component of the document.
Global Rationale: The Healthy People 2020 initiative is a 10-year strategy intended to promote
health, prevent illness, disability, and premature death. The document identifies leading health
indicators that reflect public health concerns. Risk factors for premature birth may be part of
those health indicators, but the scope of the document covers broad areas of concern. Health care
providers and other persons interested in programs to promote health have found the document to
be a useful source of information in their efforts to gain funding. Standards of care in disease
management is not a component of the document.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.2: Discuss the importance of Healthy People 2020 and its relevance to
health assessment.
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Question 4
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Type: MCSA
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The nurse is developing a handout for clients in a healthcare providers office. The nurse would
include which of the following focus areas in this handout to emphasize current changes in the
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health care delivery system?
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1. Class recommendations for diabetics concerning insulin administration A2.Guidelines from
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the Centers for Disease Control outlining plans to manage outbreaks of disease, eradicating the
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use of toxins
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2. Guidelines from the Centers for Disease Control outlining plans to manage outbreaks of
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disease, eradicating the use of toxins
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3. Resources available to treat chronic pain
4. Class listings for exercise classes available in the community
Correct Answer: 4
Rationale 1: Symptom management, illness care, and pain management are addressed by the
health care delivery system but are not the primary focus, as clients are taking a more active role
in managing their own care.
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Rationale 2: Management of outbreaks of disease is a function of governmental organizations
and health care providers in the community, but is not a focus of individual care.
Rationale 3: Symptom management, illness care, and pain management are addressed by the
health care delivery system but are not the primary focus, as clients are taking a more active role
in managing their own care.
Rationale 4: The focus of health care in the United States today is wellness, prevention of
disease, health promotion and health maintenance, for which a listing of exercise classes is
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appropriate.
Global Rationale: The focus of health care in the United States today is wellness, prevention of
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disease, health promotion, and health maintenance, for which a listing of exercise classes is
appropriate. Symptom management, illness care, and pain management are addressed by the
health care delivery system but are not the primary focus, as clients are taking a more active role
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in managing their own care. Management of outbreaks of disease is a function of governmental
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organizations and health care providers in the community, but is not a focus of individual care.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Planning
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Learning Outcome: 1.8: Discuss the elements of a teaching plan.
Question 5
Type: MCSA
The nurse is admitting a client to the acute care facility. The health history form has a place for
recording subjective data. The nurse understands that primary subjective data should be obtained
from which of the following sources?
1. The clients physical assessment
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2. The clients self-reports
3. The clients healthcare provider
4. The clients significant other
Correct Answer: 2
Rationale 1: The physical assessment will be recorded as objective data.
Rationale 2: Subjective data are gathered from the interview. The interview includes the health
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history and focused interview. Data will come from primary and secondary sources.
Rationale 3: The clients healthcare provider and significant other may contribute in the data
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subjective. This source of information is termed secondary.
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collection process. The information obtained from friends and family members is considered
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Rationale 4: The clients significant other may contribute in the data collection process but that
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input is classified as subjective.
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Global Rationale: Subjective data are gathered from the interview. The interview includes the
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health history and focused interview. Data will come from primary and secondary sources. The
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client is considered the primary source of subjective information. Family members and
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healthcare providers are examples of secondary sources of subjective information. The physical
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assessment will be recorded as objective data.
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Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.7: Describe the role of the professional nurse in health assessment.
Question 6
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Type: MCSA
The nurse is reviewing a clients medical records and notes various forms of information. The
nurse understands that which of the following are subjective data?
1. The client states, My abdomen hurts on the left side after eating.
2. The nurse notes the clients abdomen is tender on the left side during palpation.
3. The CAT scan reveals a large mass in the left lower quadrant of the abdomen.
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4. The clients hemoglobin is 14.1 gm/dL.
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Correct Answer: 1
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Rationale 1: Subjective reports by the client are those feelings or symptoms that cannot be
observed by others, of which My abdomen hurts is an example.
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Rationale 2: Physical examination findings, laboratory analysis reports and radiographic
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findings are objective data.
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Rationale 3: Physical examination findings, laboratory analysis reports and radiographic
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findings are objective data.
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Rationale 4: Physical examination findings, laboratory analysis reports and radiographic
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findings are objective data.
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Global Rationale: Subjective reports by the client are those feelings or symptoms that cannot be
observed by others. Objective reports are those factors that are based upon observations of
others. Physical examination findings, laboratory analysis reports, and radiographic findings are
objective data.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the factors to consider in health assessment.
Question 7
Type: MCSA
The nurse is reviewing a clients medical records and notes various information. The nurse
understands that which of the following is an example of objective data?
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1. I hurt my head.
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2. I am 6 years old and Im here because I fell.
3. Six-year-old Hispanic female sitting on examination table holding a towel to her forehead.
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4. Client states that she fell at the playground.
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Correct Answer: 3
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Rationale 1: Statements the client makes are subjective data.
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Rationale 2: Statements the client makes are subjective data.
Rationale 3: Objective data are data that can be observed or measured by the nurse. The nurse
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can see the child holding the towel to her head and can use her birth date to determine her age.
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Rationale 4: Statements the client makes are subjective data.
Global Rationale: Objective data are data that can be observed or measured by the nurse. The
nurse can see the child holding the towel to her head and can use her birth date to determine her
age. Statements the client makes are subjective data.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.4: Identify the factors to consider in health assessment.
Question 8
Type: MCSA
The nurse is evaluating the plan of care and notes that none of the goals have been met for the
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client with impaired gas exchange. What should the nurse do next in this situation?
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1. Report the lack of achievement of the goals to the healthcare provider.
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2. Review the data and modify the plan.
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3. Reformulate the nursing diagnosis to a more realistic one.
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4. Request a consult for the client to be seen by a pulmonologist.
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Correct Answer: 2
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Rationale 1: Reporting the lack of achievement of the goals to the healthcare provider is not
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appropriate, though reporting undesirable client physiologic responses may be.
Rationale 2: The plan of care should be evaluated periodically, at the established time frames, to
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determine achievement of the goals. If goals are not achieved, then the data need to be further
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assessed and the plan modified.
Rationale 3: Reformulating the nursing diagnosis to a more realistic one is not the best course of
action as the diagnosis established came from subjective and objective data specific to that
diagnosis.
Rationale 4: There are no data to support the need for additional medical consultations.
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Global Rationale: The plan of care should be evaluated periodically, at the established time
frames, to determine achievement of the goals. If goals are not achieved, then the data need to be
further assessed and the plan modified. Reporting the lack of achievement of the goals to the
healthcare provider is not appropriate, though reporting undesirable client physiologic responses
may be. Reformulating the nursing diagnosis to a more realistic one is not the best course of
action as the diagnosis established came from subjective and objective data specific to that
diagnosis. There are no data to support the need for additional medical consultations.
Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
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Learning Outcome: 1.5: Define the steps of the nursing process.
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Question 9
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Type: MCSA
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The community health nurse is preparing to conduct a program for a group of nursing students
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concerning health and wellness. Which of the following statements by a participant indicates the
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most comprehensive and accurate understanding of health?
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1. Health is the absence of illness, disease, and symptoms.
2. Health is a state of well-being and the use of every power the person possesses to the fullest
extent.
3. Health is the state when a person is viewed as a holistic being.
4. Health is a state of complete physical, mental, and social well-being.
Correct Answer: 4
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Rationale 1: Health is much more than the absence of illness and disease.
Rationale 2: Defining health as a state of well-being is limiting as it does not encompass the
elements of an individuals being such as physical, mental, and social.
Rationale 3: While health does require a holistic approach, this definition does not explore the
elements with the same clarity of the correct answer.
Rationale 4: Health is defined as a state of complete physical, mental, and social well-being
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(WHO, 1947).
Global Rationale: Health is defined as a state of complete physical, mental, and social well-
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being (WHO, 1947). Health is much more than the absence of illness and disease. Defining
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health as a state of well-being is limiting as it does not encompass the elements of an individuals
being such as physical, mental, and social. While health does require a holistic approach, this
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definition does not explore the elements with the same clarity of the correct answer.
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Client Need Sub:
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Client Need: Physiological Integrity
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Cognitive Level: Applying
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Nursing/Integrated Concepts: Nursing Process: Evaluation
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Question 10
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Learning Outcome: 1.1: Discuss the various definitions of health.
Type: MCSA
The nurse is caring for a client who is recovering from abdominal surgery. When determining the
best goal statement for the client concerning level of pain, which of the following is most
appropriate?
1. The client will verbalize pain relief using an intensity rating in 4 hours.
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2. The client will state that he feels fine in 4 hours.
3. The nurse will observe fewer signs of pain in the clients demeanor.
4. The nurse will reevaluate the clients pain level every 2 hours.
Correct Answer: 1
Rationale 1: The goal statement is directly related to the nursing diagnosis. Goal statements are
stated in a positive fashion, and have measurable criteria.
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Rationale 2: This statement is not related directly related to the diagnosis and is not measurable.
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because it reflects activities of the nurse and not the client.
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Rationale 3: A goal statement must be reflective of client activities. This is an incorrect answer
Rationale 4: A goal statement must be reflective of the clients activities. This is an incorrect
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answer because it reflects activities of the nurse and is not client directed. Although there is a
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time frame listed it is not correct as it is related to nursing actions.
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Global Rationale: The goal statement is directly related to the nursing diagnosis. Goal
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statements are stated in a positive fashion, and have measurable criteria. Verbalization of the
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client of pain relief using a rating scale within a specified time period is an appropriately
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formatted, measurable statement. Statements by the client indicating he is feeling fine is not
reflective of a measurable criteria. Statements indicating actions by the nurse are not correctly
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formatted goals for the client.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1.5: Define the steps of the nursing process.
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Question 11
Type: MCSA
The nurse is developing the plan of care for a client who is recovering from abdominal surgery.
When planning interventions the nurse recognizes which of the following will best meet the
needs of the client experiencing pain?
1. The healthcare provider will prescribe additional analgesics.
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4. Assist the client with guided imagery to manage pain levels.
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3. The client will vocalize reduced levels of pain within 3 hours.
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2. The client will have reduced pain after administration of analgesics.
Correct Answer: 4
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Rationale 1: The prescribing of additional analgesics does not determine the characteristics of
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the pain and does not offer patient-driven information.
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Rationale 2: This is a goal statement, not an intervention.
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Rationale 3: This is a goal statement, not an intervention.
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Rationale 4: Nursing interventions, such as assisting the client with guided imagery, are geared
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to assist in meeting client goals. The interventions are derived from the second part of the
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diagnosis, which is the etiology. The defining characteristics provide the background support for
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the diagnosis. The diagnostic label is global and requires specification before attempting to
determine a goal. The clients stated wishes are an important component of planning, and may be
included in the list of interventions as appropriate. The interventions are based upon nursing
actions.
Global Rationale: Nursing interventions are geared to assist in meeting client goals. The
interventions are derived from the second part of the diagnosis, which is the etiology. The
defining characteristics provide the background support for the diagnosis. The diagnostic label is
global and requires specification before attempting to determine a goal. The clients stated wishes
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are an important component of planning, and may be included in the list of interventions as
appropriate. The interventions are based upon nursing actions. The prescribing of additional
analgesics does not determine the characteristics of the pain and does not offer patient driven
information. The reduction of pain and vocalization of pain levels within 3 hours are goal
statements, not interventions.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Planning
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Client Need Sub:
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Learning Outcome: 1.6: Describe the critical thinking process with relevance to health
assessment.
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Question 12
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Type: MCSA
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The nursing instructor is discussing Healthy People 2020 with a group of nursing students. One
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of the students questions the instructor how this work will impact hospitalization. The best
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response by the nursing instructor would be:
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1. Healthy People 2020 is a tool for the healthcare providers to offer information to their clients.
death.
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2. Healthy People 2020 seeks to improve health and prevent illness, disability, and premature
3. The purpose of Healthy People 2020 is to reduce health care costs for hospitalized clients.
4. Healthy People 2020 is seen as a tool by hospitals to reduce length of stay.
Correct Answer: 2
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Rationale 1: Healthy People 2020 is a resource tool for all health care professionals but its
purpose is not to provide patient education between the healthcare provider and client.
Rationale 2: Healthy People 2020 presents a 10-year strategy with objectives intended to
enhance health and prevent illness, disability, and premature death.
Rationale 3: Reduction of hospital costs is the not the primary purpose of Healthy People 2020.
Rationale 4: Reduction of length of stay is the not the primary purpose of Healthy People 2020.
Global Rationale: Healthy People 2020 presents a 10-year strategy with objectives intended to
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enhance health and prevent illness, disability, and premature death. Healthy People 2020 is a
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resource tool for all health care professionals but its purpose is not to provide patient education
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between the healthcare provider and client. Reduction of hospital costs is the not the primary
purpose of Healthy People 2020.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Type: MCSA
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Question 13
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Learning Outcome: 1.2: Discuss the importance of Healthy People 2020.
The recent graduate nurse is orienting to the medical surgical care unit. The graduate nurse has
prepared a nursing care plan for a client admitted for exacerbation of ulcerative colitis. The goal
statement is, The client will resume normal bowel elimination patterns. The graduate nurse has
asked the charge nurse to review the care plan. What action by the charge nurse is indicated?
1. Express to the new nurse that the goal statement meets criteria.
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2. Explain to the new nurse that the lack of time frame makes the goal inappropriate.
3. Express to the new nurse that the goal statement is not reflective of the clients admitting
diagnosis.
4. Accept the care plan for inclusion into the clients medical record as it is accurate.
Correct Answer: 2
Rationale 1: This goal statement does not meet criteria as it lacks a time frame.
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Rationale 2: Time frames are an important component of goal statements and provide guidelines
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for when to evaluate the achievement of the goal.
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Rationale 3: The defining characteristics of the diagnosis and the etiology of the diagnosis are
components of the diagnostic statement.
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Rationale 4: This goal statement does not meet criteria as it lacks a time frame.
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Global Rationale: This goal statement does not meet criteria as it lacks a time frame. Time
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frames are an important component of goal statements and provide guidelines for when to
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evaluate the achievement of the goal. The defining characteristics of the diagnosis and the
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etiology of the diagnosis are components of the diagnostic statement. The nurses role in
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achieving the goal is not a component of the goal statement.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1.5: Define the steps of the nursing process.
Question 14
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Type: MCMA
The nurse is caring for a newly admitted client with Methicillin-resistant Staphylococcus Aureus
(MRSA). Which of the following are appropriate goals of the initial health assessment?
Standard Text: Select all that apply.
1. Determine the clients current state of health and ongoing health-promotion activities.
2. Predict risks to current health status.
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4. Determine how frequently the client is able to change positions.
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3. Use only objective data to determine client allergies.
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5. Identify health-promoting activities.
Correct Answer: 1,5
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Rationale 1: Determine the clients current state of health and ongoing health-promotion
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activities: Health assessment goals are to determine the clients current state of health and
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ongoing health-promotion activities.
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Rationale 2: Predict risks to current health status: Health assessment activities are used to
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predict risks to health, and identify health status both current and future. This includes physical,
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social, cultural, environmental, and emotional factors including wellness behaviors, illness signs
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and symptoms, client strengths and weaknesses, and risk factors.
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Rationale 3: Use only objective data to determine client allergies. The initial health
assessment includes both objective and subjective information.
Rationale 4: Determine how frequently the client is able to change positions. The initial
health assessment includes both objective and subjective information and seeks to determine the
potential an individual has to implement health-promoting activities. Health assessment activities
are used to predict risks to health, and identify health status. This includes physical, social,
cultural, environmental, and emotional factors including wellness behaviors, illness signs and
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symptoms, client strengths and weaknesses, and risk factors. The ability of the client to change
positions is not a part of the initial health assessment. .
Rationale 5: Identify health-promoting activities. The health assessment seeks to determine
the potential an individual has to implement health-promoting activities.
Global Rationale: Health assessment goals are to determine the clients current state of health
and ongoing health-promotion activities. The initial health assessment includes both objective
and subjective information and seeks to determine the potential an individual has to implement
health-promoting activities. Health assessment activities are used to predict risks to health, and
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identify health status. This includes physical, social, cultural, environmental, and emotional
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factors including wellness behaviors, illness signs and symptoms, client strengths and
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weaknesses, and risk factors. The initial health assessment does not include using objective data
to determine client allergies and is not part of the initial health assessment.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Type: MCSA
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Question 15
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Learning Outcome: 1.5: Define the steps of the nursing process.
While the nurse assesses a client who is hospitalized for an acute exacerbation of chronic
obstructive pulmonary disease (COPD), the client becomes very short of breath. The nurse
recognizes the need to stop the assessment to initiate respiratory support interventions. This is an
example of which phase of critical thinking?
1. Collection of information
2. Evaluation
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3. Generation of alternatives
4. Analysis of the situation
Correct Answer: 4
Rationale 1: Collection of information is the initial step in the process. During this phase the
nurse will assess available information.
Rationale 2: Evaluation is the final step in the process. During evaluation the nurse will
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determine the effectiveness of actions taken.
Rationale 3: When generating alternatives for action the nurse will use critical thinking skills to
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determine available options for action.
Rationale 4: The nurse in the scenario will need to employ assessment skills to review and
analyze the situation. The analysis will provide the nurse with the understanding of what the best
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plan of action will be.
Global Rationale: The nurse in the scenario will need to employ assessment skills to review and
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analyze the situation. The analysis will provide the nurse with the understanding of what the best
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plan of action will be. Collection of information is the initial step in the process. During this
phase the nurse will assess available information. Evaluation is the final step in the process.
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During evaluation the nurse will determine the effectiveness of actions taken. When generating
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action.
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alternatives for action the nurse will use critical thinking skills to determine available options for
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1.6: Describe the critical thinking process with relevance to health
assessment.
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Question 16
Type: MCMA
The nurse is completing an admission assessment. The assessment form allows for the separation
of subjective and objective data. Distinguish which of the following are examples of subjective
data utilized by the nurse.
Standard Text: Select all that apply.
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1. The clients mother informs the nurse that her daughter has not been sleeping due to pain.
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3. Abdominal assessment reveals a firm, hard abdomen.
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2. The client states, I have pain in my belly that is 7 out of 10.
4. The client is weak and looks very pale.
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5. The client appears nervous during the data collection period.
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Correct Answer: 1,2
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Rationale 1: The clients mother informs the nurse that her daughter has not been sleeping
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due to pain. Subjective data is information the client experiences and communicates to the
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nurse. This information can be provided by either the client or other individuals.
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Rationale 2: The client states, I have pain in my belly that is 7 out of 10. Subjective data is
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information the client experiences and communicates to the nurse.
Rationale 3: Abdominal assessment reveals a firm, hard abdomen. Data that are observed by
the examiner are termed objective data.
Rationale 4: The client is weak and looks very pale. Data that are observed by the examiner
are termed objective data.
Rationale 5: The client appears nervous during the data collection period. Data that are
observed by the examiner are termed objective data.
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Global Rationale: Subjective data is information the client experiences and communicates to the
nurse. This information can be provided by either the client or other individuals. Primary
subjective data is information the client experiences and communicates to the nurse. Information
provided by family is also considered subjective but is termed secondary. Assessment data that
are observed by the examiner are termed objective data. Reports by the clients mother are
considered secondary subjective information. The statements made by the client are referred to
as primary subjective data. The characteristics of the abdomen, the clients strength level, color,
and psychosocial assessment are termed objective data.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 1.4: Identify the factors to consider in health assessment.
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Question 17
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Type: MCSA
A client with hepatitis B is admitted to the hospital. When obtaining the physical assessment,
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what should the nurse keep in mind regarding client confidentiality?
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client care.
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1. Confidentiality means that information sharing is limited to those directly involved in the
2. Complete client confidentiality means that all members of the health care team may have
access to the chart.
3. Health Insurance Portability and Accountability Act (HIPAA) helps to maintain client
confidentiality and dictates who is to be communicating with the client.
4. The medical records are open to any hospital employee, including administration.
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Correct Answer: 1
Rationale 1: Confidentiality means that information sharing is limited to those directly involved
in the client care.
Rationale 2: Not all members of the health care team have access to the chart, only those who
are directly caring for the client.
Rationale 3: The Health Insurance Portability and Accountability Act (HIPAA) does not dictate
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who is allowed to communicate with the client.
Rationale 4: The medical records are open to any hospital employee, including administration.
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Global Rationale: Confidentiality means that information sharing is limited to those directly
involved in the client care. Not all members of the health care team have access to the chart, only
those who are directly caring for the client. The Health Insurance Portability and Accountability
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Act (HIPAA) does not dictate who is allowed to communicate with the client. Hospital records
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are open only to those directly related to the care of the client.
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Cognitive Level: Applying
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Client Need: Safe Effective Care Environment
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Question 18
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Learning Outcome: 1.7 Describe the role of the professional nurse in health assessment.
Type: MCSA
The charge nurse is discussing with the new graduate nurse the care planning process for clients
admitted to the unit. The graduate nurse correctly identifies the order of the steps of the nursing
process as:
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1. Diagnosis, Assessment, Planning, Implementation, Evaluation
2. Assessment, Diagnosis, Planning, Implementation, Evaluation
3. Planning, Assessment, Diagnosis, Implementation, Evaluation
4. Assessment, Planning, Diagnosis, Implementation, Evaluation
Correct Answer: 2
Rationale 1: The nursing process is a systematic, rational, dynamic, and cyclic process used by
the nurse for planning and providing care for the client. The assessment phase, step 1, involves
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the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is
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planning. Implementation is step 4. The final stage in the process, step 5, is evaluation.
Rationale 2: The nursing process is a systematic, rational, dynamic, and cyclic process used by
the nurse for planning and providing care for the client. The assessment phase, step 1, involves
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the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is
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planning. Implementation is step 4. The final stage in the process, step 5, is evaluation.
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Rationale 3: The nursing process is a systematic, rational, dynamic, and cyclic process used by
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the nurse for planning and providing care for the client. The assessment phase, step 1, involves
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the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is
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planning. Implementation is step 4. The final stage in the process, step 5, is evaluation.
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Rationale 4: The nursing process is a systematic, rational, dynamic, and cyclic process used by
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the nurse for planning and providing care for the client. The assessment phase, step 1, involves
the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is
planning. Implementation is step 4. The final stage in the process, step 5, is evaluation.
Global Rationale: The nursing process is a systematic, rational, dynamic, and cyclic process
used by the nurse for planning and providing care for the client. The assessment phase, step 1,
involves the collection of data. Step 2 of the nursing process is diagnosis. The nurse uses critical
thinking and applies knowledge from the sciences and other disciplines to analyze and synthesize
the data. Similar data is clustered together and become the basis for the nursing diagnosis. Step 3
of the process is planning. During the planning phase the nurse sets the course for the care to be
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delivered. Implementation is the fourth step. During the implementation phase, step 4, the care is
delivered. The final stage in the process, step 5, is evaluation. The professional nurse compares
the present client status to achievement of the stated goals or outcomes. At this time the nurse
will need to modify the nursing care plan.
Cognitive Level: Remembering
Client Need: Safe Effective Care Environment
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 1.6: Define the steps of the nursing process.
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Client Need Sub:
Question 19
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Type: MCSA
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A client is hospitalized with end stage liver failure secondary to many years of alcoholism. The
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nurse begins collection of information by first:
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1. Organizing how to proceed with the client and generating alternatives to the approach.
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2. Identifying assumptions that can misguide or misdirect the assessment and intervention
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process.
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3. Collecting information and determining its relevance as far as impacting the client care.
4. Identifying any inconsistencies in the communication from the client and or significant others.
Correct Answer: 2
Rationale 1: Organizing how to proceed with the client occurs after identification of
assumptions.
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Rationale 2: The process of data collection involves a systematic approach. The first step in the
process involves the identification of assumptions. Assumptions may misguide or misdirect the
process of assessment and intervention.
Rationale 3: Collecting information and determining its relevance occurs after identification of
assumptions.
Rationale 4: Identifying any inconsistencies in communication occurs after identification of
assumptions.
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Global Rationale: The process of data collection involves a systematic approach. The first step
in the process involves the identification of assumptions. Assumptions may misguide or
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misdirect the process of assessment and intervention. Additional steps in the process, in order,
include organizing the approach, determining the reliability and accuracy of the information,
distinguishing between relevant and irrelevant information, and looking for any inconsistencies
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in the information.
Cognitive Level: Applying
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Client Need: Safe Effective Care Environment
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Question 20
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Learning Outcome: 1.3: Define health assessment.
Type: MCSA
The nurse is preparing a teaching plan for a client diagnosed with type 1 diabetes mellitus. When
developing the teaching plan the nurse addresses objectives in the psychomotor domain. Which
of the following objectives best meets this criteria?
1. The client will discuss measures to take when experiencing the feeling of low blood glucose
levels.
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2. The client will describe signs and symptoms of low blood sugar.
3. The client will demonstrate how to draw up the correct dose of insulin.
4. The client will define the dimensions of diabetes mellitus.
Correct Answer: 3
Rationale 1: Cognitive objectives include those concerning the acquisition of knowledge. The
clients understanding of actions to take when experiencing low blood glucose levels is an
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example of a cognitive domain.
Rationale 2: The identification of the signs and symptoms of low blood sugar are reflective of
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the cognitive domain.
Rationale 3: The demonstration of skills such as drawing up insulin is reflective of the
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psychomotor domain.
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Rationale 4: Defining the dimensions of diabetes mellitus is consistent with the cognitive
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domain.
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Global Rationale: In the teaching plan the objectives identify specific, measurable behaviors or
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activities expected of the client. Action verbs may be from the cognitive, affective, or
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psychomotor domain. The demonstration of skills such as drawing up insulin is reflective of the
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psychomotor domain. Psychomotor objectives include the acquisition of skills. The affective
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domain refers to attitudes, feelings, values, and opinions. The identification of the signs and
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symptoms of low blood sugar are reflective of the cognitive domain. Cognitive objectives
include those concerning the acquisition of knowledge.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
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Learning Outcome: 1.4: Identify the factors to consider in health assessment.
Question 21
Type: MCSA
Which of the following statements best describes the active role of the professional nurse as an
educator?
1. Nurses must consider learning needs, goals, objectives, content, teaching methods, and
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evaluation when carrying out client education.
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2. Teaching plans are developed for informal teaching when distinct needs are identified or when
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common needs are recognized.
3. In the role of educator, the nurse should refer the client to other health care providers who
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specialize in the area of need.
4. Teaching is to be delegated to the advanced practice nurse specialist or the nurse educator.
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Correct Answer: 1
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Rationale 1: Roles of the professional nurse include teacher, both formal and informal,
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caregiver, and client advocate.
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Rationale 2: Informal teaching does not involve teaching plans.
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Rationale 3: Roles of the professional nurse include teacher, both formal and informal,
caregiver, and client advocate.
Rationale 4: Teaching is often done in collaboration with the advanced practice nurse specialist
or the nurse educator. Nurses at the bedside also must share the role of client educator.
Global Rationale: Roles of the professional nurse include teacher, both formal and informal,
caregiver, and client advocate. The professional nurse may also have advanced practice roles.
Informal teaching does not involve teaching plans. Teaching is often done in collaboration with
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the advanced practice nurse specialist or the nurse educator. Nurses at the bedside also must
share the role of client educator.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
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Learning Outcome: 1.7: Describe the role of the professional nurse in health assessment.
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Question 22
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Type: MCSA
The charge nurse has instructed the nurse to complete a focused interview on the client who has
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just been admitted to the facility with complaints consistent with kidney stones. Which of the
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following actions by the nurse indicates the best understanding of the assignment?
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1. The nurse obtains a urine sample to send for a urinalysis.
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2. The nurse takes the clients vital signs.
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3. The nurse questions the client about dietary preferences.
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4. The nurse asks the client about the characteristics of the pain being experienced.
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Correct Answer: 4
Rationale 1: The client may need to have a urine specimen that does not directly relate to
determining more information about the chief complaints of the client.
Rationale 2: 2. The client vital signs will be taken but they do not directly relate to determining
more information about the chief complaints of the client.
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Rationale 3: Dietary preferences of clients are recorded but are not a part of the focused
assessment.
Rationale 4: The focused interview is used to allow for clarification of information from the
initial interview. The goal of the focused interview is to expand the information available.
Global Rationale: The focused interview is used to allow for clarification of information from
the initial interview. The goal of the focused interview is to expand the information available.
The client may need to have a urine specimen and will need vital signs taken but they do not
directly relate to determining more information about the chief complaints of the client. Dietary
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preferences of clients are recorded but are not a part of the focused assessment.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 1.4: Identify the factors to consider in health assessment.
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Question 23
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Type: MCSA
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A female client has been admitted to the acute care unit with complaints of abdominal pain,
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nausea, and vomiting. During the interview the nurse determines the clients history includes
pelvic inflammatory disease, mitral valve prolapse, and childbirth. The assessment finds the
clients vital signs to be within normal limits. When analyzing the available data, what items
should be clustered together?
1. Vital signs, complaints of pain history of childbirth
2. Abdominal pain, nausea, vomiting, and history of pelvic inflammatory disease
3. Gender, history of mitral valve prolapse, and vital signs
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4. History of pelvic inflammatory disease, mitral valve prolapse, and pain scale reports
Correct Answer: 2
Rationale 1: The analysis of assessment data includes clustering or grouping related pieces of
information. There is no obvious relationship between these pieces of information.
Rationale 2: The analysis of assessment data includes clustering or grouping related pieces of
information. The clients complaints of abdominal pain, nausea, vomiting, and history of pelvic
inflammatory disease are interrelated items.
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Rationale 3: The analysis of assessment data includes clustering or grouping related pieces of
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information. There is no obvious relationship among these pieces of information.
Rationale 4: The analysis of assessment data includes clustering or grouping related pieces of
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information. There is no obvious relationship among these pieces of information.
Global Rationale: The analysis of assessment data includes clustering or grouping related pieces
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of information. The clients complaints of abdominal pain, nausea, vomiting, and history of pelvic
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Cognitive Level: Applying
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remaining pieces of information.
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inflammatory disease are interrelated items. There is no obvious relationship between the
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1.6: Describe the critical thinking process with relevance to health
assessment.
Question 24
Type: MCMA
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The nurse is preparing the care plan for a client who has undergone an abdominal hysterectomy
to manage endometriosis. When reviewing goal statements, which of the following reflect the
need for further development?
Standard Text: Select all that apply.
1. The nurse will assess the vital signs every 2 hours.
2. The client will walk Q2h on the first postoperative day.
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3. The client will report feeling better.
4. The client will begin a clear liquid diet on the first postoperative day.
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5. The healthcare provider will prescribe oral analgesics on the first postoperative day.
Correct Answer: 1,3,5
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Rationale 1: The nurse will assess the vital signs every 2 hours. Goal statements are used to
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provide planned outcomes for the client. Goal statements must be measurable and are reflective
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of client activities. This statement reflects actions of the nurse, not the client.
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Rationale 2: The client will walk Q2h on the first postoperative day. The goal statement is
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used to provide planned outcomes for the client. Goal statements must be measurable and
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reflective of client activities. All elements needed for an appropriate goal statement are
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represented.
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Rationale 3: The client will report feeling better. Goal statements must be measurable and
reflective of client activities. This statement is vague and does not provide a definitive means for
measurement.
Rationale 4: The client will begin a clear liquid diet on the first postpartum day. Goal
statements are used to provide planned client outcomes. This statement contains the needed
elements for a successful goal statement.
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Rationale 5: The healthcare provider will prescribe oral analgesics on the first
postoperative day. This statement is not a client-centered goal statement. This statement reflects
an intervention performed by the healthcare provider.
Global Rationale: Goal statements are used to provide planned outcomes for the client. Goal
statements must be measurable and are reflective of client activities. The only statement
reflecting these criteria is that the client will walk Q2h on the first postoperative day. Statements
reflecting actions of the nurse or healthcare provider are not goal statements. Vague statements
such as feeling better are not measurable. The statement that the client will begin a clear liquid
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diet on the first postoperative day contains the needed elements for a successful goal statement.
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
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Cognitive Level: Applying
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Nursing/Integrated Concepts: Nursing Process: Evaluation
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Learning Outcome: 1.5: Define the steps of the nursing process.
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Question 25
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Type: MCSA
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The community health nurse is preparing a program about health maintenance. The nurse has
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decided to use the Leavall and Clark model as the framework for the programming. Which of the
following program objectives best explain the concepts presented by this model?
1. The participants will recognize health as the absence of disease.
2. The participants will verbalize the role of self-actualization achievement in relation to health.
3. The participants will define health as the interrelationships between the agent, host, and the
environment.
4. Internal harmony is the foundational basis for health achievement.
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Correct Answer: 3
Rationale 1: The absence of disease and internal harmony are not specific independent models
for health.
Rationale 2: Self-actualization and health are explored in the eudaemonistic model for health.
Rationale 3: Leavall and Clark developed the ecologic model for health. This model considers
the relationship between the agent, host, and environment as the key determinants for health
status.
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Rationale 4: The absence of disease and internal harmony are not specific independent models
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for health.
Global Rationale: Leavall and Clark developed the ecologic model for health. This model
considers the relationship between the agent, host, and environment as the key determinants for
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health status. Self-actualization and health are explored in the eudaemonistic model for health.
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The absence of disease and internal harmony are not specific independent models for health.
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Chapter 2. Interviewing the Patient for a Health History
Question 1
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Type: MCMA
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The student nurse is preparing to perform a health history interview. Which of the following
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health history?
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statements indicate that the student nurse requires further education regarding the purpose of the
Standard Text: Select all that apply.
1. As the nurse, I will mainly focus on the course of the clients illness.
2. The clients health history can be gathered during the initial interview.
3. I realize that the client is sick, but I also need to perform a wellness assessment.
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4. The healthcare providers and nurses assessments should be almost identical with the same
focus.
5. The nurse typically has a more holistic point of view regarding the clients health.
Correct Answer: 1,4
Rationale 1: As the nurse, I will mainly focus on the course of the clients illness. The
healthcare provider will typically focus on the clients illness, while the nurse will focus on the
client.
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nurse can gather the health history during the initial interview.
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Rationale 2: The clients health history can be gathered during the initial interview. The
Rationale 3: I realize that the client is sick, but I also need to perform a wellness
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assessment. The nurse should perform a wellness assessment as part of the health history.
Rationale 4: The healthcare providers and nurses assessments should be almost identical
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with the same focus. The healthcare providers focus and the nurses focus regarding the clients
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health differ significantly. The nurses health history may produce information about a medical
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diagnosis, but the focus is on the clients response to the health concern as a whole person. The
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healthcare provider focuses on specific body systems or body parts of the client.
Rationale 5: The nurse typically has a more holistic point of view regarding the clients
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health. The nurse does typically have a more holistic view of the client when compared to the
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healthcare providers point of view.
Global Rationale: The healthcare provider will typically focus on the clients illness, while the
nurse will focus on the client. The healthcare providers focus and the nurses focus regarding the
clients health differ significantly. The nurses health history may produce information about a
medical diagnosis, but the focus is on the clients response to the health concern as a whole
person. The healthcare provider focuses on specific body systems or body parts of the client. The
nurse can gather the health history during the initial interview. The nurse should perform a
wellness assessment as part of the health history. The nurse does typically have a more holistic
view of the client when compared to the healthcare providers point of view.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.1: Discuss the purpose of the nursing health history.
Question 2
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Type: MCMA
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The client has been diagnosed with an early stage of wide-angle glaucoma. The nurse is
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performing a wellness assessment during the clients initial interview. Which of the following
statements by the client may be elicited during this portion of the health history?
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Standard Text: Select all that apply.
1. My mom was diagnosed with glaucoma when she was 60 years old.
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2. I pay attention to the foods that I eat, because I want my body to stay well.
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3. I think I do a good job of managing stress with yoga every day and running three times a
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week.
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4. My husband and I have 3 couples that we would classify as our very good friends.
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5. Sometimes, my eyes feel very tired and sort of ache.
Correct Answer: 2,3,4
Rationale 1: My mom was diagnosed with glaucoma when she was 60 years old. The nurse
should ask about the clients family history at some point during the health history but not during
the wellness assessment.
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Rationale 2: I pay attention to the foods that I eat, because I want my body to stay well. The
wellness assessment portion of the health history is designed to determine how the client
optimizes health and well-being. The nurse should determine how well the client is nourishing
the body during the wellness assessment.
Rationale 3: I think I do a good job of managing stress with yoga every day and running
three times a week. The wellness assessment portion of the health history is designed to
determine how the client optimizes health and well-being. The nurse should determine how well
the client is managing stress during the wellness assessment.
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Rationale 4: My husband and I have 3 couples that we would classify as our very good
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friends. The wellness assessment portion of the health history is designed to determine how the
interacting socially during the wellness assessment.
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client optimizes health and well-being. The nurse should determine how well the client is
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Rationale 5: Sometimes, my eyes feel very tired and sort of ache. The nurse should ask about
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the clients symptoms related to the condition but not during the wellness assessment.
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Global Rationale: The wellness assessment portion of the health history is designed to
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determine how the client optimizes health and well-being. The nurse should determine how the
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client is nourishing the body, managing stress, and interacting socially. The client was diagnosed
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with glaucoma. Information about the clients eyes may be gathered as the nurse focuses on the
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clients health concerns or illness. The nurse should ask about the clients family history at some
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point during the health history but not during the wellness assessment. The nurse should ask
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about the clients symptoms related to the condition but not during the wellness assessment.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.1: Discuss the purpose of the nursing health history.
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Question 3
Type: MCMA
While interviewing the client during the focused interview, the client begins to cry softly. Which
of the following interventions by the nurse are appropriate?
Standard Text: Select all that apply.
2. The nurse places the tissues within arms reach of the client.
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1. The nurse states, Its all right, I think were done with the interview.
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3. The nurse remains quiet until the nurse feels that the client is prepared to proceed with the
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interview.
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the interview so you can go home and cry later.
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4. The nurse states, I dont like these questions any more than you do, but we need to get on with
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5. The nurse states, I can see you are upset. Its all right to cry.
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Correct Answer: 2,3,5
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Rationale 1: The nurse states, Its all right, I think were done with the interview. It is not
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appropriate to conclude the interview. There may be something that can help the nurse create a
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better care plan for the client if the nurse continues with this line of questioning.
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Rationale 2: The nurse places the tissues within arms reach of the client. When the client
begins to cry or exhibits cues that the client may feel like crying, the nurse should place tissues
within close proximity to the client.
Rationale 3: The nurse remains quiet until the nurse feels that the client is prepared to
proceed with the interview. It is appropriate for the nurse to remain quiet while the client cries.
Rationale 4: The nurse states, I dont like these questions any more than you do, but we
need to get on with the interview so you can go home and cry later. It is appropriate for the
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nurse to give the client permission to cry. Some people need the assurance that it is okay to cry
and feel sad.
Rationale 5: The nurse states, I can see you are upset. Its all right to cry. The nurse should
not hurry the interview along or not provide time for the client to display emotion.
Global Rationale: When the client begins to cry or exhibits cues that the client may feel like
crying, the nurse should place tissues within close proximity to the client. It is appropriate for the
nurse to remain quiet while the client cries. It is appropriate for the nurse to give the client
permission to cry. Some people need the assurance that it is okay to cry and feel sad. It is not
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appropriate to conclude the interview. There may be something that can help the nurse create a
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better care plan for the client if the nurse continues with this line of questioning. The nurse
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should not hurry the interview along or not provide time for the client to display emotion.
Cognitive Level: Applying
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Client Need: Psychosocial Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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conducting a health history.
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Learning Outcome: 10.2: Describe communication skills used by the professional nurse when
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Question 4
Type: MCMA
The nurse recently gave birth to a stillborn infant. During the preinteraction stage, the nurse
learns that the client has had 5 elective abortions performed while she was in high school and
college. Which of the following nursing actions are appropriate to help the nurse prepare
emotionally for the initial interview with this client?
Standard Text: Select all that apply.
1. The nurse speaks with one of her nursing peers and sets up a time to role-play the interview.
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2. The nurse writes in her journal regarding her fears about meeting with the client.
3. The nurse makes an appointment to meet with her counselor prior to the interview.
4. The nurse should remain very quiet during the interview so that the initial interview will only
last for a brief time.
5. The nurse creates a list of her own goals to accomplish during the interview with this client.
Correct Answer: 1,2,3,5
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Rationale 1: The nurse speaks with one of her nursing peers and sets up a time to role-play
the interview. The nurse should speak with one of her nursing peers to role-play how the
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interview may proceed.
Rationale 2: The nurse writes in her journal regarding her fears about meeting with the
client. The nurse can write in a journal about some of her fears regarding the upcoming meeting
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with the client.
Rationale 3: The nurse makes an appointment to meet with her counselor prior to the
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interview. The nurse can make an appointment to speak with her counselor about her feelings
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prior to the interview.
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Rationale 4: The nurse should remain very quiet during the interview so that the initial
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interview will only last for a brief time. The nurse will not be able to elicit an adequate amount
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of information from the client if she is focusing only on being quiet during the interview.
Rationale 5: The nurse creates a list of her own goals to accomplish during the interview
with this client. The nurse can create a list of goals to accomplish during the interview.
Global Rationale: The nurse should speak with one of her nursing peers to role-play how the
interview may proceed. The nurse can write in a journal about some of her fears regarding the
upcoming meeting with the client. The nurse can make an appointment to speak with her
counselor about her feelings prior to the interview. The nurse can create a list of goals to
accomplish during the interview. The nurse will not be able to elicit an adequate amount of
information if she is focusing only on being quiet during the interview.
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Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.2: Describe communication skills used by the professional nurse when
conducting a health history.
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Question 5
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Type: MCMA
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The student nurse and the experienced nurse are meeting with an elderly Vietnamese client who
is unable to speak English. Which of the following actions indicate that the student nurse
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requires further education?
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Standard Text: Select all that apply.
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1. The student nurse looks intently at the translator during the interview.
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2. The student nurse is sitting directly beside the client and both of them are facing the translator.
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3. The student nurse asks one question at a time.
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for him.
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4. The student nurse has requested that the client bring his daughter to the interview to translate
5. The student nurse states, Please tell him to void in this specimen container and to use a cleancatch technique when acquiring the urine.
Correct Answer: 1,2,4,5
Rationale 1: The student nurse looks intently at the translator during the interview. The
student nurse should look at the client during the interview, not at the translator.
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Rationale 2: The student nurse is sitting directly beside the client and both of them are
facing the translator. The student nurse should across from the client. The translator should sit
next to the client.
Rationale 3: The student nurse asks one question at a time. The student nurse should ask one
question at a time.
Rationale 4: The student nurse has requested that the client bring his daughter to the
interview to translate for him. The student nurse should not request that the client use his
daughter as the translator. The student nurse should use language assistive services that health
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care agencies must provide at all points of contact, during all hours of operation.
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Rationale 5: The student nurse states, Please tell him to void in this specimen container and
to use a clean-catch technique when acquiring the urine. The student nurse should avoid
using any medical jargon. This may be difficult for the translator to understand and translate
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well.
Global Rationale: The student nurse should look at the client during the interview, not at the
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translator. The student nurse should sit across from the client. The translator should sit next to
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the client. The student nurse should not request that the client use his daughter as the translator.
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The student nurse should use language assistive services that health care agencies must provide
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at all points of contact, during all hours of operation. The student nurse should avoid using any
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medical jargon. This may be difficult for the translator to understand and translate well. The
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student nurse should ask one question at a time.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.2: Describe communication skills used by the professional nurse when
conducting a health history.
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Question 6
Type: MCSA
The nurse is interviewing the client. The nurse states, Can you tell me exactly how you feel when
you are having difficulty catching your breath? Which of the following types of communication
techniques is the nurse utilizing specifically?
1. Focusing
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2. Attending
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3. Paraphrasing
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4. Summarizing
Correct Answer: 1
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Rationale 1: Focusing is used to help the client zero in on a subject or get in touch with feelings.
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Rationale 2: Attending is when the nurse gives the client undivided attention.
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test whether it was understood.
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Rationale 3: Paraphrasing or clarifying is when the nurse restates the clients basic message to
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Rationale 4: Summarizing is when the nurse ties together the various messages that the client
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has communicated throughout the interview.
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Global Rationale: Focusing is used to help the client zero in on a subject or get in touch with
feelings. Attending is when the nurse gives the client undivided attention. Paraphrasing or
clarifying is when the nurse restates the clients basic message to test whether it was understood.
Summarizing is when the nurse ties together the various messages that the client has
communicated throughout the interview.
Cognitive Level: Understanding
Client Need: Psychosocial Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.2: Describe communication skills used by the professional nurse when
conducting a health history.
Question 7
Type: MCSA
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The nurse is interviewing the client. The nurse says to the client, It sounds like you dont like
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communication techniques is the nurse utilizing specifically?
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your new job because its more stressful than you anticipated. Which of the following types of
1. Listening
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2. Attending
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3. Questioning
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4. Paraphrasing
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Correct Answer: 4
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Rationale 1: Listening is paying undivided attention to what the client says and does.
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Rationale 2: Giving full attention to verbal and nonverbal messages is called attending. Body
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language may be as much as 93% of the message a client sends.
Rationale 3: Questioning is a very direct way of speaking with clients to obtain subjective data
for decision making and planning care. Questioning techniques include closed and open-ended
questions.
Rationale 4: Communication skills include checking to make sure that the nurse has understood
the client accurately by paraphrasing. Paraphrasing, or clarification, means that the nurse restates
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the clients basic message back to the client to ensure that the nurse understood the clients
message correctly.
Global Rationale: Communication skills include checking to make sure that the nurse has
understood the client accurately by paraphrasing. Paraphrasing, or clarification, means that the
nurse restates the clients basic message back to the client to ensure that the nurse understood the
clients message correctly. Listening is paying undivided attention to what the client says and
does. Giving full attention to verbal and nonverbal messages is called attending. Body language
may be as much as 93% of the message a client sends. Questioning is a very direct way of
Questioning techniques include closed and open-ended questions.
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Cognitive Level: Understanding
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speaking with clients to obtain subjective data for decision making and planning care.
Client Need: Psychosocial Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Question 8
Type: MCSA
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conducting a health history.
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Learning Outcome: 10.2: Describe communication skills used by the professional nurse when
The nurse is interviewing the client. Which of the following techniques should the nurse use to
decode the clients messages?
1. Listen actively and attentively.
2. Develop and transmit an idea.
3. Use words to convey the message.
4. Use body language to convey the message.
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Correct Answer: 1
Rationale 1: Decoding a message makes communication successful and may break down if the
nurse fails to listen attentively and actively.
Rationale 2: Developing and transmitting an idea is how communication takes place.
Rationale 3: Choosing words to convey a message is the definition of encoding.
Rationale 4: Displaying body language to convey a message is the definition of encoding.
Global Rationale: Decoding a message makes communication successful and may break down
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if the nurse fails to listen attentively and actively. Developing and transmitting an idea is how
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communication takes place. Choosing words and symbols to convey a message is the definition
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of encoding. Displaying body language to convey a message is the definition of encoding.
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Cognitive Level: Remembering
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Client Need: Psychosocial Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 10.2: Describe communication skills used by the professional nurse when
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conducting a health history.
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Question 9
Type: MCSA
A client tells the nurse about two abortions she had while in college. The nurse responds, What
did you major in while you were in college? This response is evidence of which type of barrier to
communication?
1. Changing the subject
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2. False reassurance
3. Cross-examination
4. Use of technical terms
Correct Answer: 1
Rationale 1: This is an example of changing the subject. This nurse is changing the subject,
which shows insensitivity to the clients thoughts and feelings. This happens when the nurse is
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not at ease with the clients comments and is unable to deal with the content.
Rationale 2: False assurance occurs when the nurse assures the client of a positive outcome
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when there is no basis for believing in it.
Rationale 3: Cross-examination is when questions are repeatedly directed to a client, causing the
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client to feel threatened.
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Rationale 4: Use of technical terms is when the nurse uses terms that are specific to the medical
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field.
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Global Rationale: This is an example of changing the subject. This nurse is changing the
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subject, which shows insensitivity to the clients thoughts and feelings. This happens when the
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nurse is not at ease with the clients comments and is unable to deal with the content. False
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assurance occurs when the nurse assures the client of a positive outcome when there is no basis
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for believing in it. Cross-examination is when questions are repeatedly directed to a client
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causing the client to feel threatened. Use of technical terms is when the nurse uses terms that are
specific to the medical field.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 10.3: Identify barriers to effective nurse-client communication
Question 10
Type: MCSA
The nurse is interviewing a client who is in acute pain. Which of the following actions by the
nurse must be performed first?
2. Attempt to reduce the pain and complete the interview later.
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3. Proceed very quickly with the interview.
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1. Interview the family for the information.
4. Document why the interview could not be completed.
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Correct Answer: 2
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Rationale 1: Although secondary sources (family members, the medical record, and other
members of the healthcare team) can be used to gather data, the client provides the primary
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information and should be the first choice for data assessment when possible.
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Rationale 2: The ability to participate in an interview is diminished when the client is
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experiencing unrelieved or acute pain. The nurse must focus on measures to help relieve pain,
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and then gather in-depth information at another time.
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Rationale 3: The client will not be able to concentrate and provide as in-depth information as
possible if experiencing pain; regardless of how fast or slow the process takes.
Rationale 4: Pain reduction is the primary goal in this situation, as the interview must be
completed in order to obtain necessary data.
Global Rationale: The ability to participate in an interview is diminished when the client is
experiencing unrelieved or acute pain. The nurse must focus on measures to help relieve pain,
and then gather in-depth information at another time. Although secondary sources (family
members, the medical record, and other members of the healthcare team) can be used to gather
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data, the client provides the primary information and should be the first choice for data
assessment when possible. The client will not be able to concentrate and provide as in-depth
information as possible if experiencing pain; regardless of how fast or slow the process takes.
Pain reduction is the primary goal in this situation, as the interview must be completed in order
to obtain necessary data.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Client Need Sub:
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Learning Outcome: 10.3: Identify barriers to effective nurse-client communication.
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Question 11
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Type: MCSA
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The nurse is admitting a young client of Cuban descent to the hospital. The nurse responds in a
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culturally sensitive manner by choosing which of the following actions?
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1. Allowing all family members to be present during the admission
2. Ensuring that the father of the young client is provided with adequate amounts of information
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regarding the young clients care
3. Requesting that all family members wait in the waiting room
4. Ensuring that the mother of the young client is provided with adequate amounts of information
regarding the young clients care
Correct Answer: 2
Rationale 1: The head of the Cuban household is the male. The clients father should be
recognized as the decision maker in this family.
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Rationale 2: The head of the Cuban household is the male. The clients father will most likely
make decisions regarding the young clients care.
Rationale 3: The head of the Cuban household is the male. The clients father should be
recognized as the decision maker in this family.
Rationale 4: Native American groups look to mothers and grandmothers to make healthcare
decisions. In Filipino households the authority in the family is shared, yet the decisions related to
health care are made mostly by the women. The head of the Cuban household is the male. The
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father should be included when providing care for the young client.
Global Rationale: The head of the Cuban household is the male. The father should be provided
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with appropriate information regarding the young clients care. The clients father will most likely
make decisions regarding the young clients care. Native American groups look to mothers and
grandmothers to make healthcare decisions. In Filipino households the authority in the family is
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shared, yet the decisions related to health care are made mostly by the women. Determination of
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roles and relationships is important when planning health care and assisting the client to make
healthcare decisions, and the nurse should be prepared to include recognized decision makers in
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Cognitive Level: Applying
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the planning process.
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.4: Describe the influence of culture on nurse-client interactions.
Question 12
Type: SEQ
The nurse is preparing to interview the client during the initial interview. Rank the following
nursing statements in order of their most likely occurrence.
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Standard Text: Click and drag the options below to move them up or down.
Choice 1. Were almost done; do you have any questions for me?
Choice 2. May I call you Anne?
Choice 3. When you said you had been having trouble with your belly, what did you mean?
Choice 4. So, can you tell me about whats been going on with your health?
Correct Answer: 2,4,3,1
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Rationale 1: The nurse should then close the interview by allowing the client to ask questions.
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Rationale 2: The nurse should first greet the client and ask if it is all right to call the client by
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her first name.
Rationale 3: The nurse should ask questions to clarify information given by the client during the
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interview.
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Rationale 4: The nurse should initially ask generalized open-ended questions about the clients
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health status.
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Global Rationale: The nurse should greet the client and ask if it is all right to call the client by
her first name. The nurse should initially generalized open-ended questions about the clients
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health status. The nurse should ask questions to clarify information given by the client during the
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interview. The nurse should then close the interview by allowing the client to ask questions.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.4: Describe the influence of culture on nurse-client interactions.
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Question 13
Type: MCSA
While conducting the clients health history, the nurse makes little eye contact with the client and
focuses intently upon the computer while documenting the clients information. The nurse faces
the computer with legs crossed. Of the following types of nursing behaviors, which is most
appropriate way to describe this situation?
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1. A lack of empathy
2. A lack of genuineness
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3. A lack of concreteness
4. A lack of positive regard
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Correct Answer: 2
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Rationale 1: Empathy is the capacity to respond to anothers feelings and experiences as if they
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communicating well with the client.
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were your own. To a lesser extent, the nurse is displaying a lack of empathy by not
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Rationale 2: Genuineness is the ability to present oneself honestly and spontaneously. This nurse
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is demonstrating a lack of genuineness. The nurse should use direct eye contact, facial
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expressions appropriate to the situation, and open body language. Facing the client, leaning
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body language.
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forward during conversation, and sitting with arms and legs uncrossed are examples of open
Rationale 3: Concreteness means speaking to the client in specific terms instead of vague
generalities. The nurse isnt necessarily providing vague information for the client.
Rationale 4: Positive regard is the ability to appreciate and respect another persons worth and
dignity with a nonjudgmental attitude. There is nothing in this scenario to suggest that the nurse
is demonstrating a lack of positive regard.
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Global Rationale: Genuineness is the ability to present oneself honestly and spontaneously.
This nurse is demonstrating a lack of genuineness. The nurse should use direct eye contact, facial
expressions appropriate to the situation, and open body language. Facing the client, leaning
forward during conversation, and sitting with arms and legs uncrossed are examples of open
body language. Empathy is the capacity to respond to anothers feelings and experiences as if
they were your own. To a lesser extent, the nurse is displaying a lack of empathy by not
communicating well with the client. Concreteness means speaking to the client in specific terms
instead of vague generalities. The nurse isnt necessarily providing vague information for the
client. Positive regard is the ability to appreciate and respect another persons worth and dignity
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with a nonjudgmental attitude. There is nothing in this scenario to suggest that the nurse is
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demonstrating a lack of positive regard.
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Cognitive Level: Applying
Client Need: Psychosocial Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 10.5: Discuss the professional characteristics used in establishing a nurse-
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client relationship.
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Type: MCMA
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Question 14
The nurse is performing a focused interview with the client. Which of the following behaviors
indicate that the client may be feeling anxious?
Standard Text: Select all that apply.
1. While seated, the client begins to wiggle his foot back and forth quickly.
2. The client leans back in his chair and seems to move away from the nurse.
3. The client crosses his arms and becomes very quiet.
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4. The client leans forward in the chair and uncrosses his legs.
5. The client seems to be distracted and is no longer making direct eye contact with the nurse.
Correct Answer: 1,2,3,5
Rationale 1: While seated, the client begins to wiggle his foot back and forth quickly. If the
client seems restless, this can indicate that the client is anxious.
Rationale 2: The client leans back in his chair and seems to move away from the nurse. The
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client who leans back in his chair may be anxious and feels invaded by the nurses questions.
Rationale 3: The client crosses his arms and becomes very quiet. The client who crosses his
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arms is expressing anxiety.
Rationale 4: The client leans forward in the chair and uncrosses his legs. The client who
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indicates that the client is preparing to open up.
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leans forward in his chair and uncrosses his arms is not displaying anxiety. This behavior
Rationale 5: The client seems to be distracted and is no longer making direct eye contact
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with the nurse. The client who seems distracted may be disengaging from the nurses interview
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due to anxiety.
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Global Rationale: If the client seems restless, this can indicate that the client is anxious. The
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client who leans back in his chair may be anxious and feels invaded by the nurses questions. The
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client who crosses his arms is expressing anxiety. The client who seems distracted may be
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disengaging from the nurses interview due to anxiety. The client who leans forward in his chair
and uncrosses his arms is not displaying anxiety. This behavior indicates that the client may be
preparing to open up with the nurse.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 10.6: Discuss the phases of the client interview.
Question 15
Type: MCMA
The nurse is preparing to interview the hospitalized client. Which of the following statements by
the clients nurse indicates that the interview should be postponed?
1. I cant seem to get her pain under control this morning.
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Standard Text: Select all that apply.
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2. I just gave her morphine sulfate through her IV for pain about 20 minutes ago.
3. She was anxious earlier and received some lorazepam.
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5. I gave her some ibuprofen about 1 hour ago.
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4. Shes been oriented to self only since admission.
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Correct Answer: 1,2,3,4
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Rationale 1: I cant seem to get her pain under control this morning. The nurse should
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postpone the interview if the client is in pain.
Rationale 2: I just gave her morphine sulfate through her IV for pain about 20 minutes
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ago. The interview should be postponed if the client received opioid pain medications because it
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may alter the ability for the client to adequately answer the nurses questions.
Rationale 3: She was anxious earlier and received some lorazepam. The nurse should
postpone the interview if the client was given lorazepam because it can sedate the client.
Rationale 4: Shes been oriented to self only since admission. The nurse should postpone the
interview if the client is confused.
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Rationale 5: I gave her some ibuprofen about 1 hour ago. Ibuprofen will not impact the
clients ability to answer questions adequately, so the interview does not need to be postponed.
Global Rationale: The nurse should postpone the interview if the client is in pain. The interview
should be postponed if the client received opioid pain medications because it may alter the
ability for the client to adequately answer the nurses questions. The nurse should postpone the
interview if the client was given lorazepam because it can sedate the client. The nurse should
postpone the interview if the client is confused. Ibuprofen will not impact the clients ability to
answer questions adequately, so the interview does not need to be postponed.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 10.6: Discuss the phases of the client interview.
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Question 16
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Type: MCSA
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The nurse says to the client, Before the healthcare provider comes in to see you, we will need to
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spend about 30 minutes talking about your current problem and any other health issues that
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might impact how you are feeling right now. The nurse is participating in which phase of the
health assessment interview?
1. Preinteraction
2. The initial interview
3. The focused interview
4. Closure of the interview
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Correct Answer: 2
Rationale 1: Preinteraction is when the nurse prepares to meet the client and reviews any
available background information.
Rationale 2: The initial interview occurs when the nurse uses a period of time to talk with the
client and document any information that would aid in care for the current health issue.
Rationale 3: The focused interview occurs during the physical assessment, while providing
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treatment, and while providing care to the client.
Rationale 4: Closure of the interview techniques can be used at the end of the initial interview or
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the focused interview.
Global Rationale: This nurse is conducting the initial interview with this client. The health
assessment interview has three phases. Preinteraction is when the nurse prepares to meet the
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client and reviews any available background information. The initial interview occurs when the
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nurse uses a period of time to talk with the client and document any information that would aid
in care for the current health issue. The focused interview occurs during the physical assessment,
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while providing treatment, and while providing care to the client. Closure of the interview
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Cognitive Level: Applying
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techniques can be used at the end of the initial interview or the focused interview.
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.6: Discuss the phases of the client interview
Question 17
Type: MCSA
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During the preinteraction stage, the nurse is preparing for the initial interview. Which of the
following settings is the least appropriate setting for the initial interview?
1. The client has been admitted to the hospital with pneumonia. The nurse is preparing to
interview the client in the clients private hospital room.
2. The client lives at home. The nurse is preparing to interview the client in the clients living
room.
3. The client lives at home. The nurse is preparing to interview the client at a small coffee shop
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not far from the clients home.
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4. The client lives at home. The nurse is preparing to interview the client in the clients backyard.
Correct Answer: 3
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Rationale 1: It is appropriate to interview the client in the clients private hospital room.
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Rationale 2: When the client lives at home, it is appropriate to interview the client in his living
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room.
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Rationale 3: There should not be other people present during the interview because it may
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hamper the clients ability to share an adequate amount of information with the nurse.
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Rationale 4: It is appropriate to interview the client in his own backyard.
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Global Rationale: There should not be other people present during the interview because it may
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hamper the clients ability to share an adequate amount of information with the nurse. A nearby
coffee shop lacks privacy. It is appropriate to interview the client in the clients private hospital
room. When the client lives at home, it is appropriate to interview the client in his living room. It
is appropriate to interview the client in his own backyard.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.6: Discuss the phases of the client interview.
Question 18
Type: MCSA
The nurse is gathering information regarding the clients psychosocial history. Which of the
following questions would be included in this assessment?
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1. How did your father die?
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2. Have you had any major surgeries?
3. Have you noticed any change in your vision?
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4. How long have you worked for your current employer?
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Correct Answer: 4
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Rationale 1: The nurse should gather information about the reasons for the fathers death when
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creating the clients genogram and documenting the clients family history.
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Rationale 2: Surgical history is a part of medical history.
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Rationale 3: Information about vision changes would be included in the review of body systems.
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Rationale 4: Elements of the psychosocial history within the health history include gathering
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information about the clients occupational history, education, financial background, roles and
relationships, family, social structure/emotional concerns, and self-concept.
Global Rationale: Elements of the psychosocial history within the health history include
gathering information about the clients occupational history, education, financial background,
roles and relationships, family, social structure/emotional concerns, and self-concept. The nurse
should gather information about the reasons for the fathers death when creating the clients
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genogram and documenting the clients family history. Surgical history is a part of medical
history. Assessment of vision would be included in the Review of Body Systems.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 10.7: Describe the components of the nursing health history.
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Question 19
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Type: MCSA
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sources would provide the nurse with this data?
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The nurse is obtaining information about a clients past medical history. Which of the following
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1. Medication list
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2. Immunization records
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3. Average amount of hours of sleep each night
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Correct Answer: 2
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4. Marital status
Rationale 1: The clients medication list is related to current history. The description of the
clients health patterns depicts a lifestyle thread that allows the nurse to see sets of related traits,
habits, or acts that affect the clients health, which then can be compared to standard health
patterns, and identification of risk potential or subsequent nursing diagnoses can be determined.
Rationale 2: Past history includes information about childhood diseases, immunizations,
allergies, blood transfusions, major illnesses, hospitalizations, labor and deliveries, surgical
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procedures, mental, emotional or psychiatric health problems, and the use of alcohol, tobacco,
and other substances.
Rationale 3: The clients sleep pattern is related to current health history. The description of the
clients health patterns depicts a lifestyle thread that allows the nurse to see sets of related traits,
habits, or acts that affect the clients health, which then can be compared to standard health
patterns, and identification of risk potential or subsequent nursing diagnoses can be determined.
Rationale 4: The clients marital status is related to current history. The description of the clients
health patterns depicts a lifestyle thread that allows the nurse to see sets of related traits, habits,
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or acts that affect the clients health, which then can be compared to standard health patterns, and
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identification of risk potential or subsequent nursing diagnoses can be determined.
Global Rationale: Past history includes information about childhood diseases, immunizations,
allergies, blood transfusions, major illnesses, hospitalizations, labor and deliveries, surgical
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procedures, mental, emotional or psychiatric health problems, and the use of alcohol, tobacco,
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and other substances. The medication list, sleep pattern, and marital status are related to current
history. The description of the clients health patterns depicts a lifestyle thread that allows the
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nurse to see sets of related traits, habits, or acts that affect the clients health, which then can be
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diagnoses can be determined.
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compared to standard health patterns, and identification of risk potential or subsequent nursing
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Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.7: Describe the components of the nursing health history.
Question 20
Type: MCSA
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The nurse is completing a focused interview. Which of the following pieces of information
would the nurse include during this interaction?
1. Identify new nursing diagnoses after clarifying previously obtained data.
2. Review information collected during clients previous health screening activities.
3. Obtain biographic data about the client.
4. Review data from previous medical records.
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Correct Answer: 1
Rationale 1: The purpose of the focused interview is to clarify previously obtained assessment
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data, gather missing information about a specific health concern, update and identify new
diagnostic cues as they occur, guide the direction of a physical assessment as it is being
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conducted, and identify or validate probable nursing diagnoses.
Rationale 2: Reviewing information collected during the clients previous health screening
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activities can be performed during the preinteraction stage.
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Rationale 3: Obtaining the clients biographical information is included in the preinteraction
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stage.
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Rationale 4: Gathering data from previous medical records is included in the preinteraction
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stage.
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Global Rationale: The purpose of the focused interview is to clarify previously obtained
assessment data, gather missing information about a specific health concern, update and identify
new diagnostic cues as they occur, guide the direction of a physical assessment as it is being
conducted, and identify or validate probable nursing diagnoses. Gathering data from previous
medical records and biographic data about the client should be performed during the
preinteraction stage.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.7: Describe the components of the nursing health history.
Question 21
Type: MCMA
The nurse is gathering client data from secondary sources. Which of the following sources would
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the nurse utilize to collect this data?
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Standard Text: Select all that apply.
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1. The clients past medical records
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2. The client
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3. The history and physical
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4. The clients physical therapist
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Correct Answer: 1,3,4,5
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5. The clients spouse
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Rationale 1: The clients past medical records. The clients past medical records is a secondary
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source of information.
Rationale 2: The client. The client is considered the primary source of information.
Rationale 3: The history and physical. The history and physical is a secondary source of
information.
Rationale 4: The clients physical therapist. The clients physical therapist is a secondary source
of information.
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Rationale 5: The clients spouse. The clients spouse is a secondary source of information.
Global Rationale: Secondary sources are used to augment and validate previously obtained
data. The following are examples of secondary sources: medical records, the clients history and
physical, a physical therapist who has worked with the client, other healthcare personnel who
have cared for the client, and the clients spouse. The client is considered the primary source of
information.
Cognitive Level: Understanding
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need: Health Promotion and Maintenance
Learning Outcome: 10.7: Describe the components of the nursing health history.
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Question 22
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Type: SEQ
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The nurse is documenting the following information that has been collected during the health
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history. Rank the following information in the order that it should be documented.
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Standard Text: Click and drag the options below to move them up or down.
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Choice 1. Diagnosed with renal insufficiency in 1997.
Choice 2. Malignant melanoma (stage I) removed from one site in 1992.
Choice 3. Coronary artery bypass graft in July 2005.
Choice 4. Diagnosed with hypertension in 2000.
Correct Answer: 3,4,1,2
Rationale 1: The third item is the clients diagnosis of renal insufficiency in 1997.
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Rationale 2: The fourth item is the clients malignant melanoma that was removed from one site
in 1992.
Rationale 3: The first thing that should be documented is the coronary artery bypass graft in July
2005.
Rationale 4: The second item is that the client was diagnosed with hypertension in 2000.
Global Rationale: When recording data, the information should be written in descending order
from present to past. The first thing that should be documented is the coronary artery bypass
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graft in July 2005. The second item is that the client was diagnosed with hypertension in 2000.
The third item is the clients diagnosis of renal insufficiency in 1997. The fourth item is the
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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clients malignant melanoma that was removed from one site in 1992.
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 10.8: Obtain a health history.
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Type: MCSA
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Question 23
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The nurse is interviewing an older African American client and determines that a teaching plan
should be implemented. Based on the clients race, which statement by the client may prompt the
nurse to plan develop a teaching plan?
1. My hands and feet are always cold.
2. I do not take calcium replacements.
3. My blood pressure is high most of the time.
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4. Im worried that my bones may be weak.
Correct Answer: 3
Rationale 1: Caucasians have a greater risk for peripheral arterial disease than African
Americans. The client with cold hands and feet may have peripheral arterial disease.
Rationale 2: Osteoporosis risk is greater for Asians and Caucasians than for African Americans.
People with a high risk for developing osteoporosis should take calcium supplements.
Rationale 3: African Americans have a higher incidence of hypertension and hypertension-
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related kidney failure than Caucasians.
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Rationale 4: African Americans typically have higher bone densities than Caucasians and
Asians and are less likely to experience problems to due to osteoporosis.
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Global Rationale: African Americans have a higher incidence of hypertension and
hypertension-related kidney failure than Caucasians. Caucasians have a greater risk for
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peripheral arterial disease than African Americans. The client with cold hands and feet may have
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peripheral arterial disease. Osteoporosis risk is greater for Asians and Caucasians than for
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African Americans. African Americans typically have higher bone densities than Caucasians and
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Asians.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.8: Obtain a health history.
Question 24
Type: MCSA
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During the course of a health history the nurse would like to review a clients medications. Which
of the following questions is most important to ask when gathering the medication history?
1. Can you tell me how much the co-pay is for your medications?
2. Do you carry health insurance?
3. Can you tell me about any over-the-counter or prescription medications that you take?
4. Where do you store your medications in your home?
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Correct Answer: 3
Rationale 1: When gathering the medication history, the nurse does not necessarily need to ask
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about the clients co-pay.
Rationale 2: When gathering the medication history, the nurse does not necessarily need to ask
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whether the client carries health insurance or not.
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Rationale 3: The nurse should gather information about medications that the client is currently
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using. The nurse should request information about all prescribed and over-the-counter
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medications that the client takes. The use of home remedies, folk remedies, herbs, teas, vitamins,
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dietary supplements, or other substances should also be listed.
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within the home.
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Rationale 4: The nurse does not necessarily need to ask where the client stores the medications
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Global Rationale: The nurse should gather information about medications that the client is
currently using. The nurse should request information about all prescribed and over-the-counter
medications that the client takes. The use of home remedies, folk remedies, herbs, teas, vitamins,
dietary supplements, or other substances should also be listed. The medication history does not
include the clients co-pay amount, if the client has a prescription benefit plan or health insurance,
or where in the home the medications are stored.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.8: Obtain a health history.
Question 25
Type: MCSA
A client has been brought to the emergency room by a family member. The client is speaking
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incoherently. To obtain information about the clients current health status, what should the nurse
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do?
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1. Call the clients healthcare provider.
2. Call the Medical Records department to obtain other records for the client.
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3. Discuss the situation with the family member who brought the client to the hospital.
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4. Conduct a thorough physical assessment and document the health history as unable to obtain.
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Correct Answer: 3
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Rationale 1: Speaking with the clients healthcare provider may be helpful when attempting to
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gather information about the clients medical history. However, the family member may be able
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to provide more information regarding the clients current health status.
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Rationale 2: Contacting the Medical Records department to ascertain this clients old records will
be helpful when gathering information about the clients health history.
Rationale 3: The primary and best source of information for the health assessment interview is
the client. In some situations, the client might be unwilling or unable to provide information. The
nurse should use another source of information if indicated. This client is incoherent and is
accompanied by a family member. The nurse should talk with the family members.
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Rationale 4: The nurse should be able to gather information about the clients current health
status from the family member who is accompanying the client. The nurse does not need to
document that this information is unavailable.
Global Rationale: The primary and best source of information for the health assessment
interview is the client. In some situations, the client might be unwilling or unable to provide
information. The nurse should use another source of information if indicated. This client is
incoherent and is accompanied by a family member. The nurse should talk with the family
members. Phoning the healthcare provider or calling Medical Records for other admission
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information might be appropriate at a later time. The nurse should not document the health
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history as unable to obtain since family members are available to provide this information.
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Chapter 3. Taking the Health History
MULTIPLE CHOICE
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1. The nurse with a patient who complains of severe pain documents every 15 minutes about
the steps taken to try to relieve the pain (without success). The nurse also documents the time
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and content of two calls made to the patients physician requesting that the physician examine
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the patient for unexpected complications. This documentation by the nurse is likely to:
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a. cause the physician to come to the attention of the hospital administration.
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b. be questioned by the nurses supervisor for time inefficiency.
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c. be used against the nurse if a lawsuit results, because it proves the nurse was not
able to relieve the pain.
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d. justify insurance reimbursement for an extended duration of hospitalization for
the patient.
ANS: D
Documentation of complications or a patients changing condition is used by insurance
companies to justify payments for hospitalization. Documentation also serves as evidence of
standards of care in a court of law.
TOP: Purposes of Documentation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: basic care and comfort
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2. A patient who is very angry and is leaving the hospital against medical advice (AMA)
demands to have the medical chart to take, because it is her personal property. An appropriate
response would be:
a. Certainly. This hospital doesnt need to keep it if you are leaving and will not be
returning here.
b. You are entitled to the information in your chart, but the chart is the property of
the hospital. I will see about having a copy made for you.
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c. The information in your chart is confidential, and you cannot leave this facility
with it.
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d. Because you are leaving against the medical advice of your physician, you may
not have the chart.
ANS: B
The chart is the property of the facility, but the patient has a legal right to the information in it
even if she is leaving AMA.
TOP: The Medical Record KEY: Nursing Process Step: N/A
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MSC: NCLEX: N/A
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3. A student nurse is assigned to a clinical unit on which one of the patients is a nationally known
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celebrity. The student reads the chart to find out why the celebrity is being treated. The student
who is not the assigned caregiver is:
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a. motivated to learn about the health problem of this patient and is appropriately
seeking knowledge during his clinical experience.
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b. doing appropriate research about nursing care as long as information is not
divulged.
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c. violating the confidentiality of the patients record.
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d. neglecting the assigned patient load and should read the unassigned patients chart
only after his assigned work is completed.
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ANS: C
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A person reading a patients chart who is not involved in the patients care is in violation of
confidentiality. Protecting the patients privacy is of prime importance.
TOP: The Medical Record KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
4. A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced
by disruption of skin surface has the following nursing documentation: Incision clean, dry, intact.
No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from
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clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing
without complication. This documentation is:
a. an example of charting by exception.
b. evidence of the use of the nursing process.
c. using the problem-oriented medical record (POMR) format.
d. usually entered on a flow sheet for treatments and vital signs.
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ANS: B
The nursing process is evident in this documentation. Assessment, interventions, and evaluation
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are all noted.
TOP: Methods of Charting KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: basic care and comfort
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5. Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?
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a. 4 cm reddened area over sacrum. Skin intact, warm, and dry.
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b. Taking fluids poorly, but more than yesterday.
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c. Apparently comfortable all night. Offers no complaints of pain.
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ANS: A
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d. Patient says she is still slightly nauseated, would like to try some toast and tea.
Provision of specific objective datasize, location, and characteristics of the patients skinis clear
and brief and informative.
TOP: The Charting Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: basic care and comfort
6. A nurse enters a notation in a patients chart but then discovers that the notation was made in
the wrong chart. The nurse correctly:
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a. draws a single line through the notation so that it is still readable and writes
mistaken entry, his signature, and the date and time.
b. removes the page on which the error is written and rewrites the other correct
notes.
c. blacks out the note to protect the confidentiality of the patient about whom it was
written and writes in the margin wrong patient, his signature, and the date and
time.
d. whites out the wrong entry and writes the note in the chart of the correct patient.
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ANS: A
When an error is made, no attempt to hide or obliterate the error should be made, because this
KEY: Nursing Process Step: Implementation
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OBJ: Theory #6 TOP: Charting Error Corrections
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may be questioned in a court of law.
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MSC: NCLEX: Physiological Integrity: basic care and comfort
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7. A resident in a skilled nursing facility for a short-term rehabilitation following a hip
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replacement says to the nurse, I dont want to have you draw any more blood for those useless
tests. When the nurse fails to convince the patient to have the blood drawn, the most appropriate
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documentation would be:
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a. Refuses to have blood drawn. Doctor notified.
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b. Refuses to have blood drawn; says tests are useless. Doctor notified.
c. Doctor notified of failure to draw ordered blood work.
d. Blood not drawn because tests are no longer desired by patient.
ANS: B
When a patient refuses a treatment, the nurse should document the exact words of the patient
regarding why the patient is refusing care.
OBJ: Clinical Practice #2 TOP: What to Document
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KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: basic care and comfort
8. A clinic nurse is documenting in a patient chart about the pain that brought the patient to seek
medical attention. The best description is:
a. Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice
cream cake for lunch.
b. Severe pain around umbilicus, unable to sleep because of pain. Started
approximately 2 hours after lunch.
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c. Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting
worse.
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d. Peri-umbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours
after lunch. No relief from antacids.
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ANS: D
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When charting a sign or symptom, the nurse should include the quality (level 7 to 8), chronology
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(after lunch, last 3 hours), and aggravating or alleviating factors, as well as associated symptoms.
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OBJ: Clinical Practice #2 TOP: The Charting Process
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KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: basic care and comfort
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9. In a chart for a patient who has had an allergic reaction to a drug and an associated nursing
diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives,
the nurse charts Subjective: denies itching. Happy with improvement in skin. Objective: rash
fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment:
skin integrity improving. Plan: check rash daily until discharge. This type of charting is an
example of:
a. charting by exception.
b. narrative style.
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c. a problem-oriented medical record (POMR).
d. the case management system.
ANS: C
The POMR focuses on a patient problem or nursing diagnosis and typically uses the SOAP
(subjective, objective, assessment, plan) format as shown here.
TOP: Methods of Charting KEY: Nursing Process Step: N/A
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MSC: NCLEX: N/A
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10. In an agency that uses specific protocols (Standard Procedures) and charting by exception, an
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advantage compared with using traditional (narrative or problem-oriented) charting is that
charting by exception:
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a. is well suited to defending nursing actions in court.
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b. contains important data certain to be noted in the narrative sections.
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c. allows staff to learn the system quickly and easily.
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d. highlights abnormal data and patient trends.
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ANS: D
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Charting by exception enables staff to see notation of changes in a patients condition at a glance.
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TOP: Methods of Charting KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
11. If an agency is using computer-assisted charting, the nurse is responsible for:
a. learning the passwords of the staff nurses and physicians so that they can
communicate with one another.
b. guarding the confidentiality of the patient record by not leaving the patient screen
on if he leaves the terminal.
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c. teaching the patient to input information about herself, such as intake and output
or symptoms the patient may experience.
d. choosing whether he will use the computer to help in charting or continue to use
traditional paper documentation.
ANS: B
Confidentiality of computer records is as important as that of the paper chart. Nurses must also
be protective of their user passwords.
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OBJ: Theory #4 TOP: Methods of Charting
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KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe Effective Care Environment: coordinated care
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after surgery. It is most important to document:
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12. A nurse begins the shift caring for a patient who has just returned from the recovery room
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a. at the end of the shift so that the nurse can give his full attention and time to the
patients needs during the shift.
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b. a nursing care plan in the chart before assessing the patient so that the nurse can
identify priorities.
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c. at least three times during the shift: at the beginning, in the middle, at the end,
and as needed.
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d. an initial assessment of the patient and a plan based on the needs of the patient as
assessed at the beginning of the shift.
ANS: D
An initial assessment should be performed at the beginning of the shift and promptly
documented. It will determine the plan and priorities. Charting should be done as close to the
time of occurrence as possible.
OBJ: Theory #1 TOP: The Charting Process
KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: basic care and comfort
13. The nurse uses the flow sheet in patient care documentation primarily:
a. to track routine assessments, treatments, and frequently given care.
b. to eliminate written narratives and to save time.
c. in computer-assisted charting to create visual graphs showing change.
d. to improve continuity of care and exchange of information among disciplines.
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ANS: A
Flow sheets are a time saver but do not eliminate narrative charting. They are used to document
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information that is routine and that would be lost in a narrative note.
TOP: Flow Sheets KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: basic care and comfort
14. In a skilled nursing facility, if all of the following are available, the best way for the new
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nurse to obtain current information about the needs and abilities of his patients would be to use
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a. physicians order sheets.
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the:
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c. nursing Kardex.
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b. nurses admission history and physical.
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d. most recent nurses notes.
ANS: C
A nursing Kardex is a 1-page summary of the patients diagnosis and current orders, treatments,
and care needs.
TOP: Nursing Kardex KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe Effective Care Environment: coordinated care
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15. When the nurse charts in narrative or source-oriented format about the patients condition and
the nursing care provided, it is appropriate for him to record:
a. Patient will go to physical therapy after lunch.
b. Diabetes in excellent control. Continue with current insulin schedule.
c. I gave the patient a thorough bath and cut her fingernails.
d. To x-ray by wheelchair @ 10:30 AM IV infusing in left arm.
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ANS: D
Documentation that includes specific information regarding time, method of travel, destination,
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and current status (that an IV medication is infusing) is a clear example of source-oriented
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charting.
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TOP: Source Oriented Charting KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Safe Effective Care Environment: coordinated care
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16. The nurse understands that a face sheet contains information pertaining to:
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a. serial measurements and observations, such as temperature, pulse, respiration,
blood pressure, and weight.
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b. plan of care for the patient, including nursing diagnoses, goals/expected
outcomes, and nursing interventions.
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c. written report of the nursing process, record of interventions implemented, and
the patients response to them.
d. patient data, including patients name, address, phone number, insurance
company, and admitting diagnosis.
ANS: D
The type of information contained on a face sheet includes patient data, including the patients
name, address, phone number, next of kin, hospital identification number, religious preference,
place of employment, insurance company, occupation, name of admitting physician, and
admitting diagnosis.
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OBJ: Theory #4 TOP: Documentation Forms
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe Effective Care Environment: coordinated care
17. A nurse understands that the physicians directives for patient care are also referred to as the:
a. history and physical.
b. physicians orders.
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c. progress notes.
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d. face sheet.
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ANS: B
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The physicians directives for patient care are the same as the physicians orders.
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OBJ: Clinical Practice #4 TOP: The Medical Record
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KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
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18. A nurse tells her neighbor personal information about a hospitalized patient. Telling her
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neighbor about this indicates that the:
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a. nurse is actively promoting nursing as a profession, and it is important to share
information that might encourage others to pursue a nursing career.
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b. actions of the nurse are appropriate since his neighbor is his confidante, and the
neighbor has assured him the information provided will not be shared.
c. nurse has violated the confidentiality of the patient by discussing personal
information about the patient with his neighbor.
d. nurse has not violated the confidentiality of the patient because the patient is
terminal; sharing this information will not harm the patient.
ANS: C
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As a legal record, the contents of the chart must be kept confidential and can be given out only
with the patients written consent because it contains personal information regarding the patient.
Only those health professionals caring directly for the patient, or those involved in research or
teaching, should have access to the chart. Protecting the privacy of the patient is of prime
importance. Patient information is not discussed with others who are not directly involved in the
patients care.
TOP: Patient Confidentiality KEY: Nursing Process Step: N/A
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MSC: NCLEX: N/A
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19. The Quality and Safety Education for Nurses (QSEN) project has identified the most
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important pre-licensing skills for nurses as:
a. effective communication.
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b. informatics.
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c. familiarity with medical terms.
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d. writing nursing care plans.
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ANS: B
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The Quality and Safety Education for Nurses (QSEN) project has identified informatics as an
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important pre-licensing skill.
TOP: Informatics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
20. Advantages of source-oriented or narrative charting include all of the following except that
it:
a. encourages documentation of normal and abnormal findings.
b. gives information on the patients condition and care in chronological order.
c. indicates the patients baseline condition for each shift.
d. includes aspects of all steps of the nursing process.
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ANS: A
A disadvantage of source-oriented, or narrative, charting is that it encourages documentation of
both normal and abnormal findings, making it difficult to separate pertinent from irrelevant
information.
TOP: The Charting Process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
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21. Which examples of documentation would be most informative to transcribe to the patients
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medical record?
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a. Patient consumed two slices of bread and a cup of coffee at breakfast.
b. Patient does not appear to be hungry after consuming breakfast.
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c. Patient ate a small amount of bread and drank a little coffee for breakfast.
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d. Patient ate well for breakfast, lunch, and dinner and seems content.
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ANS: A
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Use of the words appears to or seems in phrases such as appears to be resting should be avoided.
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Chart the behavior; the patient either is or is not resting. Words that have ambiguous meanings
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and slang should not be used in charting. For example, how much is a little, a small amount, or a
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large amount? What do phrases such as ate well and taking fluids poorly mean? Although such
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words give a general idea of what is meant, they are not specific.
TOP: Source Oriented Charting KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe Effective Care Environment: coordinated care
COMPLETION
22. Charting that follows the nursing process and uses nursing diagnoses while placing the plan
of care within the nurses progress notes is
charting.
ANS:
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PIE
problem identification, intervention, and evaluation
The nurse needs to be able to define PIE charting.
TOP: Documentation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe Effective Care Environment: coordinated care
23. Health care professionals assigned to a patient require access to the chart to review
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information and to document care given. All contents of the chart must be kept
. The
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contents of the chart should not be discussed with persons who are not involved in the care of the
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patient.
ANS:
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confidential
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The nurse needs to be able to identify what confidentiality entails.
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TOP: Confidentiality KEY: Nursing Process Step: N/A
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MSC: NCLEX: N/A
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24. The nurse explains that should a patient return to the hospital for treatment within
ANS:
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years, the medical chart can be retrieved from medical records for review.
10
ten
Medical records are kept in the health information department of a hospital for a period of 10
years.
TOP: Storage of Medical Records KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Safe Effective Care Environment: coordinated care
25. When using a case management system of charting a(n)
, an unexpected event in
the patients condition is documented on the back of the pathway sheets.
ANS:
variance
A variance is an unexpected event in the patients course of care. An example would be a healing
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Chapter 4. Assessing Nutrition and Anthropometric Measurements
Question 1
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wound that was complicated by an infection.
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Type: MCSA
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The nurse has calculated the BMI (body mass index) of a 54-year-old client who weighs 169
pounds and is 6 feet in height, and has obtained a result of 23. The nurse would correctly
interpret this results as which of the following?
1. Mild malnutrition
2. Normal
3. Overweight
Correct Answer: 2
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Rationale 1: Mild malnutrition is considered a BMI of 1718.49.
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4. Obese class 1
Rationale 2: Normal BMI ranges between 18.5 and 24.9.
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Rationale 3: Overweight BMIs are between 25 and 29.9.
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Rationale 4: Obese class 1 BMIs are between 30 and 34.9.
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Global Rationale: Adult BMI classification places a result of 23 within the range of normal,
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which includes BMIs between 18.5 and 24.9. Mild malnutrition is considered a BMI of 1718.49.
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Overweight BMIs are between 25 and 29.9. Obese class 1 BMIs are 3034.9.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9.1: Define nutritional health.
Question 2
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Type: MCSA
The nurse is using a dietary recall tool to obtain a nutritional history on a client. The nurse must
recognize the greatest limitation of using this assessment tool is which of the following?
1. Clients do not remember liquid intake from day to day.
2. It does not reflect food preferences of the client.
3. Clients do not provide reliable nutritional information.
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4. It does not reflect occasional food habits.
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Correct Answer: 4
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Rationale 1: The diet recall does not reflect all flood and liquids taken in during the previous 24
hours or longer.
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Rationale 2: A 24-hour dietary recall does not need to reflect food preferences of the client to
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provide the needed information.
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Rationale 3: Although a 24-hour dietary recall is not the most reliable method to obtain
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information, it is considered somewhat reliable.
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Rationale 4: The food habits that are employed occasionally are not the focus of a 24-hour
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dietary recall. It is used to determine recent intake.
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Global Rationale: One limitation of the 24-hour dietary recall is that it does not, or may not,
reflect food habits that occur occasionally but not on the day recalled. It is not the most reliable
way of obtaining information since it does rely on the clients memory; however, it is considered
somewhat reliable and a useful tool for nutritional assessment. It does not need to reflect food
preferences. The diet recall does reflect all food and liquids taken in during the previous 24
hours, or longer period, if asked.
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9.6: Describe existing validated nutritional assessment tools.
Question 3
Type: MCSA
The nurse is obtaining tricep skinfold measurements on a client. Which of the following
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2. Two inches and centered below the scapula
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1. Midpoint of the arm between the scapula and the elbow
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locations would the nurse correctly use for this assessment?
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3. One inch around the umbilicus
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4. Lateral aspect of thigh
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Correct Answer: 1
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Rationale 1: Tricep skinfold measurements are done at the midpoint of the arm equidistant from
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the uppermost posterior edge of the acromion process of the scapula and the olecranon process of
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the elbow.
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Rationale 2: Tricep skinfold measurements are done at the midpoint of the arm equidistant from
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the uppermost posterior edge of the acromion process of the scapula and the olecranon process of
the elbow, not 2 inches and centered below the scapula.
Rationale 3: Tricep skinfold measurements are done at the midpoint of the arm equidistant from
the uppermost posterior edge of the acromion process of the scapula and the olecranon process of
the elbow, not at the umbilical region.
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Rationale 4: Tricep skinfold measurements are done at the midpoint of the arm equidistant from
the uppermost posterior edge of the acromion process of the scapula and the olecranon process of
the elbow, not in the lateral aspect of thigh.
Global Rationale: Tricep skinfold measurements are done at the midpoint of the arm equidistant
from the uppermost posterior edge of the acromion process of the scapula and the olecranon
process of the elbow. The remaining answers are not tricep skinfolds.
Cognitive Level: Applying
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need: Physiological Integrity
Learning Outcome: 9.4: Identify physical and laboratory parameters utilized in a nutrition
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assessment
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Question 4
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Type: MCSA
The nurse using the body mass index (BMI) to assess weight in a client should understand which
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of the following limitations of this method?
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1. There is lack of correlation of the values in the BMI table with those in height-weight tables.
2. Assumption that all individuals have equal body composition at each given weight
3. BMI is difficult to accurately calculate.
4. The BMIs use to determine the risk for obesity is reduced in individuals who are on reduced
calorie diets.
Correct Answer: 2
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Rationale 1: There is lack of correlation of the values in the BMI table with those in heightweight tables. A clinical limitation of body mass index is the assumption that all individuals
have equal body composition at each given weight. This has not been found to be true.
Rationale 2: Assumption that all individuals have equal body composition at each given
weight. A clinical limitation of body mass index is the assumption that all individuals have equal
body composition at each given weight. This has not been found to be true. The amount of
muscle mass, body fat, and bone mineral content varies according to high level of fitness, race,
and ethnic differences.
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standard formula and has a relationship with height and weight.
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Rationale 3: BMI is difficult to accurately calculate. BMI is easily calculated using the
Rationale 4: The BMIs use to determine the risk for obesity is reduced in individuals who
are on reduced calorie diets. The BMI is not used to determine the risk for obesity. The use of
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the tool is not limited by an individuals current caloric intake.
Global Rationale: A clinical limitation of body mass index is the assumption that all individuals
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have equal body composition at each given weight. This has not been found to be true. The
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amount of muscle mass, body fat, and bone mineral content varies according to high level of
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fitness, race, and ethnic differences. BMI is easily calculated using the standard formula and has
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a relationship with height and weight. The BMI is not used to determine the risk for obesity. The
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use of the tool is not limited by an individuals current caloric intake.
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Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9.4: Identify physical and laboratory parameters utilized in a nutrition
assessment.
Question 5
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Type: MCSA
The nurse is performing a nutritional assessment and is concerned about undernutrition in a
client. Which of the following conditions would cause the nurse to suspect this nutritional
disorder?
1. Renal failure
2. Hypertension
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3. Wound that will not heal
4. Delayed menopause
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Correct Answer: 3
Rationale 1: Renal failure. There are many causes of kidney failure which are not related to
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nutrition.
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Rationale 2: Hypertension. Hypertension often accompanies overnutrition.
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Rationale 3: Wound that will not heal. Undernutrition can lead to delayed growth,
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and lack of proper development.
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compromised immune status, poor wound healing, muscle loss, physical and functional decline,
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Rationale 4: Delayed menopause. Delay in menopause is not a nutritional concern.
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Global Rationale: Undernutrition can lead to delayed growth, compromised immune status,
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poor wound healing, muscle loss, physical and functional decline, and lack of proper
development. Overnutrition results from excesses in nutrient intake or stores and can manifest
itself in conditions such as obesity, hypertension, hypercholesterolemia, or toxic levels of stored
vitamins or minerals. There are many causes of kidney failure that are not related to nutrition.
Delay in menopause is not a nutritional concern.
Cognitive Level: Remembering
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9.1: Define nutritional health.
Question 6
Type: MCSA
The nurse is assessing a 12-month-old child and needs to determine length. The nurse would
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correctly use which of the following procedures to obtain this information?
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1. Get assistance to measure the child from head to toe in prone position.
2. Wait until the child is sleeping and hold the child upright in front of a tape measure attempting
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for the best accuracy possible.
3. Place the child in a supine position and measure from the crown of the head to the heel while
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holding the legs straight.
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4. Have the mother to assist the child in standing in front of a tape measure.
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Correct Answer: 3
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Rationale 1: Get assistance to measure the child from head to toe in prone position. The
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nurse may enlist help from others to measure, but the measurement is from head to heel, not head
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to toe, and not in prone position.
Rationale 2: Wait until the child is sleeping and hold the child upright in front of a tape
measure attempting for the best accuracy possible. It is incorrect to hold a client in a standing
position to obtain a height measurement, either with the client awake or asleep.
Rationale 3: Place the child in a supine position and measures from the crown of the head
to the heel while holding the legs straight. Recumbent length is obtained on persons who
cannot stand freely for height measurements. The length is measured using a device, or by
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having the person lie flat in the supine position and measuring from the crown of the head to the
heel with toes pointed upward and knees straight.
Rationale 4: Have the mother to assist the child in standing in front of a tape measure. It is
incorrect to hold a client in a standing position to obtain a height measurement, either with the
client awake or asleep.
Global Rationale: Recumbent length is obtained on persons who cannot stand freely for height
measurements. The length is measured using a device, or by having the person lie flat in the
supine position and measuring from the crown of the head to the heel with toes pointed upward
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and knees straight. It is incorrect to hold a client in a standing position to obtain a height
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measurement, either with the client awake or asleep. The nurse may enlist help from others to
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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measure, but the measurement is from head to heel, not head to toe, and not in prone position.
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet
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history.
Type: MCSA
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Question 7
The nurse is interviewing a 20-year-old client who is 14 weeks pregnant and seeking prenatal
care. She tells the nurse that she likes to eat ice and occasionally eats dirt. The nurse should
anticipate which of the following laboratory studies to be ordered?
1. Folate level
2. Calcium levels
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3. Plasma lead level
4. Hair analysis
Correct Answer: 3
Rationale 1: Folate level. Folate and calcium levels may not be affected by PICA.
Rationale 2: Calcium levels. Folate and calcium levels may not be affected by PICA.
Rationale 3: Plasma lead level. Lead levels should be obtained in pregnant women reporting
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PICA because the soil eaten can be a source of environmental contamination.
Rationale 4: Hair analysis. Hair analysis may yield information about other issues but is not
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appropriate given the above scenario.
Global Rationale: PICA refers to the craving and ingestion of nonfood substances. Lead levels
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should be obtained in pregnant women reporting PICA because the soil eaten can be a source of
environmental contamination. Folate and calcium levels may not be affected. Hair analysis may
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yield information about other issues but is not appropriate given the above scenario.
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Cognitive Level: Analyzing
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 9.2: Outline risk factors that affect nutritional health status.
Question 8
Type: MCSA
The nurse is admitting a 69-year-old client with a possible hip fracture. The client is overweight,
so the nurse understands that there is an increased likelihood risk for which of the following?
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1. Decubiti
2. Degenerative joint disease
3. Chronic pain
4. Stroke
Correct Answer: 2
Rationale 1: Decubiti. Overweight clients may be at an increased risk for the development of
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decubiti but this is not a direct finding associated with a hip fracture.
Rationale 2: Degenerative joint disease. Overweight and obesity are risk factors for
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degenerative joint disease and functional and mobility problems as a result of the stressors on the
joints from the excess weight.
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Rationale 3: Chronic pain. There is no relationship between the clients weight, possible hip
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fracture and the presence of chronic pain.
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Rationale 4: Stroke. There is inadequate information to support the risk for stroke.
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Global Rationale: Overweight and obesity are risk factors for degenerative joint disease and
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functional and mobility problems. Overweight clients may be at an increased risk for the
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development of decubiti but this is not a direct finding associated with a hip fracture. There is no
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relationship between the clients weight, possible hip fracture and the presence of chronic pain.
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There is inadequate information to support the risk for stroke.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 9.2: Outline risk factors that affect nutritional health status.
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Question 9
Type: MCSA
The nurse is teaching a newly diagnosed diabetic about appropriate serving sizes for foods. The
nurse would include which of the following estimates for a single serving of meat?
1. One cup
2. Size of a balled fist
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3. Five ounces
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4. Three ounces
Correct Answer: 4
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Rationale 1: One cup. One cup is larger than the recommended portion size for animal proteins.
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Rationale 2: Size of a balled fist. A balled fist represents a cup-sized serving, which is too large
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for a portion of animal proteins.
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Rationale 3: Five ounces. The recommended portion size for animal proteins is 3 ounces.
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Rationale 4: Three ounces. The recommended portion size for animal proteins is 3 ounces, or a
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portion approximately the same size as a deck of cards.
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Global Rationale: The recommended portion size for animal proteins is 3 ounces, which can be
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correctly estimated by comparing to the size of a deck of cards. The size of a balled fist is too
large for a serving of animal proteins. Five ounces exceeds the recommend amount for protein
intake during a single serving.
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet
history data.
Question 10
Type: MCMA
The nurse has reviewed the assessment findings for a recently admitted client. The nurse notes
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the clients dietary intake of the vitamin B complex to be lacking. Which of the findings confirm
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this deficiency?
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Standard Text: Select all that apply.
1. Loss of fat
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2. Muscle wasting
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3. Hyporeflexia
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4. Spoon nails
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Correct Answer: 3,5
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5. Ataxia
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Rationale 1: Loss of fat. A series of vitamins make up the vitamin B complex. These vitamins
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are found in meat products and whole grains. A loss of fat is associated with a deficiency in
protein or overall caloric intake.
Rationale 2: Muscle wasting. A series of vitamins make up the vitamin B complex. These
vitamins are found in meat products and whole grains. A loss of muscle tissue is associated with
a lack of protein intake.
Rationale 3: Hyporeflexia. A series of vitamins make up the vitamin B complex. These
vitamins are found in meat products and whole grains. Thiamine is also known as Vitamin B1. It
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is responsible for nervous system functioning. Thiamine deficiency is associated with
hyporeflexia.
Rationale 4: Spoon nails. Spoon nails are noted with a lack of iron intake.
Rationale 5: Ataxia. A series of vitamins make up the vitamin B complex. These vitamins are
found in meat products and whole grains. Vitamin B12 is also referred to as Cobalamin. Vitamin
B12 deficiencies are associated with ataxia.
Global Rationale: A series of vitamins make up the vitamin B complex. These vitamins are
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found in meat products and whole grains. Thiamine is also known as vitamin B1. It is responsible
for nervous system functioning. Thiamine deficiency is associated with hyporeflexia. Vitamin
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B12 is also referred to as Cobalamin. Vitamin B12 deficiencies are associated with ataxia. A
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lack of caloric intake and protein deficiency is associated with a loss of fat. Protein deficiencies
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are also associated with muscle wasting. Spoon nails are seen with iron deficiencies.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 9.6: Differentiate between normal and abnormal findings in a nutritional
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Question 11
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assessment.
Type: HOTSPOT
The nurse is using waist circumference to assess overnutrition in an adult female. Place a
horizontal line across the figure to indicate correct placement for the measurement tape.
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Correct Answer:
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Rationale : The waist circumference may be used to assess for overnutrition in a client. It is not
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Global Rationale:
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useful for determining overnutrition in a pregnant female or in the client with ascites.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9. 9: Determine specific nutritional assessment techniques and tools
appropriate for unique stages in the life span.
Question 12
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Type: MCMA
A Bioelectrical Impedance Analysis (BIA) is being performed on a client. Which of the
following is associated with this test?
Standard Text: Select all that apply.
1. Instruct the client to be NPO for 6 to 8 hours prior to the assessment.
2. Instruct the client to discontinue all vitamin and mineral supplementation for 24 hours prior to
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the assessment.
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4. Place electrodes on the dorsal surface of the clients foot.
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3. Instruct the client to lie in a supine position during the assessment.
5. Place electrodes on the dorsal surface of the clients hand.
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Correct Answer: 3,4,5
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Rationale 1: Instruct the client to be NPO for 6 to 8 hours prior to the assessment. Altered
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hydration and altered skin temperature will cause measurement error by altering electrical
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current flow. Clients should be well hydrated when employing BIA technology, or dehydration
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will slow conductivity and give a falsely high body fat measurement.
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Rationale 2: Instruct the client to discontinue all vitamin and mineral supplementation for
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24 hours prior to the assessment. Calculations are based on the knowledge that muscle and
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fluids have a higher electrolyte and water content than does fat and thus conduct electrical
current differently. Discontinuation of vitamin and mineral supplementation does not impact test
findings.
Rationale 3: Instruct the client to lie in a supine position during the assessment. During the
assessment the client will be instructed to lie in a supine position.
Rationale 4: Place electrodes on the dorsal surface of the clients foot. Electrodes are placed
on the dorsal surface of the clients foot for the test.
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Rationale 5: Place electrodes on the dorsal surface of the clients hand. Electrodes are placed
on the dorsal surface of the clients hand for the test.
Global Rationale: Bioelectrical impedance analysis (BIA) is a noninvasive tool for assessing
body composition employing principles of electroconduction through water, muscle, and fat. In
traditional BIA, electrodes are placed on the dorsal surfaces of the right foot and hand with the
client in the supine position on a nonconductive surface. Calculations are based on the
knowledge that muscle and fluids have a higher electrolyte and water content than does fat and
thus conduct electrical current differently. Altered hydration and altered skin temperature will
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cause measurement error by altering electrical current flow. Clients should be well hydrated
when employing BIA technology, or dehydration will slow conductivity and give a falsely high
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body fat measurement. Clients cannot be placed as NPO status prior to the testing for 6 to 8
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hours as this would alter the readings. The use of vitamin and mineral supplementation will not
impact test findings.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Type: MCSA
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Question 13
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Learning Outcome: 9.6: Describe existing validated nutritional assessment tools.
The nurse is assessing a 9-month-old girl during a well-child checkup. She is quiet and does not
demonstrate much social interaction. The child appears petite and unusually small for her age.
The nurse plots her height and weight on a growth chart and sees that the baby was in the 50th
percentile for weight at age 6 months, and the baby is in the 5th percentile at this visit. The nurse
suspects which of the following conditions in this child?
1. Congestive heart failure
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2. Dehydration
3. Undernutrition
4. Hypoglycemia
Correct Answer: 3
Rationale 1: Congestive Heart Failure. There is no indication the client has cardiac problems.
Rationale 2: Dehydration.There is no indication the clients hydration status is compromised.
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Rationale 3: Undernutrition. Undernutrition can lead to growth faltering, compromised
immune status, poor wound healing, muscle loss, physical and functional decline, and lack of
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proper development. The clients weight changes indicate a lack of nutritional intake.
Rationale 4: Hypoglycemia. There is no indication the client has alterations in endocrine
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function.
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Global Rationale: Undernutrition, also called malnutrition, describes health effects of
insufficient nutrient intake or stores. Children who drop at least 2 percentile bands are at risk for
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undernutrition. There are no indications the client has cardiac-healthrelated concerns.
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Cognitive Level: Applying
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Hypoglycemia is not applicable in this situation.
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment
into the nursing care process.
Question 14
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Type: MCSA
The nurse is performing anthropometric measurements on a client in the clinic setting. The nurse
would use which of the following definitions of this term when explaining this to the client?
1. The assessment is obtained by subtracting the height in centimeters from the weight in pounds
and multiplying by 2.
2. The assessment includes any scientific measurement of the body for nutritional analysis.
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3. The measurements include the use of growth chart evaluations to plot height and weight.
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4. The measurement estimates skinfold thicknesses.
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Correct Answer: 2
Rationale 1: The assessment is obtained by subtracting the height in centimeters from the
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weight in pounds and multiplying by 2. Anthropometric measurements are specific body
measurements such as height, weight, and measurement of body fat. It does not utilize the
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calculation of weight and height in this manner.
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Rationale 2: The assessment includes any scientific measurement of the body for nutritional
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analysis. Anthropometric measurements are any scientific measurements of the body.
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Rationale 3: The measurements include the use of growth chart evaluations to plot height
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and weight. Anthropometric measurements are any scientific measurements of the body. They
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are not simply growth chart evaluations.
Rationale 4: The measurement estimates skinfold thicknesses. Anthropometric measurements
are any scientific measurements of the body. They may include height, weight, measurement of
body fat, and muscle composition. They may include measurements of skinfold thickness, not
estimations.
Global Rationale: Anthropometric measurements are any scientific measurements of the body.
They may include height, weight, measurement of body fat, and muscle composition. They may
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include measurements of skin fold thickness. They are not simply growth chart evaluations or
calculations using combinations of numbers.
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9.9: Determine specific nutritional assessment techniques and tools
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appropriate for unique stages in the life span.
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Question 15
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Type: MCSA
The nurse is calculating the percent weight change of a 40-year-old female, weighing 156
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pounds 1 month ago, and 140 pounds on current examination. The nurse would correctly record:
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1. 5%
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2. 10%
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3. 12%
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4. 14.3%
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Correct Answer: 2
Rationale 1: 5%: A 5% weight loss would result in a weight of approximately 146 lb.
Rationale 2: 10%: A weight loss of 15% would result in a weight of approximately 141 lb.
Rationale 3: 12%: A weight loss of 12% would result in a weight of approximately 137 lb.
Rationale 4: 14.3%: A weight loss of 14.3% would result in a weight of approximately 134 lb.
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Global Rationale: The formula for calculating percent weight change is: [156 lbs 140 lbs/156
lbs] x 100. These calculations yield an answer of 10 percent.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet
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history data.
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Question 16
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Type: MCMA
The nurse is preparing an inservice for staff on the risk factors for poor nutritional health. Which
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Standard Text: Select all that apply.
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of the following would the nurse include as risk factors for overnutrition?
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1. Alcohol abuse
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2. Sedentary lifestyle
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3. Excess intake of fat, sugar, calories, or nutrients
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4. Lack of knowledge about food preparation
5. Lack of knowledge about portion sizes
Correct Answer: 2,3,4,5
Rationale 1: Alcohol abuse. Alcohol abuse is statistically linked to undernutrition.
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Rationale 2: Sedentary lifestyle. The lack of calorie burning activity of a sedentary lifestyle is
associated with overnutrition and weight gain.
Rationale 3: Excess intake of fat, sugar, calories, or other nutrients. Is commonly linked to
overnutrition and weight gain.
Rationale 4: Lack of knowledge about food preparation. Food preparation may result in
overnutrition as unhealthy techniques may be employed.
Rationale 5: Lack of knowledge about portion sizes. Portion control is key in the management
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of weight gain and loss. Lack of knowledge about portion control may result in over eating.
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Global Rationale: Overnutrition results from excesses in nutrient intake or stores and can
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manifest itself in conditions such as obesity, hypertension, hypercholesterolemia, or toxic levels
of stored vitamins or minerals. Sedentary lifestyles are linked to overnutrition. Individuals who
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are inactive typically require a lower caloric intake and will burn a lower number of calories. An
excessive intake of fat, sugar, calories, and other nutrition places an individual at risk for
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overnutrition. Individuals who have a lack of knowledge concerning food preparation may fix
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and consume foods that are not nutritionally balanced, possibly increasing their risk for
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overnutrition. Knowledge of recommended portion sizes helps to ensure adequate nutritional
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intake. A lack of portion size recommendations may result in overeating. Alcohol abuse is
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statistically linked to undernutrition.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9.2: Outline risk factors that affect nutritional health status.
Question 17
Type: MCMA
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The graduate nurse in orientation notices that a dietician evaluates each postoperative clients
chart. They know that this is done primarily to:
Standard Text: Select all that apply.
1. Meet a regulatory agency requirement.
2. Determine nutritional needs.
3. Check for any cultural dietary considerations.
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4. Check to see if there are any potential food-drug interactions.
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5. Assess for overnutrition.
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Correct Answer: 2,3,4
Rationale 1: Meet a regulatory agency requirement. Although the collection of dietary
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information may be needed to meet the requirements of a regulatory agency, it is not the priority
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action in this situation.
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Rationale 2: Determine nutritional needs. The assessment of a clients nutritional health
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requires a collaborative approach by multidisciplines. Postoperative clients may have different
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nutritional needs to promote healing.
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Rationale 3: Check for any cultural dietary considerations. The nutritional selections
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suggested need to incorporate a clients religious or cultural considerations, or the plan will not be
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a feasible one for the client.
Rationale 4: Check to see if there are any potential food-drug interactions. As medications
may change postoperatively, assessing for potential interactions with foods may prevent a
problem in the future.
Rationale 5: Assess for overnutrition. Concerns regarding overnutrition are not the most
important for the client who has recently had surgery.
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Global Rationale: The evaluation of the clients postoperative chart by the dietician is done to
assess the nutritional needs of the client. Clients in the postoperative phase of their care are
attempting to heal. Healing is facilitated by adequate nutritional intake. The incorporation of
cultural dietary preferences will best ensure that the client eat the foods provided by the facility
and promote adequate nutritional intake. The potential for food-drug interactions must be
included in the plan of care. Medications may be changed in the postoperative period warranting
the assessment. Determination of these potential interactions will help to prevent complications
in the client. The review of the postoperative chart may be a requirement of certain regulatory
agencies but is not the most important factor. The risk for overnutrition may exist for the client
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but is not the primary focus for the assessment of the chart during the postoperative period.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 9.5: Identify components of a diet history and techniques for gathering diet
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history.
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Question 18
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Type: MCSA
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An 80-year-old male client is brought to the emergency room by his son with a preliminary
diagnosis of dehydration. The client is agitated. When the nurse asks the client to open his mouth
for an oral exam, the client yells, You dont need to look in my mouth to see what is wrong with
me! The nurses best rationale for looking in his mouth is:
1. That a complete physical exam must be performed.
2. To assess for poorly-fitting dentures.
3. To assess for oral lesions.
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4. To assess mucous membranes.
Correct Answer: 4
Rationale 1: A complete physical exam must be performed. The completion of a physical
examination is needed during the admission process, but it is not the most important reason for
the oral examination for this client.
Rationale 2: To assess for poorly-fitting dentures. The clients poor nutritional status may be
the result of poorly fitting dentures. This will need to be determined, but it is not the most
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important reason for completing this portion of the assessment.
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Rationale 3: To assess oral lesions. The presence of oral lesions may impact the ability of the
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client to have adequate nutritional intake. The assessment for the presence of the lesions
important but not as important as the determination of the presence and degree of dehydration.
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Rationale 4: To assess mucus membranes. The condition of the mucous membranes is the
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most important rationale for the assessment of the oral cavity. The determination of the presence
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and degree of dehydration is key in beginning the clients treatment.
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Global Rationale: Poor dental health may contribute to malnutrition. If a client has oral
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ulcerations in the mouth, poorly-fitting dentures, decaying or loose teeth, it may be painful to eat
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or drink. This could cause a client to have a limited oral intake of food and fluids. Assessment of
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mucous membranes for moistness and color is part of an assessment when considering
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dehydration.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9.8: Differentiate between normal and abnormal findings in a nutritional
assessment.
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Question 19
Type: MCSA
A 24-year-old client visits the healthcare provider office for a routine yearly gynecological exam.
The nurse is providing education to the client. The client asks for an explanation of why the
nurse recommended that she take a multivitamin that contains folic acid. The nurses best
response would be:
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3. Folic acid can help with your chances of getting pregnant.
4. Most people do not get enough folic acid.
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Correct Answer: 1
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2. Everyone should take vitamin supplements.
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1. If you become pregnant, you will already be taking folic acid.
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Rationale 1: If you become pregnant, you will already be taking folic acid. The client in the
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scenario is of childbearing age. Folic acid is essential for all women of childbearing potential. It
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is important for a healthy outcome of a pregnancy. Some women are not aware of being pregnant
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at first and are not already taking folic acid. By suggesting a supplement, it will already be
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present in the body if the woman becomes pregnant.
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Rationale 2: Everyone should take vitamin supplements. Not everyone needs vitamin
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supplements or have low folic acid levels if their dietary intake is balanced and appropriate.
Rationale 3: Folic acid can help with your chances of getting pregnant. Folic acid is a
vitamin. Not everyone needs vitamin supplements or have low folic acid levels if their dietary
intake is balanced and appropriate.
Rationale 4: Most people do not get enough folic acid. Not everyone needs vitamin
supplements or have low folic acid levels if their dietary intake is balanced and appropriate.
Global Rationale: Folic acid is essential for all women of childbearing potential. It is important
for a healthy outcome of a pregnancy. It does not help a person become pregnant. Some women
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are not aware of being pregnant at first and are not already taking folic acid. By suggesting a
supplement, it will already be present in the body if the woman becomes pregnant. Not everyone
needs vitamin supplements or have low folic acid levels if their dietary intake is balanced and
appropriate.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Implementation
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Client Need Sub:
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Learning Outcome: 9.3: Discuss the objectives described in Healthy People 2020 which relate
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to nutrition.
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Question 20
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Type: MCSA
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A nurse is preparing to review an overweight clients food recall diary for the past week. Which
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of the following choices would be most helpful when teaching a client about recommended
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portion sizes?
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2. Food cups
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1. Measuring cups
3. Everyday items such as a deck of cards
4. Plastic containers
Correct Answer: 3
Rationale 1: Measuring cups. Having a client use measuring cups, food scales, and plastic
containers can be helpful when preparing foods at home, but not realistic when estimating
portion sizes at restaurants.
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Rationale 2: Food cups. Having a client use measuring cups, food scales and plastic containers
can be helpful when preparing foods at home, but not realistic when estimating portion sizes at
restaurants.
Rationale 3: Everyday items such as a deck of cards. By using everyday items such as a deck
of cards to determine meat sizes or a golf ball to determine a tablespoon measurement, a client
can learn to visually estimate appropriate portions. This visual teaching method may be a useful
and easy approach for clients.
Rationale 4: Plastic containers. Having a client use measuring cups, food scales, and plastic
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containers can be helpful when preparing foods at home, but not realistic when estimating
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portion sizes at restaurants.
Global Rationale: Determining portion sizes is difficult for most clients. When keeping a diet
diary or doing a diet recall, the client may be confused if the number of meals is adequate but he
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continues to gain weight. Having a client use measuring cups, food scales, and plastic containers
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can be helpful when preparing foods at home, but not realistic when estimating portion sizes at
restaurants. By using everyday items such as a deck of cards to determine meat sizes or a golf
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ball to determine a tablespoon measurement, a client can learn to visually estimate appropriate
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Cognitive Level: Applying
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portions. This visual teaching method may be a useful and easy approach for clients.
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment
into the nursing care process.
Question 21
Type: MCSA
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An overweight female client is reluctant to get on the scales at the healthcare providers office.
She verbalizes that she does not want to know how much she actually weighs. The nurses best
response would be:
1. The doctor requires all of her clients to be weighed.
2. This information is very important. If you step on the scales, I will just write your weight
down and not say it out loud.
4. We can just use your weight from your visit last year.
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Correct Answer: 2
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3. I really do not like it either, but it has to be done.
Rationale 1: The doctor requires all of her clients to be weighed. Explaining that the weight
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is required does not really meet the concerns being voiced by the client.
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Rationale 2: This information is very important. If you step on the scales, I will just write
your weight down and not say it out loud. A clients weight is part of the anthropometric
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measurements. The height, weight, and body fat and muscle composition are part of these
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measurements. By using these values with a physical assessment, a clients nutritional status may
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be evaluated. Promoting the confidentiality of the procedure may help to reassure and calm the
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client.
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of rights.
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Rationale 3: I really do not like it either, but it has to be done. Forcing the client is a violation
Rationale 4: We can just use your weight from your visit last year. Using a weight that is a
year old will not accurately reflect a current trend or change. The data can still be gathered for a
nutritional assessment and the clients wishes met by measuring the clients weight without
verbalizing what it is.
Global Rationale: A clients weight is part of the anthropometric measurements. The height,
weight, and body fat and muscle composition are part of these measurements. By using these
values with a physical assessment, a clients nutritional status may be evaluated. Forcing the
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client is a violation of rights. Using a weight that is a year old will not accurately reflect a current
trend or change. The data can still be gathered for a nutritional assessment and the clients wishes
met by measuring the clients weight without verbalizing what it is.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 9.10: Discuss strategies for integrating a complete nutritional assessment
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into the nursing care process.
Question 22
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Type: MCSA
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The nurse has collected data on clients who have visited a health fair in the mall. Which of the
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following clients is most in need of a detailed nutritional assessment?
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1. A 21-year-old female who has just begun college and has lost 5 pounds in the first semester
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2. A 2 year old whose mother stated that he seems to be growing faster than she can buy him
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clothes
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3. A 50-year-old male who reported that he lost 10 pounds in 6 weeks without even trying
4. A 35-year-old female who has gained 15 pounds in a year after the birth of her first child
Correct Answer: 3
Rationale 1: A 21-year-old female who has just begun college and has lost 5 pounds in the
first semester. The female that just began college has had activity and nutrition changes.
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Rationale 2: A 2 year old whose mother stated that he seems to be growing faster than she
can buy him clothes. Toddlers experience growth spurts that are normal physiological
processes.
Rationale 3: A 50-year-old male who reported that he lost 10 pounds in 6 weeks without
even trying. Unintentional weight loss is considered clinically significant and requires further
assessment. The cause is not readily apparent and may be due to a disease process.
Rationale 4: A 35-year-old female who has gained 15 pounds in a year after the birth of her
first child. In the first year after the birth of a child a woman may increase body weight as a
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result of diet, activity, and hormonal changes.
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Global Rationale: Unintentional weight loss is considered clinically significant and requires
further assessment. The cause is not readily apparent and may be due to a disease process. The
female that just began college has had activity and nutrition changes. The 2 year old seems to be
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growing sufficiently and the 35-year-old female has had recent body changes.
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Chapter 5. Assessment Techniques
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Question 1
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Type: HOTSPOT
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The nursing instructor is demonstrating, to a group of nursing students, the proper technique for
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assessing a client for fremitus. Which part of the hand will the instructor use to demonstrate
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proper technique?
Standard Text: Select the correct area on the image.
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Correct Answer:
Rationale : Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the
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base of the fingers on the ulnar surface of the hand.
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Global Rationale:
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Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when
performing physical assessment.
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Question 2
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Type: MCSA
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The nurse is preparing to assess the thorax of an infant using the assessment technique of direct
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percussion. To correctly perform this assessment the nurse will use the:
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1. hyperextended middle finger of the nondominant hand.
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3. palm of the nondominant hand.
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2. closed fist of dominant hand.
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4. fingertips of the dominant hand.
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Correct Answer: 4
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Rationale 1: Indirect percussion is the technique most commonly used and performed by placing
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the hyperextended middle finger of the nondominant hand firmly over the area to be examined
and striking it with a plexor.
Rationale 2: Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver,
and kidneys and involves placing the palm of the nondominant hand flat against the body surface
and striking the nondominant hand with the closed fist of the dominant hand.
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Rationale 3: The palm of the nondominant hand is used to assess pain and tenderness of the
gallbladder, liver, and kidneys in blunt percussion.
Rationale 4: Direct percussion is the technique of tapping the body with the fingertips of the
dominant hand. It is used to assess thorax of an infant and also to assess the sinuses of an adult
client.
Global Rationale: Direct percussion is the technique of tapping the body with the fingertips of
the dominant hand. It is used to assess the thorax of an infant and also to assess the sinuses of an
adult client. Indirect percussion is the technique most commonly used and performed by placing
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the hyperextended middle finger of the nondominant hand firmly over the area to be examined
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and striking it with a plexor. Blunt percussion is used for assessing pain and tenderness in the
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gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat
against the body surface and striking the nondominant hand with the closed fist of the dominant
hand. The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder,
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liver, and kidneys in blunt percussion.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when
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performing physical assessment.
Question 3
Type: MCSA
During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds
over most of the chest. Which of the following would be the best action for the nurse to take
next?
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1. Document this as abnormal.
2. Wet the chest hair before auscultating the chest.
3. Place the diaphragm on top of the clients shirt.
4. Switch from the diaphragm to the bell.
Correct Answer: 2
Rationale 1: The crackling sounds may or may not be an abnormal finding; the cause of the
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sounds should be fully investigated before the nurse documents the finding as abnormal.
Rationale 2: Friction on either the bell or the diaphragm from coarse body hair may cause a
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crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from
friction, the nurse should wet the hair on the clients chest before auscultation.
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Rationale 3: Auscultating lung sounds over the clients clothing will increase rather than
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decrease friction sounds.
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Rationale 4: Lung sounds are high-pitched sounds, best heard with the diaphragm of the
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stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm
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or the bell, so switching them wont make a difference.
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Global Rationale: Friction on either the bell or the diaphragm from coarse body hair may cause
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a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from
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friction, the nurse should wet the hair on the clients chest before auscultation. The crackling
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sounds may or may not be an abnormal finding; the cause of the sounds should be fully
investigated before the nurse documents the finding as abnormal. Auscultation of lung sounds
over the clients clothing will increase rather than decrease friction sounds. Lung sounds are highpitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause
abnormal crackling sounds using either the diaphragm or the bell, so switching them wont make
a difference.
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when
performing physical assessment.
Question 4
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Type: MCSA
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The nursing instructor is observing a student nurse who is performing abdominal palpation on an
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adult client. In order to assess organs that lie deep within the abdominal cavity (e.g., kidneys,
spleen), the student nurse should press on the clients abdomen using which of the following
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techniques?
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1. Downward pressure of 12 cm using the finger pads
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2. Side to side pressure of 1 cm using the finger pads
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3. Downward pressure of 24 cm using the palmar surface of the fingers
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Correct Answer: 3
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4. Light pressure using the base of the fingers (metacarpophalangeal joints)
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Rationale 1: Downward depression of 12 cm using the finger pads is not sufficient depth to
assess structures that lie deep within the abdominal cavity. This describes moderate palpation,
used for most of the structures of the body, but not the kidney or spleen.
Rationale 2: Side-to-side palpation of 1 cm in depth will not be sufficient to examine structures
that lie deep within a body cavity or those that are covered with thick muscle. This may be
sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical
lymph node).
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Rationale 3: Deep palpation of 24 cm (3/41 inches) is used to palpate an organ lying deep within
a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the
fingers of the dominant hand on the skin surface with the extended fingers of the nondominant
hand covering and guiding the fingers downward.
Rationale 4: Light pressure using the base of the fingers or metacarpophalangeal joints is the
technique used in the assessment for vibratory tremors, or fremitus.
Global Rationale: Deep palpation of 24 cm (3/41 inches) is used to palpate an organ lying deep
within a body cavity such as the spleen or the kidneys. This is done by placing the palmar
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surface of the fingers of the dominant hand on the skin surface with the extended fingers of the
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nondominant hand covering and guiding the fingers downward. Downward depression of 12 cm
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using the finger pads is not sufficient depth to assess structures that lie deep within the
abdominal cavity. This describes moderate palpation, used for most of the structures of the body,
but not the kidney or spleen. Side-to-side palpation of 1 cm in depth will not be sufficient to
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examine structures that lie deep within a body cavity or those that are covered with thick muscle.
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This may be sufficient to determine the size and consistency of a finding in the soft tissue (such
as a cervical lymph node). Light pressure using the base of the fingers or metacarpophalangeal
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Cognitive Level: Applying
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joints is the technique used in the assessment for vibratory tremors, or fremitus.
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when
performing physical assessment.
Question 5
Type: MCSA
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The nurse is preparing to assess a clients abdomen. Which of the following sequences will the
nurse use to assess this body area?
1. Percussion, Palpation, Auscultation, Inspection
2. Auscultation, Inspection, Palpation, Percussion
3. Inspection, Palpation, Percussion, Auscultation
4. Inspection, Auscultation, Percussion, Palpation
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Correct Answer: 4
Rationale 1: Assessement always begins with inspection. Percussing and palpating the abdomen
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before auscultating could alter the natural sounds of the abdomen.
Rationale 2: Assessment always begins with inspection. In the assessment of the abdomen,
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inspection is followed by auscultation.
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Rationale 3: Inspection, palpation, percussion, and auscultation is the usual order of assessment
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except when assessing the abdomen.
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Rationale 4: The nurse alters the usual order of the four basic techniques of assessment when
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examining the abdomen. The correct order for abdominal assessment is inspection, auscultation,
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percussion, and finally palpation. Percussing and palpating before auscultating could alter the
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natural sounds of the abdomen.
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Global Rationale: The nurse alters the usual order of the four basic techniques of assessment
when examining the abdomen. The correct order for abdominal assessment is inspection,
auscultation, percussion, and finally palpation. Percussing and palpating before auscultating
could alter the natural sounds of the abdomen. Assessment always begins with inspection. In the
assessment of the abdomen, inspection is followed by auscultation, then percussion, and finally
palpation. Inspection, palpation, percussion, and auscultation is the usual order of assessment
except when assessing the abdomen.
Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when
performing physical assessment.
Question 6
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Type: MCSA
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The nurse is inspecting a clients chest and upper extremities. Which of the following would be
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the appropriate method for the nurse to assess these body areas?
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1. Examine the right arm, the chest, and then the left arm.
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2. Examine the left arm, the chest, and then the right arm.
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3. Examine the left arm, the right arm, and then the chest.
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4. Examine the chest and examine the arms at the conclusion of the exam as the client is re-
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dressing.
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Correct Answer: 3
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Rationale 1: The nurse should compare the left and right arms before moving to the chest.
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Rationale 2: The nurse should compare the left and right arms before moving to the chest.
Rationale 3: Inspection begins with a survey of the clients appearance and a comparison of the
right and left sides of the body, which should be nearly symmetrical. The nurse should compare
the left and right arms before moving to the chest.
Rationale 4: The nurse should give the client privacy at the conclusion of the physical
assessment to re-dress.
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Global Rationale: Inspection begins with a survey of the clients appearance and a comparison
of the right and left sides of the body, which should be nearly symmetrical. The nurse should
compare the left and right arms before moving to the chest. The nurse should give the client
privacy at the conclusion of the physical assessment to re-dress.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Implementation
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Client Need Sub:
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Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when
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performing physical assessment.
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Question 7
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Type: MCSA
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A client has a reddened area on the left forearm. Which of the following assessment techniques
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should the nurse use to assess this area?
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1. Percussion
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2. Light palpation
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3. Moderate palpation
4. Deep palpation
Correct Answer: 2
Rationale 1: Percussion is used to determine the size and shape of organs and masses and
whether underlying tissue is solid or filled with air or fluid.
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Rationale 2: Light palpation is used to assess surface characteristics, such as skin texture, pulse,
or a tender, inflamed area near the surface of the skin.
Rationale 3: Moderate palpation is used to assess most of the other structures of the body.
Rationale 4: Deep palpation is used to assess an organ that lies deep within a body cavity.
Global Rationale: Light palpation is used to assess surface characteristics, such as skin texture,
pulse, or a tender, inflamed area near the surface of the skin. Percussion is used to determine the
size and shape of organs and masses and whether underlying tissue is solid or filled with air or
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fluid. Moderate palpation is used to assess most of the other structures of the body. Deep
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palpation is used to assess an organ that lies deep within a body cavity.
Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Cognitive Level: Applying
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Question 8
Type: MCSA
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performing physical assessment.
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Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when
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While auscultating a clients lungs, the nurse identifies more than one sound. Which of the
following should the nurse do?
1. Obtain a stethoscope with longer tubing.
2. Ask another nurse to listen to the lung sounds.
3. Hold the stethoscope tubing while listening to the lung sounds.
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4. Close the eyes and focus on one sound at a time.
Correct Answer: 4
Rationale 1: Long tubing on a stethoscope can distort sounds; this would not help the nurse
identify chest sounds.
Rationale 2: Asking another nurse to listen to the lung sounds would not help the nurse discern
the tones being heard.
Rationale 3: Touching the stethoscope tubing can cause additional sounds and should be
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avoided.
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Rationale 4: Closing the eyes and concentrating on each sound may help the nurse focus on the
sound.
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Global Rationale: Closing the eyes and concentrating on each sound may help the nurse focus
on the sound. Long tubing on a stethoscope can distort sounds; this would not help the nurse
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identify chest sounds. Asking another nurse to listen to the lung sounds would not help the nurse
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discern the tones being heard. Touching the stethoscope tubing can cause additional sounds and
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Cognitive Level: Applying
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should be avoided.
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when
performing physical assessment.
Question 9
Type: MCSA
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The nurse is assessing a clients right lower extremity and during inspection notes an area of
redness. In order to assess the temperature of the clients skin, the nurse should use which part of
the hand?
1. Fingertips
2. Metacarpophalgeal joints
3. Dorsal surface
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4. Ulnar surface
Correct Answer: 3
such as pulses, superficial lymph nodes, or crepitus.
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Rationale 1: The fingertips are used for identifying underlying skin structures and functions
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Rationale 2: The metacarpophalgeal joint area of the hand is used to assess for vibration, or
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fremitus.
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Rationale 3: The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is
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the best area to assess skin temperature.
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Rationale 4: The ulnar surface of the hand is also used to assess for fremitus.
Global Rationale: The skin on the dorsal surface of the fingers and the hand is thinner;
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therefore, it is the best area to assess skin temperature. The fingertips are used for identifying
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underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus. The
metacarpophalgeal joint area of the hand is used to assess for vibration, or fremitus. The ulnar
surface of the hand is also used to assess for fremitus.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when
performing physical assessment.
Question 10
Type: MCSA
The nurse is preparing to percuss the lower lobes of a clients lungs. The percussion technique
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appropriate for this body area would be:
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1. direct percussion.
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2. blunt percussion.
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3. indirect percussion.
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4. any of the percussion techniques.
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Correct Answer: 3
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Rationale 1: Direct percussion is the technique of tapping the body with the fingertips of the
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dominant hand. It is used to examine the thorax of an infant and to assess the sinuses of an adult.
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Rationale 2: Blunt percussion involves placing the palm of the nondominant hand flat against
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the body surface and striking the nondominant hand with the dominant hand. A closed fist of the
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dominant hand is used to deliver the blow.
Rationale 3: Percussion of the lungs is done using indirect percussion, as it produces sounds that
are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most
commonly used.
Rationale 4: In order to gain accurate objective information, it is important for the nurse to
choose the proper assessment technique, which in this situation is indirect percussion.
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Global Rationale: Percussion of the lungs is done using indirect percussion, as it produces
sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is
the most commonly used. Direct percussion is the technique of tapping the body with the
fingertips of the dominant hand. It is used to examine the thorax of an infant and to assess the
sinuses of an adult. Blunt percussion involves placing the palm of the nondominant hand flat
against the body surface and striking the nondominant hand with the dominant hand. A closed
fist of the dominant hand is used to deliver the blow. This method is used for assessing pain and
tenderness in the gallbladder, liver, and kidneys. In order to gain accurate objective information,
it is important for the nurse to choose the proper assessment technique, which in this situation is
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indirect percussion.
Client Need: Health Promotion and Maintenance
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Client Need Sub:
tp
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Cognitive Level: Remembering
ng
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when
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performing physical assessment.
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Question 11
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Type: MCMA
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The nurse is teaching a group of health assistants about the stethoscope. Which of the following
statements about the stethoscope will the nurse include in this teaching session?
Standard Text: Select all that apply.
1. The stethoscope works by blocking out environmental sounds.
2. Short tubing provides the listener with the most accurate sounds.
3. The bell of the stethoscope is used for high-pitched sounds, such as lung sounds.
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4. Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection.
5. The binaurals should fit snugly in the ears.
Correct Answer: 1,2,5
Rationale 1: The stethoscope works by blocking out environmental sounds. The stethoscope
works by blocking out environmental sounds; it does not amplify sounds in the body.
Rationale 2: Short tubing provides the listener with the most accurate sounds. Short tubing
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provides the listener with the most accurate sounds; longer tubing may distort sound.
Rationale 3: The bell of the stethoscope is used for high-pitched sounds, such as lung
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sounds. The bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart
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murmur. The diaphragm is used for high-pitched sounds, such as normal heart sounds and lung
sounds.
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Rationale 4: Cleaning the stethoscope is not necessary since it is not a vehicle for the spread
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of infection. The stethoscope should be cleaned after examining a client to prevent the spread of
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infection.
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Rationale 5: The binaurals should fit snugly in the ears. The binaurals should fit snugly yet
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comfortably in the ears.
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Global Rationale: The stethoscope works by blocking out environmental sounds; it does not
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amplify sounds in the body. Short tubing provides the listener with the most accurate sounds;
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longer tubing may distort sound. The binaurals should fit snugly yet comfortably in the ears. The
bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart murmur. The
diaphragm is used for high-pitched sounds, such as normal heart sounds and lung sounds. The
stethoscope should be cleaned after examining a client to prevent the spread of infection.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.2: Explain the purpose of equipment required to perform physical
assessment.
Question 12
Type: MCMA
The nurse uses the otoscope in the physical assessment of a client. The nurse understands that
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this instrument is used to:
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Standard Text: Select all that apply.
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1. Inspect the nose.
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3. Inspect the internal structures of the eye.
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4. Assess pulses that are not palpable.
5. Detect fungal infections of the skin.
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2. Funnel light into the ear canal.
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Correct Answer: 1,2
Rationale 1: Inspect the nose. The otoscope can be used to inspect the nose, by inserting a wide
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speculum into the clients naris.
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Rationale 2: Funnel light into the ear canal. The otoscope funnels light into the ear canal to
allow the examiner to inspect the tympanic membrane (eardrum) as well as the ear canal itself.
Rationale 3: Inspect the internal structures of the eye. The ophthalmoscope is used to inspect
the internal structure of the eye.
Rationale 4: Assess pulses that are not palpable. The Doppler uses ultrasonic waves to detect
pulses that are difficult to palpate.
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Rationale 5: Detect fungal infections of the skin. A Woods lamp produces a black light that
emits a yellow-green fluorescence on skin in the presence of a fungal infection.
Global Rationale: The otoscope can be used to inspect the nose, by inserting a wide speculum
into the clients naris. The otoscope funnels light into the ear canal to allow the examiner to
inspect the tympanic membrane (eardrum) as well as the ear canal itself. The ophthalmoscope is
used to inspect the internal structure of the eye. The Doppler uses ultrasonic waves to detect
pulses that are difficult to palpate. A Woods lamp produces a black light that emits a yellowgreen fluorescence on skin in the presence of a fungal infection.
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Cognitive Level: Remembering
tp
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Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
ng
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Learning Outcome: 6.2: Explain the purpose of equipment required to perform a complete
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physical assessment.
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Question 13
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Type: MCSA
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The nurse is using an ophthalmoscope to assess the optic disc in a client. The nurse would
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suspect hemorrhage of the optic disc is present when which of the following colors is visualized
through the red-free filter of the ophthalmoscope?
1. Green
2. Black
3. Red
4. Yellow
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Correct Answer: 2
Rationale 1: The color green is not an expected finding of fundoscopic examination of the eye.
Rationale 2: The red-free filter is used to examine the optic disc for hemorrhage. This filter
shines a green beam into the eye and if hemorrhage is present, the disc will appear black.
Rationale 3: The color red is observed as the red reflex; light reflecting off the retina when a
bright white light is shined through the pupil. This is a normal finding.
Rationale 4: Yellow is the color of a normal optic disc. This is elicited using the bright white
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light of the ophthalmoscope.
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Global Rationale: The red-free filter is used to examine the optic disc for hemorrhage. This
filter shines a green beam into the eye and if hemorrhage is present, the disc will appear black.
The color green is not an expected finding of fundoscopic examination of the eye. The color red
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is observed as the red reflex; light reflecting off the retina when a bright white light is shined
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through the pupil. This is a normal finding. Yellow is the color of a normal optic disc. This is
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Cognitive Level: Remembering
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elicited using the bright white light of the ophthalmoscope.
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.2: Explain the purpose of equipment required to perform a complete
physical assessment.
Question 14
Type: HOTSPOT
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The nursing instructor is teaching a group of nursing students the correct assessment of normal
heart sounds. Draw an arrow on the part of the stethoscope that should be used by the nursing
student to auscultate normal heart sounds.
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale :
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Global Rationale:
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.2: Explain the purpose of equipment required to perform a complete
physical assessment.
Question 15
www.mynursingtestprep.com
Type: MCSA
The nurse is about to perform a physical assessment on an adult client. Before beginning this
phase of the clients health assessment, the nurse should first:
1. Provide a gown for the client to change into.
2. Explain to the client what will happen during the examination.
3. Obtain a written consent.
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4. Wash hands in the presence of the client.
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Correct Answer: 2
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Rationale 1: The client may need to change into a gown in order for the nurse to perform the
assessment; however, the nurse should first explain what will be happening before asking the
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client to change clothing.
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Rationale 2: The first thing the nurse should do prior to beginning the physical assessment of a
client is explain to the client what is about to happen. This helps to relieve a clients anxiety and
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enlists the clients cooperation with the assessment.
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Rationale 3: Obtaining a written consent is not necessary, unless an invasive procedure will be
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performed.
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Rationale 4: Handwashing should be performed just before the nurse begins to touch the client
assessment.
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and after a full explanation of the process is given and again at the completion of the physical
Global Rationale: The first thing the nurse should do prior to beginning the physical assessment
of a client is explain to the client what is about to happen. This helps to relieve a clients anxiety
and enlists the clients cooperation with the assessment. The client may need to change into a
gown in order for the nurse to perform the assessment; however, the nurse should first explain
what will be happening before asking the client to change clothing. Obtaining a written consent
is not necessary, unless an invasive procedure will be performed. Handwashing should be
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performed just before the nurse begins to touch the client and after a full explanation of the
process is given.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when
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performing physical assessment.
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Question 16
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Type: MCSA
The nurse is assessing an anxious-appearing client who is experiencing abdominal pain. The
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nurse should use which of the following techniques to put the client at ease when assessing the
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clients abdomen?
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1. Palpate known painful areas first.
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2. Touch each area lightly before applying deeper palpation.
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3. Perform the exam as quickly as possible.
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4. Refrain from conversation during the assessment.
Correct Answer: 2
Rationale 1: Known painful areas are usually the last area to be palpated as pain and tenderness
cause the client to tense.
Rationale 2: Touch informs the client that the examination of the area is about to begin and may
prevent a startled reaction.
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Rationale 3: Touch informs the client that the examination of the area is about to begin and may
prevent a startled reaction.
Rationale 4: The client will be more relaxed if the nurse talks during the assessment, explaining
each movement in advance. The nurse often needs to ask the client questions during the
assessment to gain a broader knowledge of the clients health.
Global Rationale: Known painful areas are usually the last area to be palpated as pain and
tenderness cause the client to tense. Touch informs the client that the examination of the area is
about to begin and may prevent a startled reaction. The nurse should proceed slowly, using
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smooth, deliberate movements during the exam. The client will be more relaxed if the nurse talks
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during the assessment, explaining each movement in advance. The nurse often needs to ask the
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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client questions during the assessment to gain a broader knowledge of the clients health.
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when
Type: MCSA
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Question 17
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performing physical assessment.
The nurse is assessing an adult client when suddenly the client refuses to continue the
examination. What is the nurses next step?
1. Give the client a short break and then resume the assessment.
2. Document what was done and what was refused.
3. Summon another nurse to the room to serve as a witness.
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4. Enlist the assistance of the clients family to encourage the rest of the assessment.
Correct Answer: 2
Rationale 1: The nurse must never attempt to influence or coerce the client to agree to a
procedure; giving the client a break and then resuming the assessment could be viewed as a form
of coercion.
Rationale 2: The client has the right to refuse care. It is important to document what has been
done and what, if anything, has been refused.
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Rationale 3: It is not necessary for another nurse to witness a clients refusal of care. The nurse
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should document what was done and what the client refused.
Rationale 4: Allowing a family member to be present during the assessment may be helpful, but
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the clients wishes (refusal) must be respected.
Global Rationale: The client has the right to refuse care. It is important to document what has
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been done and what, if anything, has been refused. The nurse must never attempt to influence or
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coerce the client to agree to a procedure; giving the client a break and then resuming the
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assessment could be viewed as a form of coercion. It is not necessary for another nurse to
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witness a clients refusal of care. The nurse should document what was done and what the client
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refused. Allowing a family member to be present during the assessment may be helpful, but the
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clients wishes (refusal) must be respected.
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Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when
performing physical assessment.
Question 18
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Type: MCMA
The nurse is preparing to perform a complete health assessment on a client. Which of the
following activities should the nurse perform just prior to this examination?
Standard Text: Select all that apply.
1. Put on nonsterile gloves.
2. Provide an opportunity for the client to void.
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3. Wash hands in the presence of the client.
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4. Turn on soft music to relax the client.
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5. Lower the lights in the room to prevent glare.
Correct Answer: 2,3
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Rationale 1: Put on nonsterile gloves. Gloves are needed only if the nurse may come into
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contact with the clients blood or body fluids, such as during the assessment of the genitalia or
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anus.
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Rationale 2: Provide an opportunity for the client to void. The client should be given an
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opportunity to void prior to physical assessment. This helps the client feel more comfortable and
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facilitates the assessment of the abdomen and reproductive organs.
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Rationale 3: Wash hands in the presence of the client. The nurse should always perform
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handwashing in the presence of the client prior to physical contact. This demonstrates that the
nurse is providing for the clients safety and also protects the nurse.
Rationale 4: Turn on soft music to relax the client. The assessment should take place in a
quiet environment in order for the nurse to correctly identify sounds and their characteristics.
Rationale 5: Lower the lights in the room to prevent glare. The room should be brightly lit to
facilitate good visibility.
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Global Rationale: The client should be given an opportunity to void prior to physical
assessment. This helps the client feel more comfortable and facilitates the assessment of the
abdomen and reproductive organs. The nurse should always perform handwashing in the
presence of the client prior to physical contact. This demonstrates that the nurse is providing for
the clients safety and also protects the nurse. Gloves are needed only if the nurse may come into
contact with the clients blood or body fluids, such as during the assessment of the genitalia or
anus. The assessment should take place in a quiet environment in order for the nurse to correctly
identify sounds and their characteristics. The room should be brightly lit to facilitate good
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visibility.
Cognitive Level: Applying
tp
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Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when
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performing physical assessment.
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Question 19
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Type: MCSA
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The nurse is assessing a client for hepatomegaly by percussing over the liver. The nurse would
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expect to hear which of the following sounds when percussing the liver?
1. Loud, low-pitched
2. Soft, high-pitched
3. Drum-like
4. Abnormally loud
Correct Answer: 2
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Rationale 1: Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs
such as the intestines.
Rationale 2: Dullness is a soft, high-pitched tone of short duration, usually heard over solid
organs such as the liver.
Rationale 3: Resonance is a loud, low-pitched tone of normal findings over the lungs.
Rationale 4: Hyperresonance is an abnormally loud, low tone of longer duration heard when air
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is trapped in the lungs.
Global Rationale: Dullness is a soft, high-pitched tone of short duration, usually heard over
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solid organs such as the liver. Tympany is a loud, high-pitched, drum-like tone that is heard over
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air-filled organs such as the intestines. Resonance is a loud, low-pitched tone of normal findings
over the lungs. Hyperresonance is an abnormally loud, low tone of longer duration heard when
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air is trapped in the lungs.
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Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Question 20
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physical assessment.
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Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of
Type: MCSA
A client is brought to the emergency department by ambulance after being found on the floor by
a family member. The nurse begins the assessment of the client. Which of the following findings
would indicate, to the nurse, the need for a more detailed neurological assessment of this client?
1. Asymmetry of the clients smile
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2. Grimacing with movement
3. Talking in a loud voice
4. Inability to follow directions
Correct Answer: 1
Rationale 1: Asymmetry of facial expressions is a cue that the client may be experiencing a
neurological problem and the nurse should perform an assessment of the cranial nerves.
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Rationale 2: Grimacing with movement provides a cue that the client may be experiencing a
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musculoskeletal problem.
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Rationale 3: Talking in a loud voice may cue the nurse that the client has hearing loss.
Rationale 4: The clients inability to follow directions may also be the result of a hearing loss.
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Global Rationale: Asymmetry of facial expressions is a cue that the client may be experiencing
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a neurological problem and the nurse should perform an assessment of the cranial nerves.
Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal
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problem. Talking in a loud voice may cue the nurse that the client has hearing loss. The clients
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Cognitive Level: Analyzing
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inability to follow directions may also be the result of a hearing loss.
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of
physical assessment.
Question 21
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Type: MCSA
The nurse is performing an abdominal assessment and has just completed inspection. Which of
the following techniques would the nurse correctly choose to use next in this assessment?
1. Percussion
2. Palpation
3. Transillumination
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4. Auscultation
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Correct Answer: 4
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Rationale 1: Percussing before auscultating the abdomen may alter the natural sounds of the
abdomen.
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Rationale 2: Palpation prior to auscultation of the abdomen could alter the natural sounds;
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therefore auscultation is performed immediately following inspection.
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Rationale 3: Transillumination of the abdomen is not part of the abdominal assessment.
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Rationale 4: Auscultation of the abdomen is the assessment technique that follows inspection. It
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is important to listen before touching to avoid altering a clients natural abdominal sounds.
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Global Rationale: Auscultation of the abdomen is the assessment technique that follows
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inspection. It is important to listen before touching to avoid altering a clients natural abdominal
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sounds. Percussing before auscultating the abdomen may alter the natural sounds of the
abdomen. Palpation prior to auscultation of the abdomen could alter the natural sounds, therefore
auscultation is performed immediately following inspection. Transillumination of the abdomen is
not part of the abdominal assessment
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
www.mynursingtestprep.com
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of
physical assessment.
Question 22
Type: MCSA
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The nurse is using a Doppler ultrasonic stethoscope to assess a clients pulse in the lower
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extremity and is unable to locate the pulse. What is the nurses next action?
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1. Check the pressure applied to the probe.
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3. Immediately inform the healthcare provider.
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2. Add more gel to the end of the probe.
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4. Send the equipment for repair.
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Correct Answer: 1
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Rationale 1: Heavy pressure to the probe should be avoided because it may impede blood
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flowthe probe should be placed gently against the clients skin, over the artery to be auscultated.
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interference.
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Rationale 2: A small amount of gel is applied to the end of the Doppler probe to eliminate
Rationale 3: Informing the healthcare provider may be premature until it is determined that the
Doppler probe is being used correctly.
Rationale 4: Sending the equipment for repair is premature at this time.
Global Rationale: Heavy pressure to the probe should be avoided because it may impede blood
flowthe probe should be placed gently against the clients skin, over the artery to be auscultated.
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A small amount of gel is applied to the end of the Doppler probe to eliminate interference.
Informing the healthcare provider may be premature until it is determined that the Doppler probe
is being used correctly. Sending the equipment for repair is premature at this time.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of
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physical assessment.
Question 23
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Type: MCSA
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A client has a visible pulsation in the middle of his abdomen. The assessment technique the
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nurse should use to assess this pulsation is:
2. Light palpation.
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3. Moderate palpation.
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1. Percussion.
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4. Deep palpation.
Correct Answer:
Rationale 1: Percussion is used to determine the size and shape of organs and masses and
whether underlying tissue is solid or filled with air or fluid.
Rationale 2: Light palpation is used to assess surface characteristics, such as skin texture, pulse,
or a tender, inflamed area near the surface of the skin.
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Rationale 3: With moderate palpation, the nurse uses the palmar surface of the fingers to
determine the depth, size, shape, consistency, and mobility of organs, as well as any pain,
tenderness, or pulsations that might be present.
Rationale 4: Deep palpation is used to assess an organ that lies deep within a body cavity.
Global Rationale: With moderate palpation, the nurse uses the palmar surface of the fingers to
determine the depth, size, shape, consistency, and mobility of organs, as well as any pain,
tenderness, or pulsations that might be present. Percussion is used to determine the size and
shape of organs and masses and whether underlying tissue is solid or filled with air or fluid.
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Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender,
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inflamed area near the surface of the skin. Deep palpation is used to assess an organ that lies
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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deep within a body cavity.
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of
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Type: MCSA
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Question 24
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physical assessment.
The nurse is conducting an assessment of a client with right lower quadrant abdominal pain.
Which of the following should the nurse do when palpating the abdomen of this client?
1. Assess the painful area first using moderate palpation.
2. Assess the painful area last using deep palpation.
3. Assess the painful area last using light palpation.
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4. Assess the painful area first using deep palpation.
Correct Answer: 2
Rationale 1: Painful areas are not palpated first.
Rationale 2: Known painful areas of the body are usually the last area to be palpated. The
assessment of structures of the abdomen requires moderate to deep palpation.
Rationale 3: Light palpation is used to evaluate surface characteristics, not the structures of the
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abdomen.
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Rationale 4: While deep palpation is the appropriate technique, the painful area is examined last.
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Global Rationale: Known painful areas of the body are usually the last area to be palpated. The
assessment of structures of the abdomen requires moderate to deep palpation. Painful areas are
not palpated first. Light palpation is used to evaluate surface characteristics, not the structures of
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the abdomen. While deep palpation is the appropriate technique, the painful area is examined
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last.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of
physical assessment.
Question 25
Type: MCSA
While percussing a clients lung area the nurse notes a flat tone. This tone would indicate:
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1. The nurse is percussing over a bone.
2. A normal finding.
3. The lungs are solidified.
4. Air is trapped in the lungs.
Correct Answer: 1
Rationale 1: Flat tones are high-pitched, soft tones of short duration and are the result of
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percussion over solid tissue such as muscle or bone.
Rationale 2: Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of
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long duration known as resonance.
Rationale 3: Solidified areas of the lung will produce dullness on percussion, a high-pitched soft
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tone of short duration.
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Rationale 4: Percussion over the lung where air has become trapped produces an abnormally
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loud, low tone of longer duration than resonance.
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Global Rationale: Flat tones are high-pitched, soft tones of short duration are the result of
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percussion over solid tissue such as muscle or bone. Percussion over normal lung tissue should
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elicit a loud, low-pitched, hollow tone of long duration known as resonance. Solidified areas of
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the lung will produce dullness on percussion, a high-pitched soft tone of short duration.
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Percussion over the lung where air has become trapped produces an abnormally loud, low tone of
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longer duration than resonance.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of
physical assessment.
Question 26
Type: MCSA
The nurse is unable to palpate a clients pedal pulses. Which of the following items will the nurse
use to help locate this clients pedal pulses?
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1. Stethoscope
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2. Doppler
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3. Transilluminator
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4. Goniometer
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Correct Answer: 2
Rationale 1: A stethoscope is used to auscultate body sounds such as blood pressure and heart,
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lung, and abdominal sounds.
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Rationale 2: The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a
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regular stethoscope, such as peripheral pulses.
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Rationale 3: A transilluminator detects blood, fluid, or masses in body cavities.
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Rationale 4: A Goniometer is used to measure the degree of joint flexion and extension.
Global Rationale: The Doppler uses ultrasonic waves to detect sounds that are difficult to hear
with a regular stethoscope, such as peripheral pulses. A stethoscope is used to auscultate body
sounds such as blood pressure and heart, lung, and abdominal sounds. A transilluminator detects
blood, fluid, or masses in body cavities. A goniometer is used to measure the degree of joint
flexion and extension.
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of
physical assessment.
Question 27
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Type: MCSA
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While performing a physical assessment on an adult client, the nurse identifies an unfamiliar
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heart sound. The nurse suspects that this is a murmur. What is the nurses next step?
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1. Inform the client of the abnormality.
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2. Stop the assessment and refer the client to the healthcare provider immediately.
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3. Bring in another examiner to assess the finding.
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4. Document the finding and reassess at the clients next visit.
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Correct Answer: 3
Rationale 1: When the nurse identifies an unfamiliar finding, it is appropriate to consult with a
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colleague to assess the finding.
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Rationale 2: Informing the client of the abnormality may cause the client undue anxiety, as the
finding may be a normal variant.
Rationale 3: The nurse needs to complete the assessment before deciding on the urgency of
referral to the health care provider, and this includes having a colleague assess the nurses
unfamiliar finding.
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Rationale 4: The finding should be investigated at this visit, first by asking another examiner to
assess the concern.
Global Rationale: When the nurse identifies an unfamiliar finding, it is appropriate to consult
with a colleague to assess the finding. Informing the client of the abnormality may cause the
client undue anxiety, as the finding may be a normal variant. The nurse needs to complete the
assessment before deciding on the urgency of referral to the healthcare provider, and this
includes having a colleague assess the nurses unfamiliar finding. The finding should be
investigated at this visit, first by asking another examiner to assess the concern.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of
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physical assessment.
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Question 28
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Type: MCSA
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The nurse is preparing to examine several clients in the clinic setting. Which of the following
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clients would need the greatest degree of special consideration during a physical examination?
1. 59-year old with flu symptoms
2. 3-year-old child in for a well check-up
3. 17-year old who complains of fatigue
4. 68-year old with chronic lung disease
Correct Answer: 4
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Rationale 1: A client ill with an acute condition such as a flu-like illness is not the same risk
category as the older client with a chronic disease.
Rationale 2: Assessment approaches and techniques may vary for children, but a 3-year old is
not considered at the same risk potential as a client with a chronic respiratory illness.
Rationale 3: Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but
in general the position changes required during the complete health assessment should not be
taxing on a teen.
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Rationale 4: Clients who are frail, weak, debilitated, or suffering from a chronic illness may
become extremely fatigued during the physical examination due to frequent position changes.
and should complete the exam in a timely fashion.
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The nurse should make every effort to minimize the number of position changes for the client
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Global Rationale: Clients who are frail, weak, debilitated, or suffering from a chronic illness
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may become extremely fatigued during the physical examination due to frequent position
changes. The nurse should make every effort to minimize the number of position changes for the
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client and should complete the exam in a timely fashion. A client ill with an acute condition such
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as a flu-like illness is not the same risk category as the older client with a chronic disease.
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Assessment approaches and techniques may vary for children, but a 3-year old is not considered
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at the same risk potential as a client with a chronic respiratory illness. Fatigue in a teenager may
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indicate anemia or it may be caused by lack of sleep, but in general the position changes required
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during the complete health assessment should not be taxing on a teen.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of
physical assessment.
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Question 29
Type: MCMA
The nurse is preparing to assess an adult client who presents to the emergency room after falling
down some steps at home. The client complains of left ankle pain and has open abrasions to the
left knee and shin. Which of the following should the nurse incorporate into the physical
assessment of this client?
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Standard Text: Select all that apply.
1. Wash hands in the presence of the client.
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2. Put on nonsterile gloves to examine the client.
3. Ensure that the client has an empty bladder before beginning the physical assessment.
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4. Instruct the client to hold all questions and comments until the completion of the assessment
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so that the nurse can focus on the exam.
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5. Assess only the left lower extremity since this is the injured body part.
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Correct Answer: 1,2
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Rationale 1: Wash hands in the presence of the client. The nurse should always perform
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handwashing prior to physical contact with a client.
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Rationale 2: Put on nonsterile gloves to examine the client. Because this client has open
wounds, the nurse should wear gloves during the physical assessment to protect against bloodborne pathogens.
Rationale 3: Ensure that the client has an empty bladder before beginning the physical
assessment. When the clients abdomen will be examined, it is important to have the client empty
the bladder to promote client comfort and facilitate the examination. It is not a priority in this
situation.
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Rationale 4: Instruct the client to hold all questions and comments until the completion of
the assessment so that the nurse can focus on the exam. The nurse should encourage the client
to ask questions and offer comments during assessment. This helps the nurse gain accurate
information and helps to relieve a clients anxiety.
Rationale 5: Assess only the left lower extremity since this is the injured body part. The
nurse should always do a comparison of both sides of the body.
Global Rationale: The nurse should always perform handwashing prior to physical contact with
a client. Because this client has open wounds, the nurse should wear gloves during the physical
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assessment to protect against blood-borne pathogens. When the clients abdomen will be
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examined, it is important to have the client empty the bladder to promote client comfort and
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facilitate the examination. It is not a priority in this situation. The nurse should encourage the
client to ask questions and offer comments during assessment. This helps the nurse gain accurate
information and helps to relieve a clients anxiety. The nurse should always do a comparison of
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both sides of the body.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Question 30
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Learning Outcome: 6.5: Apply the principles of Standard Precautions in practice.
Type: MCSA
A senior nursing student is working in an elementary school with the school nurse. The student
cares for a child who fell on the school playground and sustained multiple abrasions to the lower
extremities. Which action by the nursing student would require immediate intervention by the
school nurse?
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1. The student nurse puts on nonsterile gloves prior to assessing the childs injuries.
2. The student nurse disposes of blood-soaked gauze in the office trash bin.
3. The student nurse performs handwashing before touching the child.
4. The student nurse asks the child permission to assess the injuries.
Correct Answer: 2
Rationale 1: The use of nonsterile gloves protects the student nurse from direct contact with the
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childs blood.
Rationale 2: The student nurse should dispose of waste soiled with blood and/or body fluids in a
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biohazard bin, not the office trash bin.
Rationale 3: Handwashing should be performed before and after client care.
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Rationale 4: Asking permission to assess the childs injuries gains the childs attention and
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cooperation.
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Global Rationale: The student nurse should dispose of waste soiled with blood and/or body
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fluids in a biohazard bin, not the office trash bin. The use of nonsterile gloves protects the
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student nurse from direct contact with the childs blood. Handwashing should be performed
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before and after client care. Asking permission to assess the childs injuries gains the childs
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attention and cooperation.
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Chapter 6. General Survey and Assessing Vital Signs
Question 1
Type: MCSA
The nurse is entering the room to assess a newly admitted client. Which of the following best
describes the purpose for a general survey? The general survey:
1. allows for vital signs prior to starting exam.
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2. provides an opportunity for the client to relax before the exam.
3. yields information to guide the physical assessment.
4. provides the information necessary for the diagnosis.
Correct Answer: 3
Rationale 1: Vital signs are not part of the general survey. The general survey consists of four
major observations: physical appearance, mental status, mobility, and behavior.
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Rationale 2: The purpose of the general survey is to allow the nurse the opportunity to gather
clues to guide the rest of the assessment; the purpose is not to give the client an opportunity to
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relax.
Rationale 3: The general survey allows the nurse to observe the client and gain clues to guide
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the remainder of the assessment.
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Rationale 4: The general survey does not provide the necessary information to identify client
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problems or nursing diagnosis, but rather serves as a guide for a more detailed assessment.
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Global Rationale: The general survey allows the nurse to observe the client and gain clues to
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guide the remainder of the assessment. Vital signs are not part of the general survey. The purpose
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of the general survey is to allow the nurse the opportunity to gather clues to guide the rest of the
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assessment; the purpose is not to give the client an opportunity to relax. The general survey
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consists of four major observations: physical appearance, mental status, mobility, and behavior.
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The general survey does not provide the necessary information to identify client problems or
nursing diagnosis, but rather serves as a guide for a more detailed assessment.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub: Safety and Infection Control
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 7.1: Describe the general survey as part of a comprehensive health
assessment.
Question 2
Type: MCSA
The nurse observes the client walking into the room and climbing up on the exam table. The
nurse notes this activity as a way to obtain data related to which of the following?
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1. The clients mobility status
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2. Subjective assessments related to ambulation
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3. Activity tolerance
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4. Strength of upper and lower extremities
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Correct Answer: 1
Rationale 1: During a general survey, the nurse observes the client performing routine activities,
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such as walking and sitting. This allows the nurse to begin to gather data about the clients
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mobility. These data will then be incorporated into the remainder of exam and history.
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Rationale 2: Observation is an objective assessment.
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Rationale 3: Activity tolerance is not a component of the general survey. The general survey
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consists of physical appearance, mental status, mobility, and behavior.
Rationale 4: Watching the client walk and sit gives the nurse information about the strength of a
clients lower extremities, but tells the nurse nothing about the clients upper extremity strength.
Global Rationale: During a general survey, the nurse observes the client performing routine
activities, such as walking and sitting. This allows the nurse to begin to gather data about the
clients mobility. These data will then be incorporated into the remainder of exam and history.
Observation is an objective assessment. Activity tolerance is not a component of the general
survey. The general survey consists of physical appearance, mental status, mobility, and
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behavior. Watching the client walk and sit gives the nurse information about the strength of a
clients lower extremities, but tells the nurse nothing about the clients upper extremity strength.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.1: Describe the general survey as part of the comprehensive health
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assessment.
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Question 3
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Type: MCMA
The nurse is assessing an adult client. Which of the following observations should the nurse
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Standard Text: Select all that apply.
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include when documenting the general survey of this client?
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1. Blood pressure 112/68, pulse 68, 98.6 (F), respiratory rate 16.
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2. Thin, well-nourished male client, appears younger than stated age.
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3. Client moves about exam room without difficulty.
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4. Abdomen flat, nondistended, bowel sounds present, nontender on palpation.
5. Responds appropriately to questions.
Correct Answer: 2,3,5
Rationale 1: Blood pressure 112/68, pulse 68, 98.6 (F), respiratory rate 16. The vital signs are
objective information, but not part of the actual general survey.
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Rationale 2: Thin, well-nourished male client, appears younger than stated age. The general
survey is composed of 4 major categories of observation: physical appearance, mental status,
mobility, and behavior of the client. The documentation thin, well-nourished male client,
appears younger than stated age reflects the clients physical appearance, one of the components
of the general survey.
Rationale 3: Client moves about exam room without difficulty. The documentation client
moves about exam room without difficulty describes the clients overall mobility, another
component of the general survey.
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Rationale 4: Abdomen flat, nondistended, bowel sounds present, nontender on palpation.
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The documentation abdomen flat, nondistended, bowel sounds present, nontender on palpation is
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specific to the abdominal assessment and not part of the general survey.
Rationale 5: Responds appropriately to questions. The documentation responds appropriately
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to questions comments on the nurses observations regarding the clients behavior and mental
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status, 2 other components of the general survey.
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Global Rationale: The general survey is composed of 4 major categories of observation:
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physical appearance, mental status, mobility, and behavior of the client. The documentation thin,
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well-nourished male client, appears younger than stated age reflects the clients physical
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appearance, one of the components of the general survey. The documentation client moves about
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exam room without difficulty describes the clients overall mobility, another component of the
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general survey. The documentation responds appropriately to questions comments on the nurses
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observations regarding the clients behavior and mental status, 2 other components of the general
survey. The vital signs are objective information, but not part of the actual general survey. The
documentation abdomen flat, nondistended, bowel sounds present, nontender on palpation is
specific to the abdominal assessment and not part of the general survey.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.2: Identify components of the general survey.
Question 4
Type: MCSA
The nurse is preparing to assess a clients mental status within the general survey. Which of the
following should the nurse use to assess this status?
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1. Note the number of times the client looks to significant other while answering interview
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questions.
2. Ask the client to describe elements of his health history.
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3. Study the clients clothing selections.
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4. Notice the clients ability to make eye contact during the examination.
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Correct Answer: 2
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Rationale 1: Observing the client walking into the examination room would help assess
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mobility.
Rationale 2: The general survey is composed of four major categories of observation: physical
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appearance, mental status, mobility, and client behavior. Asking the client to describe elements
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of his health history would help assess mental status.
Rationale 3: Studying the clients clothing selections would help assess physical appearance.
Rationale 4: Noticing the clients ability to make eye contact would help assess client behavior.
Global Rationale: The general survey is composed of four major categories of observation:
physical appearance, mental status, mobility, and client behavior. Asking the client to describe
elements of his health history would help assess mental status. Observing the client walking into
the examination room would help assess mobility. Studying the clients clothing selections would
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help assess physical appearance. Noticing the clients ability to make eye contact would help
assess client behavior.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 7.2: Identify parts of the general survey.
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Question 5
Type: MCSA
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During an interview with an older adult client, the nurse notes the client is confused as to day
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and time. The nurse would document this finding as an indicator of which of the following?
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1. Affect and mood
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3. Willingness to cooperate
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4. Level of anxiety
Correct Answer: 2
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2. Orientation
Rationale 1: The clients affect and mood are revealed through speech, body language and facial
expression.
Rationale 2: Clients ability to state name, location, and the date and time of day assesses
orientation to person, place, and time.
Rationale 3: The client was not uncooperative, but rather confused to day and time.
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Rationale 4: Like affect and mood, the clients level of anxiety is revealed through speech, body
language and facial expression.
Global Rationale: Clients ability to state name, location, and the date and time of day assesses
orientation to person, place, and time. The clients affect and mood are revealed through speech,
body language and facial expression. The client was not uncooperative, but rather confused to
day and time. Like affect and mood, the clients level of anxiety is revealed through speech, body
language and facial expression.
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Cognitive Level: Applying
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Client Need: Psychosocial Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 7.2: Identify components of the general survey.
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Question 6
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Type: MCSA
The nurse is obtaining the initial vital signs on a client in the emergency room with seizure
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activity of unknown etiology. The nurse should choose which of the following methods to obtain
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1. Axillary
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the most accurate reading of the clients temperature?
2. Oral
3. Rectal
4. Tympanic
Correct Answer: 3
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Rationale 1: Although axillary is the safest, it is also the least accurate.
Rationale 2: Measuring the temperature orally requires the clients cooperation, which is not
possible during seizure activity.
Rationale 3: A rectal temperature should be taken if the client is comatose, confused, having
seizures, or unable to close the mouth.
Rationale 4: Measuring the temperature tympanically requires the clients cooperation, which is
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not possible during seizure activity.
Global Rationale: A rectal temperature should be taken if the client is comatose, confused,
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having seizures, or unable to close the mouth. Although axillary is the safest, it is also the least
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accurate. Both oral and tympanic require the clients cooperation in order to maintain safety,
Cognitive Level: Applying
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Client Need: Safe Effective Care Environment
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which is not possible during seizure activity.
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Client Need Sub: Safety and Infection Control
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 7.3: Measure vital signs.
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Question 7
Type: HOTSPOT
The nurse is assessing a clients left femoral pulse. Identify the area on the diagram below where
the nurse would locate this pulse.
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Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : The nurse would palpate the left femoral pulse over the left femoral artery of the
client.
Global Rationale:
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.3: Measure vital signs.
Question 8
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Type: MCSA
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The nurse is caring for a pediatric client and needs to obtain vital signs. Which of the following
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route and sequence will the nurse use to obtain vital signs on a healthy newborn?
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1. Rectal temperature, respirations, pulse rate
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2. Respirations, pulse rate, blood pressure, rectal temperature
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3. Respirations, apical pulse rate, axillary temperature
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4. Oral temperature, respirations, pulse rate, blood pressure
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Correct Answer: 3
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Rationale 1: The temperature should be taken last, as it may cause the infant to cry, altering the
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rate of respirations and pulse.
Rationale 2: A blood pressure is not a routine vital sign obtained on a healthy infant. If a blood
pressure is done, a Doppler stethoscope is used in infants and children under the age of 2.
Rationale 3: Respirations should be assessed first in the assessment of a newborn, followed by
the apical pulse, and finally the temperature. The rectal temperature is the most accurate;
however an axillary temperature is appropriate since it can lead to rectal perforation.
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Rationale 4: Oral temperatures are not used for temperature measurement in children under the
age of 5.
Global Rationale: Respirations should be assessed first in the assessment of a newborn,
followed by the apical pulse, and finally the infants temperature. While the rectal temperature is
the most accurate, there is risk of rectal perforation. This question addresses a healthy newborn;
therefore an axillary temperature is appropriate. The temperature (any route) should be assessed
last, as it may cause the infant to cry, altering the rate of respirations and pulse. A blood pressure
is not a routine vital sign obtained on a healthy infant. If a blood pressure is done, a Doppler
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
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Client Need Sub:
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temperature measurement in children under the age of 5.
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stethoscope is used in infants and children under the age of 2. Oral temperatures are not used for
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 7.3: Measure vital signs.
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Question 9
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Type: MCSA
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A young adult client presents to the clinic complaining of a sore throat, swollen glands, and fever
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following oral surgery for extraction of impacted wisdom teeth. In order to complete the initial
assessment of this client, the nurse needs to obtain the clients temperature. Which method should
the nurse choose for this assessment?
1. Oral
2. Tympanic
3. Rectal
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4. Axillary
Correct Answer: 2
Rationale 1: The nurse would not want to use the oral route for this client since the client has
recently had oral surgery.
Rationale 2: The nurse should take the clients temperature using a tympanic thermometer.
Infection may be a concern in this client; therefore, an accurate temperature is necessary. Using
the ear for temperature assessment is quick, noninvasive, and reliable.
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Rationale 3: A rectal temperature is invasive and unnecessary in the assessment of this clients
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temperature.
Rationale 4: The axillary route is sometimes used in the temperature assessment of infants and
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children. It is considered the least accurate method of measurement.
Global Rationale: The nurse should take the clients temperature using a tympanic thermometer.
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Infection may be a concern in this client; therefore, an accurate temperature is necessary. Using
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the ear for temperature assessment is quick, noninvasive, and reliable. The nurse would not want
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to use the oral route for this client since the client has recently had oral surgery. A rectal
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temperature is invasive and unnecessary in the assessment of this clients temperature. The
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axillary route is sometimes used in the temperature assessment of infants and children. It is
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considered the least accurate method of measurement.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.3: Measure vital signs.
Question 10
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Type: MCSA
While assessing an adult clients pulse, the nurse notes an irregular rate. The nurse should assess
the pulse by counting the beats for:
1. 2 minutes.
2. 1 minute.
3. 30 seconds and multiply by 2.
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4. 15 seconds and multiply by 4.
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Correct Answer: 2
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Rationale 1: It is not necessary for the nurse to count the pulse for 2 minutes, as heart rate is
expressed in beats per minute.
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Rationale 2: With any irregular pulse, the rate needs to be counted for 1 full minute.
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Rationale 3: If the pulse is regular, the nurse may count the beats for 30 seconds and multiply by
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2.
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Rationale 4: Counting for 15 seconds and multiplying by 4 may not yield an accurate result, and
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therefore should not be used in assessing the rate.
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Global Rationale: With any irregular pulse, the rate needs to be counted for 1 full minute. It is
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not necessary for the nurse to count the pulse for 2 minutes, as heart rate is expressed in beats per
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minute. If the pulse is regular, the nurse may count the beats for 30 seconds and multiply by 2.
Counting for 15 seconds and multiplying by 4 may not yield an accurate result, and therefore
should not be used in assessing the rate.
Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub: Safety and Infection Control
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.3: Measure vital signs.
Question 11
Type: MCSA
The nurse educator is preparing an inservice on pain management for the staff. One of the staff
nurses asks, What is the most important part of a pain assessment? How should the nurse
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educator respond to this question?
1. Pain is only partially subjective and primarily a physiologic experience, so vital signs are the
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most important assessment.
2. A clients response to pain is always based on the underlying cause, so the clients admitting
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diagnosis is important.
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a change in blood pressure or pulse rate.
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3. Vital signs are not reliable indicators of acute pain, because only some clients are able to elicit
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4. The response to pain is unique and based on numerous factors, which need to be assessed.
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Correct Answer: 4
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Rationale 1: Vital signs are only a portion of the pain assessment. The nurse must consider
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many factors since pain is an individual experience and no two people experience pain in the
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same way. A patients level of pain cannot be determined by his physiologic response only.
Rationale 2: Pain is unique to each person and may be experienced differently by clients with
the same diagnosis.
Rationale 3: Vital signs can be indicators of pain. In the early stages of acute pain, the
sympathetic nervous system is stimulated, causing increases in blood pressure, pulse, and
respiratory rates.
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Rationale 4: Pain is a subjective experience, and the response is unique to each individual. The
factors that impact the response are numerous and include age, sex, culture, and developmental
level, as well as previous experience with pain and health status.
Global Rationale: Pain is a subjective experience, and the response is unique to each individual.
The factors that impact the response are numerous and include age, sex, culture, and
developmental level, as well as previous experience with pain and health status. Vital signs are
only a portion of the pain assessment. The nurse must consider many factors since pain is an
individual experience and no two people experience pain in the same way. A patients level of
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pain cannot be determined by his physiologic response only. Pain is unique to each person and
may be experienced differently by clients with the same diagnosis. Vital signs can be indicators
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increases in blood pressure, pulse, and respiratory rates.
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of pain. In the early stages of acute pain, the sympathetic nervous system is stimulated, causing
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 7.3: Measure vital signs.
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Question 12
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Type: FIB
During the assessment of an adult clients blood pressure, the nurse notes the following on the
sphygmomanometer: first faint tapping sounds at 136, swishing sounds at 120, clear tapping
sounds at 108, muffled sounds at 98, and silence at 76. This nurse would document this clients
blood pressure as
.
Standard Text:
Correct Answer: 136/76
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Rationale : The sounds above are the 5 phases of Korotkoffs sounds. The first sound heard
(Phase 1) is recorded as the systolic blood pressure. This is when the blood pressure cuff has
been released just enough to allow the first spurts of blood to pass through the artery. Phase 2 is
marked by the period in which the sounds change from tapping to swishing; blood flows
turbulently through the artery. Phase 3 is when blood flows through the artery during systole but
collapses during diastole; the sounds are crisp and tapping. During Phase 4, the sounds become
muffled and have a soft blowing quality. The pressure in the cuff does not completely collapse
the artery in any part of the cardiac cycle. The diastolic blood pressure is marked by the
beginning of silence (Phase 5). This is when the cuff no longer collapses the artery, and blood is
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free flowing through the artery.
Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
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Global Rationale:
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 7.3: Measure vital signs.
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Question 13
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Type: MCSA
using the:
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The nurse is assessing a 15-month-old baby. The nurse should assess this babys pulse rate by
1. Radial artery.
2. Brachial artery.
3. Apical site.
4. Carotid artery.
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Correct Answer: 3
Rationale 1: In older children and adults, the radial artery is used to assess the pulse.
Rationale 2: In preschool children, the brachial artery is used to assess the pulse.
Rationale 3: The apical site is the site of choice to assess the pulse rate of a child who is under 2
years of age.
Rationale 4: The carotid pulse is assessed in adult clients as part of the cardiovascular
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assessment.
Global Rationale: The apical site is the site of choice to assess the pulse rate of a child who is
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under 2 years of age. In preschool children, the brachial artery is used to assess the pulse. In
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older children and adults, the radial artery is used to assess the pulse. The carotid pulse is
assessed in adult clients as part of the cardiovascular assessment.
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Cognitive Level: Remembering
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Type: MCMA
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Question 14
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Learning Outcome: 7.3: Measure vital signs.
The nursing instructor is observing the student nurse take a blood pressure on an older adult
client. The nursing instructor intervenes when the student nurse is observed doing which of the
following?
Standard Text: Select all that apply.
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1. The student nurse ushers the client into the exam room and immediately assesses the clients
blood pressure.
2. The student nurse places the blood pressure cuff on the clients arm over a lightweight, longsleeved sweater.
3. The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood
pressure.
4. The student nurse has the client sit in a chair and supports the clients arm on a table at the
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level of the heart.
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5. The student nurse places the blood pressure cuff on the thigh of a client with a bilateral
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mastectomy and takes the blood pressure using the popliteal artery.
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Correct Answer: 1,2,3
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Rationale 1: The student nurse ushers the client into the exam room and immediately
assesses the clients blood pressure. The client should sit quietly for at least 5 minutes before
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the blood pressure is taken. Immediately assessing the blood pressure after a client walks from
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the waiting room to exam room may not yield an accurate reading.
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Rationale 2: The student nurse places the blood pressure cuff on the clients arm over a
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lightweight, long-sleeved sweater. The clients blood pressure should be assessed on a bare arm.
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If the client is wearing a long sleeved garment and it can be pushed up without constricting the
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arm, this is acceptable; otherwise the arm should be removed from the sleeve.
Rationale 3: The student nurse immediately reinflates the cuff after identifying the
palpatory systolic blood pressure. Once the cuff is inflated and the nurse identifies the
palpatory systolic blood pressure, the nurse should wait at least 1530 seconds before inflating the
cuff again.
Rationale 4: The student nurse has the client sit in a chair and supports the clients arm on
a table at the level of the heart. In order to obtain an accurate blood pressure, the client should
be seated with the arm slightly flexed, supported at the level of the heart with palm facing up.
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Rationale 5: The student nurse places the blood pressure cuff on the thigh of a client with a
bilateral mastectomy and takes the blood pressure using the popliteal artery. Clients who
have suffered trauma to the upper extremities, have shunts in the upper extremities, or have had
mastectomies should not have their blood pressures assessed on the affected sides. The nurse can
place the blood pressure cuff on the thigh and assess the blood pressure using the popliteal
artery.
Global Rationale: The client should sit quietly for at least 5 minutes before the blood pressure is
taken. Immediately assessing the blood pressure after a client walks from the waiting room to
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exam room may not yield an accurate reading. The clients blood pressure should be assessed on
a bare arm. If the client is wearing a long-sleeved garment and it can be pushed up without
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constricting the arm, this is acceptable; otherwise the arm should be removed from the sleeve.
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Once the cuff is inflated and the nurse identifies the palpatory systolic blood pressure, the nurse
should wait at least 1530 seconds before inflating the cuff again. In order to obtain an accurate
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blood pressure, the client should be seated with the arm slightly flexed, supported at the level of
the heart with palm facing up. Clients who have suffered trauma to the upper extremities, have
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shunts in the upper extremities, or have had mastectomies should not have their blood pressures
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assessed on the affected sides. The nurse can place the blood pressure cuff on the thigh and
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Cognitive Level: Analyzing
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assess the blood pressure using the popliteal artery.
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.3: Measure vital signs.
Question 15
Type: MCSA
The nurse is assessing a toddler when the childs mother tells the nurse that the child has had a
fever for the past two days. When the nurse asks the mother what the temperature has been, the
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mother replies that she hasnt actually taken it but the childs skin has felt very warm. Which of
the following would be the most appropriate response for the nurse?
1. When our skin feels warm, it means our blood vessels are constricted.
2. The only reliable indicator of body temperature is by feeling the forehead.
3. Our skin temperature changes when our surroundings change temperature.
4. The temperature of the skin is not related to what is happening inside our bodies.
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Rationale 1: Fever causes vasodilation, not vasoconstriction.
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Correct Answer: 3
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Rationale 2: When fever is present, the skin all over the body may feel warm, not just the
forehead, thus the only reliable indicator of body temperature is measuring the core temperature
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with a thermometer.
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Rationale 3: The surface temperature of the body is constantly changing in response to
environmental influences and as a result is not a reliable indicator of actual health status. To
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obtain accurate temperature, the core temperature, or the temperature of the deep tissues of the
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body, needs to be assessed.
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Rationale 4: The temperature of the skin is related to what is happening inside the body. Fever is
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a sign of the disruption of homeostasis in the body. This may be due to a bacterial or viral
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infection. Fever causes vasodilation, which can make the skin feel warm to the touch.
Global Rationale: The surface temperature of the body is constantly changing in response to
environmental influences and as a result is not a reliable indicator of actual health status. To
obtain accurate temperature, the core temperature, or the temperature of the deep tissues of the
body, needs to be assessed. Fever causes vasodilation, not vasoconstriction. When fever is
present, the skin all over the body may feel warm, not just the forehead, thus the only reliable
indicator of body temperature is measuring the core temperature with a thermometer. The
temperature of the skin is related to what is happening inside the body. Fever is a sign of the
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disruption of homeostasis in the body. This may be due to a bacterial or viral infection. Fever
causes vasodilation, which can make the skin feel warm to the touch.
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 7.4: Discuss factors that affect vital signs.
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Question 16
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Type: MCMA
The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure
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reading of 172/98. The nurse understands that the following factors may be applicable in this
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Standard Text: Select all that apply.
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situation.
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1. Arteriosclerosis decreases the ventricular force necessary for ejection of blood.
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2. Arteriosclerosis increases blood vessel elasticity.
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3. Arteriosclerosis decreases blood vessel compliance.
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4. Age decreases blood vessel elasticity.
5. Arteriosclerosis plays no role in the blood pressure of this client.
Correct Answer: 3,4
Rationale 1: Arteriosclerosis decreases the ventricular force necessary for ejection of blood.
Arteriosclerosis requires greater ventricular force and leads to increased blood pressure.
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Rationale 2: Arteriosclerosis increases blood vessel elasticity. Arteriosclerosis decreases the
elasticity of the arteries.
Rationale 3: Arteriosclerosis decreases blood vessel compliance. Arteriosclerosis results in
hardened and rigid arteries, which are less compliant.
Rationale 4: Age decreases blood vessel elasticity. Elasticity of blood vessels decreases with
age and also leads to increased blood pressure.
Arteriosclerosis plays no role in the blood pressure of this client.
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Rationale 5: Arteriosclerosis plays no role in the blood pressure of this client.
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Global Rationale: Arteriosclerosis results in hardened and rigid arteries, which are less
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compliant. Elasticity of blood vessels decreases with age and also leads to increased blood
pressure. Arteriosclerosis requires greater ventricular force and leads to increased blood pressure.
Arteriosclerosis decreases the elasticity of the arteries. Arteriosclerosis has a direct effect on
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blood pressure; decreased elasticity and compliance is directly related to the increase in blood
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pressure.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.4: Discuss factors that affect vital signs.
Question 17
Type: MCSA
The nurse needs to take a blood pressure on a very thin client, and the only cuff available is a
standard size. The nurse would anticipate which of the following readings?
1. An accurate reading
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2. A falsely elevated reading
3. The reading will depend on the overall health of the client
4. A false low reading
Correct Answer: 4
Rationale 1: In a very thin client, a small (or even pediatric) blood pressure cuff should be used
to obtain an accurate reading. Using a standard cuff on this client will yield a falsely low result.
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Rationale 2: When the bladder of the cuff is too narrow, the blood pressure reading will be
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falsely elevated.
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Rationale 3: While the reading will depend on the overall health of the client, it is important to
obtain an accurate reading by using the proper equipment.
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Rationale 4: In this situation, the bladder of the cuff is too wide, resulting in the blood pressure
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reading being falsely low. To obtain accurate blood pressure readings, it is imperative that the
nurse select the proper cuff. The bladder of the blood pressure cuff must be an appropriate fit in
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both length and width for the clients arm. The length of the bladder should equal 80% of the
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circumference of the limb. The width of the bladder should equal 40% of the circumference of
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the limb.
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Global Rationale: In this situation, the bladder of the cuff is too wide, resulting in the blood
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pressure reading being falsely low. To obtain accurate blood pressure readings, it is imperative
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that the nurse select the proper cuff. The bladder of the blood pressure cuff must be an
appropriate fit in both length and width for the clients arm. The length of the bladder should
equal 80% of the circumference of the limb. The width of the bladder should equal 40% of the
circumference of the limb. In a very thin client, a small (or even pediatric) blood pressure cuff
should be used to obtain an accurate reading. Using a standard cuff on this client will yield a
falsely low result. When the bladder of the cuff is too narrow, the blood pressure reading will be
falsely elevated. While the reading will depend on the overall health of the client, it is important
to obtain an accurate reading by using the proper equipment.
Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.4: Discuss the factors that affect vital signs.
Question 18
Type: MCSA
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The nurse is caring for a client diagnosed with breast cancer, who underwent a left-sided
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mastectomy two days prior. The nurse has delegated vital signs on this client to the patient care
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assistant (PCA). What specific instructions should the nurse provide to the (PCA) in delegating
1. Take the blood pressure on the right arm.
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2. No special instructions are needed.
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this task?
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3. Take the blood pressure on the left arm.
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4. Take the blood pressure on both arms for a baseline.
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Correct Answer: 1
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Rationale 1: The blood pressure should be taken in the arm opposite the surgical site. Blood
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pressures should not be taken on the same side as a mastectomy. It should also not be taken on an
arm with a shunt, trauma, or disease. If this is not possible, then a thigh pressure should be
obtained.
Rationale 2: The nurse should be sure to provide the PCA with instructions to use the arm
opposite the surgical site for blood pressure readings.
Rationale 3: The left arm should not be used for blood pressure readings, intravenous fluids, or
other invasive procedures.
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Rationale 4: It is not possible to take the blood pressure using both arms, since the left arm
should never be used again for blood pressure readings. If bilateral readings become necessary,
the thighs should be used so that a comparison can be made.
Global Rationale: The blood pressure should be taken in the arm opposite the surgical site.
Blood pressures should not be taken on the same side as a mastectomy. It should also not be
taken on an arm with a shunt, trauma, or disease. If this is not possible, then a thigh pressure
should be obtained. The nurse should be sure to provide the PCA with instructions to use the arm
opposite the surgical site for blood pressure readings. The left arm should not be used for blood
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pressure readings, intravenous fluids, or other invasive procedures. It is not possible to take the
blood pressure using both arms, since the left arm should never be used again for blood pressure
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readings. If bilateral readings become necessary, the thighs should be used so that a comparison
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can be made.
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Client Need: Safe Effective Care Environment
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Cognitive Level: Applying
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 7.4: Discuss factors that affect vital signs.
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Type: MCSA
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Question 19
A young adult client notes height as 5 feet 11 inches and weight as 200 lbs. Upon assessment, the
client is found to be 5 feet 9 inches tall with a weight of 225 lbs. The nurse identifies the most
likely reason for this discrepancy between the clients self-reported height and weight and the
objective information indicates:
1. The client does not have a scale at home.
2. The client may have a image of self inconsistent with actual findings.
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3. The client did not want to tell the truth.
4. The client is trying to hide a chronic illness.
Correct Answer: 2
Rationale 1: The best reason for the inconsistency is the client has a different image of himself
than what is objectively measurable.
Rationale 2: The nurse has no way of knowing if the client has a scale at home and does not
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account for the discrepancy in height.
Rationale 3: The inconsistency between reported height and weight and actual height and weight
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does not mean the client is being untruthful; it is what the client believes to be true.
Rationale 4: The inconsistency between reported height and actual height and weight does not
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indicate that the client is trying to hide a chronic illness.
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Global Rationale: The best reason for the inconsistency is the client has a different image of
himself than what is objectively measurable. The nurse has no way of knowing if the client has a
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scale at home and does not account for the discrepancy in height. The inconsistency between
reported height and weight and actual height and weight does not mean the client is being
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untruthful; it is what the client believes to be true. The inconsistency between reported height
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and actual height and weight does not indicate that the client is trying to hide a chronic illness.
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Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 7.4: Discuss factors that affect vital signs.
Question 20
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Type: MCSA
During the evening assessment of a febrile client admitted to the nursing unit with abdominal
pain, the nurse assesses a lower than normal blood pressure and a rapid pulse. These findings
suggest to the nurse that the client may be experiencing:
1. anxiety.
2. an abdominal infection.
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3. a medication reaction.
4. a diurnal variation
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Correct Answer: 2
Rationale 1: The physiologic response to anxiety is increased heart rate and increased blood
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pressure.
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Rationale 2: The lowered blood pressure and increased heart rate in a febrile client with
abdominal pain is suggestive of infection. Fever causes vasodilation, which in turn causes an
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increase in heart rate.
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Rationale 3: There is no information to suggest that the client is experiencing a reaction to
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medication.
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Rationale 4: Diurnal variation of blood pressure is exhibited by lower morning blood pressure
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that increases throughout the day.
Global Rationale: The lowered blood pressure and increased heart rate in a febrile client with
abdominal pain is suggestive of infection. Fever causes vasodilation, which in turn causes an
increase in heart rate. The physiologic response to anxiety is increased heart rate and increased
blood pressure. There is no information to suggest that the client is experiencing a reaction to
medication. Diurnal variation of blood pressure is exhibited by lower morning blood pressure
that increases throughout the day.
Cognitive Level: Analyzing
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Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 7.4: Discuss the factors that affect vital signs.
Question 21
Type: MCSA
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An older adult client says to the nurse, Im gaining weight around my middle and my legs look
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like chicken legs. An appropriate response by the nurse to this client is:
1. Older people often put on weight around the middle, but lose muscle in the legs, making the
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legs appear thinner. This is normal.
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2. Have you been doing any exercises to slim down your middle?
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3. This is very unusual. I will let the healthcare provider know.
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4. Lets talk about your diet to see why youre gaining weight around your middle.
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Correct Answer: 1
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Rationale 1: Older adults experience a decrease in overall muscle mass and they lose
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subcutaneous fat in the face forearms and legs; however, there is an increase in fat deposits in the
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abdomen and hips. This is a normal occurrence in the older adult client.
Rationale 2: While exercise is important for overall health and the client should be encouraged
to participate in 30 minutes of exercise on most days, this is a normal occurrence in the older
adult and this should be explained to the client.
Rationale 3: This is not an unusual finding in an older adult client. It is not necessary to alert the
healthcare provider.
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Rationale 4: Excessive calorie intake would lead to weight gain all over the body, not just the
middle.
Global Rationale: Older adults experience a decrease in overall muscle mass and they lose
subcutaneous fat in the face forearms and legs; however, there is an increase in fat deposits in the
abdomen and hips. This is a normal occurrence in the older adult client. While exercise is
important for overall health and the client should be encouraged to participate in 30 minutes of
exercise on most days, this is a normal occurrence in the older adult and this should be explained
to the client. This is not an unusual finding in an older adult client. It is not necessary to alert the
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healthcare provider. Excessive calorie intake would lead to weight gain all over the body, not
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
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Client Need Sub:
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just the middle.
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 7.4: Discuss factors that affect vital signs.
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Question 22
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Type: MCSA
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The night nurse is reviewing the vital signs of a client in an extended care facility. The nurse
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notes the clients oral temperature at 6 a.m. was 98.0F, but that evening, the clients oral
temperature was 99.2F. The nurse suspects that this variation in temperature is indicative of:
1. The clients temperature has been improperly assessed either in the morning or evening; the
nurse cant be sure which.
2. The client is developing an infection.
3. The client is experiencing stress.
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4. The clients temperature is demonstrating diurnal variations.
Correct Answer: 4
Rationale 1: The difference in body temperature is evidence of diurnal variation. Core body
temperature is lowest during the early morning and becomes higher during the course of the day.
Rationale 2: There is no evidence to suggest the temperatures were incorrectly assessed and the
same routes were used for both assessments.
Rationale 3: There is no evidence to suggest that the client is developing an infection other than
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the higher evening body temperature.
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Rationale 4: There is nothing to suggest that this client is under a great deal of stress which may
elevate body temperature.
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Global Rationale: The difference in body temperature is evidence of diurnal variation. Core
body temperature is lowest during the early morning and becomes higher during the course of
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the day. There is no evidence to suggest the temperatures were incorrectly assessed and the same
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routes were used for both assessments. There is no evidence to suggest that the client is
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developing an infection other than the higher evening body temperature. There is nothing to
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suggest that this client is under a great deal of stress, which might elevate body temperature.
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Cognitive Level: Analyzing
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 7.4: Discuss factors that affect vital signs.
Question 23
Type: MCMA
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A nurse has been asked to present a program on blood pressure for a group of adults at a
community center. Which of the following true statements should the nurse incorporate into the
presentation?
Standard Text: Select all that apply.
1. Females tend to have higher blood pressure readings than males of the same age.
2. Middle-aged African American males tend to have higher blood pressures than American
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4. Blood pressure readings tend to be lowest in the evening.
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3. Stress can result in an increase in blood pressure.
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males of European descent.
5. During physical activity, blood pressure decreases.
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Correct Answer: 2,3
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Rationale 1: Females tend to have higher blood pressure readings than males of the same
age. After puberty, females tend to have lower blood pressure readings than males of the same
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age.
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Rationale 2: Middle-aged African American males tend to have higher blood pressures
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than American males of European descent. African American males over the age of 35 tend to
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have higher blood pressure readings than American males of European descent.
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Rationale 3: Stress can result in an increase in blood pressure. Stress increases cardiac output
and arterial vasoconstriction, resulting in increased blood pressure.
Rationale 4: Blood pressure readings tend to be lowest in the evening. Blood pressure is
sensitive to diurnal variations; blood pressure is lower in the morning and peaks in the late
afternoon.
Rationale 5: During physical activity, blood pressure decreases. During physical activity,
blood pressure increases due to the increase in cardiac output.
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Global Rationale: African American males over the age of 35 tend to have higher blood
pressure readings than American males of European descent. Stress increases cardiac output and
arterial vasoconstriction, resulting in increased blood pressure. After puberty, females tend to
have lower blood pressure readings than males of the same age. Blood pressure is sensitive to
diurnal variations; blood pressure is lowest in the morning and peaks in the late afternoon.
During physical activity, blood pressure increases due to the increase in cardiac output.
Cognitive Level: Understanding
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Client Need: Health Promotion and Maintenance
Learning Outcome: 7.4: Discuss factors that affect vital signs.
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Question 24
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Type: MCMA
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A client presents to the primary care clinic and is disheveled in appearance, with stained, dirty
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clothing, body odor, and uncombed hair. Based on this observation, which of the following
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should the nurse assess during the history and physical exam?
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Standard Text: Select all that apply.
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2. Depression
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1. Occupation
3. Smoking history
4. Self-concept
5. Immunization status
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Correct Answer: 1,2,4
Rationale 1: Occupation. The way a client dresses and maintains physical hygiene may provide
clues to the clients occupation (perhaps the client has a physical job and has just come from
work).
Rationale 2: Depression. The way a client dresses and maintains physical hygiene may provide
clues to the state of the clients mental health.
Rationale 3: Smoking history. The clients disheveled appearance does not directly clue the
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nurse to explore the clients smoking history. Clues that would lead the nurse to fully explore the
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fingers from tobacco, hoarseness of the voice, and/or a cough.
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clients smoking history would include the smell of smoke on the client, the discoloration of the
Rationale 4: Self-concept. The way a client dresses and maintains physical hygiene may provide
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clues to the clients sense of self-esteem and body image.
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assess the clients immunization status.
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Rationale 5: Immunization status. The observations made by the nurse do not clue the nurse to
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Global Rationale: The way a client dresses and maintains physical hygiene may provide clues
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to a variety of things, such as what the client does for a living (perhaps the client has a physical
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job and has just come from work), the clients sense of self-esteem and body image, as well as be
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an indicator of mental illness, anxiety, or depression. The clients disheveled appearance does not
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directly clue the nurse to explore the clients smoking history. Clues that would lead the nurse to
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fully explore the clients smoking history would include the smell of smoke on the client, the
discoloration of the fingers from tobacco, hoarseness of the voice, and/or a cough. The
observations made by the nurse do not clue the nurse to assess the clients immunization status.
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.
Question 25
Type: MCSA
The nurse is doing a general survey on an infant for a well-child check. During the survey, the
baby has a liquid stool. The mother becomes very angry and asks the nurse to change the diaper
because she just cant deal with the odor. This response is important to the nurse because:
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1. the child may have an illness causing diarrhea.
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3. the mother may be feeding the child a poor diet.
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2. it may be a reflection of the mother-child relationship.
4. the child may have an illness that is increasing the odor of stool.
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Correct Answer: 2
Rationale 1: The loose stool may be a sign of illness; however, there is not enough information
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to determine if the child is ill, and the mothers response is inappropriate.
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Rationale 2: Observation of the interaction between the child and mother can provide
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information suggestive of child abuse. The mothers demonstration of disgust with any aspect of
childs behavior or such things as odor or stool can be clues that there may be a problem with the
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relationship and should be evaluated further.
Rationale 3: The loose stool may be the result of the childs diet; however, the mothers response
is inappropriate.
Rationale 4: The loose stool may be a sign of illness; however, there is not enough information
to determine if the child is ill, and the mothers response is inappropriate.
Global Rationale: Observation of the interaction between the child and mother can provide
information suggestive of child abuse. The mothers demonstration of disgust with any aspect of
childs behavior or such things as odor or stool can be clues that there may be a problem with the
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relationship and should be evaluated further. The loose stool may be a sign of illness; however,
there is not enough information to determine if the child is ill, and the mothers response is
inappropriate. The loose stool may be the result of the childs diet; however, the mothers response
is inappropriate. The loose stool may be a sign of illness; however, there is not enough
information to determine if the child is ill, and the mothers response is inappropriate.
Chapter 7. Assessing Pain
Question 1
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Type: MCSA
The nurse is caring for a teenager and is assessing pain level with the vital signs. The client is
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reporting pain but when the nurse asks for a description of the pain the client says, It just hurts.
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Why cant I have something? The nurse would choose to do which of the following next?
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1. Leave the room and come back later.
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2. Provide questions that require yes or no answers related to pain.
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3. Ask the client what they would like to have for pain.
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4. Continue with the vital signs assessment.
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Correct Answer: 2
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Rationale 1: Leaving the room will not provide effective pain management.
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Rationale 2: People who are not feeling well or who are in pain may have difficulty with openended questions, such as Describe. The nurse may be better able to obtain an accurate description
of their pain by having them respond to descriptive words.
Rationale 3: Asking the client what she would like for pain is not appropriate without a
complete assessment.
Rationale 4: If the client is in pain, moving on to the vital signs will not yield additional
information.
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Global Rationale: People who are not feeling well or who are in pain may have difficulty with
open-ended questions, such as Describe. The nurse may be better able to obtain an accurate
description of their pain by having them respond to descriptive words. Leaving the room will not
provide effective pain management. Asking the client what she would like for pain is not
appropriate without a complete assessment. If the client is in pain, moving on to the vital signs
will not yield additional information.
Cognitive Level: Applying
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain.
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Question 2
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Type: MCSA
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The nurse is working at pain clinic and is preparing an orientation for new staff nurses. Which of
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the following definitions of pain would the nurse correctly choose to include in this orientation?
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Pain is:
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1. Validated by the nurse determining the cause of the pain.
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2. Unpleasant sensations, typically experienced upon movement.
3. Whatever the experiencing person says it is.
4. Very subjective so observations must be used to assess levels and intensity.
Correct Answer: 3
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Rationale 1: At times, the cause of the pain is not determined at the time the client reports it.
The nurses role is not to validate the clients report but to assess and assist in alleviating or
managing the pain.
Rationale 2: Pain involves unpleasant sensations, though not always limited to movement.
Rationale 3: The most widely accepted definition of pain is the one offered by McCaffery:
whatever the experiencing person says it is, existing whenever he or she says it does (McCaffery
& Pasero, 1999, p. 5).
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Rationale 4: Pain is a subjective experience and the clients report of pain must be trusted in
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order to effectively manage it.
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Global Rationale: The most widely accepted definition of pain is the one offered by McCaffery:
whatever the experiencing person says it is, existing whenever he or she says it does (McCaffery
& Pasero, 1999, p. 5). It involves unpleasant sensations, though not always limited to movement.
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At times, the cause of the pain is not determined at the time the client reports it. The nurses role
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is not to validate the clients report but to assess and assist in alleviating or managing the pain.
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Pain is a subjective experience and the clients report of pain must be trusted in order to
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effectively manage it.
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Cognitive Level: Remembering
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 8.1: Provide a definition of pain.
Question 3
Type: MCSA
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The client is in the triage area of the Emergency Department when a client arrives complaining
of chest and arm pain. The client also reports jaw pain, but states that the chest pain hurts more.
The nurse observes the client rubbing his left arm. The nurse suspects what type of pain?
1. Phantom pain
2. Radiating pain
3. Intractable pain
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4. Cutaneous pain
Correct Answer: 2
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Rationale 1: Phantom pain is a painful sensation perceived in an absent body part or a body part
that is paralyzed.
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and then spreads to other adjacent body parts.
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Rationale 2: The client is describing radiating pain, which has an origin in one part of the body
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Rationale 3: Intractable pain does not respond to relief measures.
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Rationale 4: Cutaneous pain is pain experienced in the cutaneous tissues.
Global Rationale: The client is describing radiating pain, which has an origin in one part of the
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body and then spreads to other adjacent body parts. Phantom pain is a painful sensation
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perceived in an absent body part or a body part that is paralyzed. Cutaneous pain is pain
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experienced in the cutaneous tissues. Intractable pain does not respond to relief measures.
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 8.1: Provide a definition of pain.
Question 4
Type: MCSA
The nurse is caring for two clients involved in a motor vehicle accident. Both clients required
explorative abdominal surgery. Neither has received any pain medication in six hours and both
have asked. However, one client is in greater distress than the other. Which pain theory is useful
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in explaining this phenomenon? The theory of:
1. Pattern.
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2. Specificity.
3. Stress.
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4. Gate control.
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Correct Answer: 4
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Rationale 1: Pattern theory implies that the pattern of the stimulus is more important than the
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specific stimulus. It does not address the psychosocial component of pain.
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Rationale 2: Specificity theory holds that pain neurons are specific and unique and the specific
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pain neurons transport the sensations directly to the brain.
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Rationale 3: Stress does influence a clients perception of pain but is not a specific theory.
Rationale 4: Gate control theory attempts to explain the involvement of the brain as well as
nerve fibers in the pain experience. The involvement of the brain helps explain why painful
stimuli are interpreted differently by people experiencing pain.
Global Rationale: Gate control theory attempts to explain the involvement of the brain as well
as nerve fibers in the pain experience. The involvement of the brain helps explain why painful
stimuli are interpreted differently by people experiencing pain. Specificity theory holds that pain
neurons are specific and unique and the specific pain neurons transport the sensations directly to
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the brain. Pattern theory implies that the pattern of the stimulus is more important than the
specific stimulus. It does not address the psychosocial component of pain. Stress may impact a
clients perception of pain but is not a specific theory.
Cognitive Level: Remembering
Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 8.2: Identify the physiology of pain.
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Client Need Sub:
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Question 5
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Type: MCSA
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The nurse is caring for a client who denies having pain. The nurse has noticed the client
grimacing and clenching his teeth when moving. The clients spouse has asked the nurse why
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some people deny obvious pain. What response by the nurse is most appropriate?
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1. You should try to find out why your husband is denying the pain.
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2. Have you talked to the healthcare provider about this?
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3. Some people feel reporting their pain is a sign of weakness.
4. Maybe we are wrong and pain is not really bad.
Correct Answer: 3
Rationale 1: The spouse has sought assistance from the nurse. The nurse should attempt to
respond to the inquiry.
Rationale 2: The spouse is asking for information that is within the scope of nursing practice.
There is no need to refer to the healthcare provider at this time.
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Rationale 3: Adult clients may deny the presence of pain. Sometimes the denial is an effort not
to appear weak.
Rationale 4: The nonverbal behaviors indicate the presence of pain.
Global Rationale: Adult clients may deny the presence of pain. Sometimes the denial is an
effort not to appear weak. The spouse has sought assistance from the nurse. The nurse should
attempt to respond to the inquiry. The spouse is asking for information that is within the scope of
nursing practice. There is no need to refer to the healthcare provider at this time. The nonverbal
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behaviors indicate the presence of pain.
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Cognitive Level: Analyzing
tp
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Client Need: Psychosocial Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 8.4: Discuss factors that influence pain.
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Question 6
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Type: MCSA
A client with chronic pain from spinal stenosis has asked the nurse for assistance with pain
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management. The client is well dressed and composed, with normal vital signs. The nurse
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observes that the client grimaces when sitting but rates the pain at only a 2. The nurse suspects
which of the following? The client:
1. Needs to exercise instead of taking pain medication.
2. Is not in severe pain and does not need treatment.
3. Is getting better.
4. Has adapted to the pain and is able to control behaviors.
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Correct Answer: 4
Rationale 1: The plan of care to determine interventions cannot be determined at this point.
Rationale 2: The client has stated that she is there for assistance with pain management, and the
nurse has not completed the assessment.
Rationale 3: Determining that the clients condition is improving is beyond the scope of practice
for the nurse.
Rationale 4: People with chronic pain develop their individual coping styles to deal with pain,
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discomfort, or suffering. Also, physiologic responses may be marked in acute pain but because
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of central nervous system adaptation, physiologic responses are likely to be absent. Therefore,
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behavioral and physiologic responses are not good indicators of pain.
Global Rationale: People with chronic pain develop their individual coping styles to deal with
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pain, discomfort, or suffering. Also, physiologic responses may be marked in acute pain but
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because of central nervous system adaptation, physiologic responses are likely to be absent.
Therefore, behavioral and physiologic responses are not good indicators of pain. Determining
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that the clients condition is improving is beyond the scope of practice for the nurse. The client
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has stated that she is there for assistance with pain management, and the nurse has not completed
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the assessment. The plan of care to determine interventions cannot be determined at this point.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8.4: Discuss factors that influence pain.
Question 7
Type: MCSA
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The nurse is caring for two clients who both are in pain due to sickle cell anemia. One of the
clients rates his pain as a 7 out of 10 (1 is no pain and 10 is the worst pain possible). This client
is moving around easily and is eating well, but has asked for pain medicine. The nurse would
choose which of the following actions?
1. Wait 30 minutes and see if the client is still requesting the pain medicine.
2. Administer half the ordered does of pain medication.
4. Notify the healthcare provider that the client is faking his pain.
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Correct Answer: 3
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3. Administer the pain medication if it is has been longer than the ordered interval.
Rationale 1: Waiting to administer the medication is inappropriate and is an action that appears
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to negate the clients reports.
Rationale 2: Administration of only a portion of the ordered medication places the nurse in a
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position of prescribing medications and is outside the nurses scope of practice.
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Rationale 3: Since pain occurs whenever the experiencing person says it does and is whatever
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the experiencing person says it is, the nurse should accurately assess and treat the pain with the
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pain medication if that is what is ordered.
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Rationale 4: Notification to the healthcare provider that the patient is faking the pain is
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inappropriate as there is no evidence of this action.
Global Rationale: Since pain occurs whenever the experiencing person says it does and is
whatever the experiencing person says it is, the nurse should accurately assess and treat the pain
with the pain medication if that is what is ordered. Waiting to administer the medication is
inappropriate and is an action that appears to negate the clients reports. Administration of only a
portion of the ordered medication places the nurse in a position of prescribing medications and is
outside the nurses scope of practice. Notification to the healthcare provider that the patient is
faking the pain is inappropriate as there is no evidence of this action.
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Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.4: Discuss factors that influence pain.
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Question 8
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Type: MCSA
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The nurse is assessing a postoperative client that reports a pain level of 10 on a 1 to 10 scale. The
client is grimacing and appears anxious. Which of the following actions should the nurse
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perform first?
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1. Administer pain medication if it has been longer than the ordered interval.
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2. Offer to call the pastoral service to provide spiritual counseling.
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3. Obtain an order for an anti-anxiety medication.
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Correct Answer: 1
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4. Call the family to come in and stay with the client.
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Rationale 1: Pain needs to be well managed and pain should be assessed with vital signs. Pain is
the 5th vital sign. Pain needs to be well managed with pain medications given on a scheduled
basis, so that the pain does not get out of control. Once the pain is under control, the nurse can
assess other factors influencing the clients pain response.
Rationale 2: Spiritual counseling may not be helpful if the pain is not managed effectively.
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Rationale 3: Relieving the anxiety may help in alleviating pain and should be considered with
other forms of pain management. However, relieving anxiety will be easier if the pain is
managed effectively.
Rationale 4: The presence of family members may provide comfort to the client, but is not the
priority intervention.
Global Rationale: Pain needs to be well managed and pain should be assessed with vital signs.
Pain is the 5th vital sign. Pain needs to be well managed with pain medications given on a
scheduled basis, so that the pain does not get out of control. Once the pain is under control, the
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nurse can assess other factors influencing the clients pain response. Spiritual counseling may not
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be helpful if the pain is not managed effectively. Relieving the anxiety may help in alleviating
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pain and should be considered with other forms of pain management. However, relieving anxiety
will be easier if the pain is managed effectively. The presence of family members may provide
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comfort to the client, but is not the priority intervention.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Type: MCMA
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Question 9
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Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain.
The nurse is assessing a client admitted with severe abdominal pain. Which of the following
would the nurse include as essential components of the pain assessment?
Standard Text: Select all that apply.
1. Description of the pain
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2. Temperature, pulse, respirations, and blood pressure
3. Pain intensity rating
4. Family medical history
5. Previous pain experience
Correct Answer: 1,2,3,5
Rationale 1: Description of the pain. The nurse assessing the client will need to determine
characteristics of the pain. These characteristics expressed by the client will aid in the
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management of the condition
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Rationale 2: Temperature, pulse, respirations, and blood pressure. The vital signs of the
client reporting acute pain will likely provide supportive information concerning the pain being
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experienced.
Rationale 3: Pain intensity rating. An integral part of the definition of pain is that it is what the
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individual reports it to be. The degree of intensity will be needed to determine the level of pain
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being experienced. The degree of pain intensity assessment will be a key component in the
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interventions being used to manage the pain.
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Rationale 4: Family medical history. While the family medical history is a component of a
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generalized health assessment it is not specific to the assessment of pain.
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Rationale 5: Previous pain experience. An individuals past experience with pain is a
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determining factor in the ability to manage pain. Past experience will also impact reports of pain
by the client.
Global Rationale: The nurse assessing the client will need to determine characteristics of the
pain. These characteristics expressed by the client will aid in the management of the condition.
The vital signs of the client reporting acute pain will likely provide supportive information
concerning the pain being experienced. An integral part of the definition of pain is that it is what
the individual reports it to be. The degree of intensity will be needed to determine the level of
pain being experienced. The degree of pain intensity assessment will be a key component in the
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interventions being used to manage the pain. While the family medical history is a component of
a generalized health assessment it is not specific to the assessment of pain. An individuals past
experience with pain is a determining factor in the ability to manage pain. Past experience will
also impact reports of pain by the client.
Cognitive Level: Applying
Client Need: Physiological Integrity
Learning Outcome: 8.5: Provide a definition of pain.
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Question 10
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Type: MCSA
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The nurse is caring for a client complaining of a backache and administers ibuprofen. The client
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asks the nurse how the medication will help the pain. The nurse understands that ibuprofens
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effect occurs during which phase of nocioception?
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1. Transduction
4. Modulation
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3. Perception
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2. Transmission
Correct Answer: 1
Rationale 1: Since ibuprofen blocks the production of prostaglandin, it acts during the
transduction phase.
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Rationale 2: In the transmission phase, the pain impulse travels from peripheral nerve fibers to
the spinal cord to the brain stem and thalamus and ultimately, to the somatic sensory cortex.
Rationale 3: Perception occurs when the client becomes aware of the pain.
Rationale 4: Modulation is the process by which neurons in the brain stem send signals back
down stimulating the release of neurotransmitters that can inhibit the ascending pain impulses.
Global Rationale: Since ibuprofen blocks the production of prostaglandin, it acts during the
transduction phase. In the transmission phase, the pain impulse travels from peripheral nerve
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fibers to the spinal cord to the brain stem and thalamus and ultimately, to the somatic sensory
cortex. Perception occurs when the client becomes aware of the pain. Modulation is the process
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neurotransmitters that can inhibit the ascending pain impulses.
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by which neurons in the brain stem send signals back down stimulating the release of
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Cognitive Level: Remembering
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Implementation
Type: MCSA
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Question 11
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Learning Outcome: 8.2: Identify the physiology of pain.
A nurse working in a healthcare providers office is interviewing a client that reports experiencing
daily migraines. The nurse decides to further assess the impact of the clients pain. An appropriate
choice of assessment tools would be which of the following?
1. Psychologic well-being inventory
2. Body Diagram tool
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3. Intensity rating scale
4. Brief Pain Inventory
Correct Answer: 4
Rationale 1: A psychological well-being inventory may yield information about the impact of
pain on the clients sense of well-being but is not designed to specifically assess the elements of
pain.
Rationale 2: A unidimensional tool such as the Body Diagram is useful for assessing pain
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severity at the time the client is experiencing pain.
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severity at the time the client is experiencing pain.
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Rationale 3: A unidimensional tool such as the intensity rating scale is useful for assessing pain
Rationale 4: Migraine pain is chronic in nature and, therefore, a multidimensional tool such as
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the Brief Pain Inventory is the most useful for assessing two or more elements of the pain and the
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impact of pain on daily living.
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Global Rationale: Migraine pain is chronic in nature and, therefore, a multidimensional tool
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such as the Brief Pain Inventory is the most useful for assessing two or more elements of the pain
and the impact of pain on daily living. A unidimensional tool such as the Body Diagram and
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intensity rating scale is useful for assessing pain severity at the time the client is experiencing
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pain. A psychological well-being inventory may yield information about the impact of pain on
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the clients sense of well-being but is not designed to specifically assess the elements of pain.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain.
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Question 12
Type: MCSA
The nurse understands amount of pain stimulation that is needed for an individual to feel pain is
referred to as:
1. Pain threshold.
2. Pain tolerance.
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3. Somatic interval.
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4. Cephalgia reporting.
Correct Answer: 1
Rationale 1: The pain threshold is the amount of pain stimulation a person requires in order to
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feel pain.
Rationale 2: Pain tolerance refers to the ability of an individual to manage differing levels of
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discomfort.
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Rationale 3: Somatic interval is not legitimate pain terminology.
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Rationale 4: Cephalgia reporting is not legitimate pain terminology.
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Global Rationale: The pain threshold is the amount of pain stimulation a person requires in
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order to feel pain. Pain tolerance refers to the ability of an individual to manage differing levels
of discomfort. Somatic interval and cephalgia reporting are not legitimate pain terminology.
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 8.2: Identify the physiology of pain.
Question 13
Type: MCSA
The nurse is examining a client is in the Emergency Department. The client has recently been
discharged after a right above-the-knee amputation. The client tells the nurse that her right foot
hurts. The nurse suspects what type of pain?
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1. Phantom pain
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2. Radiating pain
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3. Intractable pain
4. Cutaneous pain
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Correct Answer: 1
Rationale 1: The client is describing phantom pain, which is a painful sensation perceived in an
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absent body part or a body part that is paralyzed.
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Rationale 2: Radiating pain has an origin in one part of the body and then spreads to other
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adjacent body parts.
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Rationale 3: Intractable pain does not respond to relief measures.
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Rationale 4: Cutaneous pain is pain experienced in the cutaneous tissues.
Global Rationale: The client is describing phantom pain, which is a painful sensation perceived
in an absent body part or a body part that is paralyzed. Radiating pain has an origin in one part of
the body and then spreads to other adjacent body parts. Intractable pain does not respond to relief
measures. Cutaneous pain is pain experienced in the cutaneous tissues.
Cognitive Level: Remembering
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8.3: Describe the different types of pain.
Question 14
Type: MCMA
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The nurse is assessing a client admitted with chronic back pain. Which of the following would
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the nurse associate with this type of pain?
Standard Text: Select all that apply.
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1. Sudden onset
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2. Interferes with daily activities
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3. Lower intensity
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4. Prolonged in duration
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Correct Answer: 2,4
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5. Sharp elevations in body temperature
longer.
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Rationale 1: Sudden onset. Chronic pain is recurring and persists for a period of 6 months or
Rationale 2: Interferes with daily activities. Chronic pain invades the life of a client. The daily
activities of the client with chronic pain are impacted.
Rationale 3: Lower intensity. The level of intensity experienced by the client with chronic pain
will vary. It is not necessarily low in intensity.
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Rationale 4: Prolonged in duration. By definition, chronic pain lasts for a period of 6 months
or longer.
Rationale 5: Sharp elevations in body temperature. Sharp elevations in vital signs are not
associated with chronic pain.
Global Rationale: Chronic pain is recurring and persists for a period of 6 months or longer. It
invades the life of a client, impacting the daily activities of the client. The level of intensity
experienced by the client with chronic pain will vary. It is not necessarily low in intensity. Sharp
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elevations in vital signs are not associated with chronic pain.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 8.3: Describe the different types of pain.
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Question 15
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Type: MCSA
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The parents of a 13-month-old infant requiring a veinipuncture for laboratory studies ask the
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nurse what they can do to help with pain during the procedure. Which of the following would be
the best action for the nurse to take?
1. Have the parents leave the area during the procedure.
2. Tell the parents to touch and reassure the infant during the procedure.
3. Wait until the infant is asleep to do the procedure.
4. Administer an analgesic 30 minutes before the procedure.
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Correct Answer: 2
Rationale 1: Having the parents leave the area may cause the infant to react very strongly to the
painful stimulus.
Rationale 2: The nurse understands that the presence of supportive people may affect the infants
perception of the severity of the pain, and provide reassurance and security.
Rationale 3: Being awakened from a sound sleep by painful stimuli may cause the infant to react
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very strongly.
Rationale 4: Administering an analgesic is inappropriate as the infant is not yet experiencing the
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pain, and after the relatively quick procedure is over, the infant should no longer feel any pain.
Global Rationale: The nurse understands that the presence of supportive people may affect the
infants perception of the severity of the pain, and provide reassurance and security.
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Administering an analgesic is inappropriate as the infant is not yet experiencing the pain, and
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after the relatively quick procedure is over, the infant should no longer feel any pain. Having the
parents leave the area may cause the infant to react very strongly to the painful stimulus, as will
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Cognitive Level: Applying
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being awakened from a sound sleep by painful stimuli.
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.4: Discuss factors that influence pain.
Question 16
Type: MCSA
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A recently licensed nurse states, My client keeps saying he is in pain. I dont believe him because
I had the same surgery last year and didnt feel nearly as bad as he claims. What response by the
more experienced nurse is most appropriate?
1. It sounds as if your client is a drug seeker.
2. You should contact the healthcare provider.
3. I would call the nursing supervisor for this one.
Correct Answer: 4
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Rationale 1: There is no evidence that this client is drug seeking.
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4. Pain differs from person to person.
Rationale 2: Contact with the healthcare provider is premature at this time.
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Rationale 3: Contact with the nursing supervisor is premature at this time.
Rationale 4: Pain has been defined as whatever the experiencing person says it is, existing
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whenever he or she says it does. Pain reports will vary between people.
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Global Rationale: Pain has been defined as whatever the experiencing person says it is, existing
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whenever he or she says it does. Pain reports will vary between people. There is no evidence that
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this client is drug seeking. Contact with the healthcare provider and nursing supervisor is
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premature at this time.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.4: Discuss factors that influence pain.
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Question 17
Type: MCMA
The nurse is performing an assessment on a 23-year-old client who is being seen for chronic
back pain. During the assessment, which of the following findings can be anticipated?
Standard Text: Select all that apply.
1. Increased pulse rate
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2. Increased respiratory rate
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3. Normal pulse rate
4. Normal blood pressure
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5. Diaphoresis
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Correct Answer: 3,4
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Rationale 1: Increased pulse rate. The heart rate of the client in chronic pain will be within
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normal limits. The heart rate will more likely be increased in the client with acute pain.
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Rationale 2: Increased respiratory rate. The respiratory rate of the client experiencing chronic
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client with acute pain.
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pain will most likely be within normal levels. The respiratory rate will most likely increase in the
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Rationale 3: Normal pulse rate. The pulse rate of the client experiencing chronic pain will
likely be within normal limits. Elevations in pulse rate are seen in clients experiencing acute
pain.
Rationale 4: Normal blood pressure. The blood pressure findings in the client experiencing
chronic pain will most likely be within normal limits. Elevations are most often seen in clients
experiencing acute pain.
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Rationale 5: Diaphoresis. Diaphoresis is seen most likely in the client in acute pain, not chronic
pain.
Global Rationale: The heart rate, respiratory rate, and blood pressure of the client in chronic
pain will likely be within normal limits. The heart rate, respiratory rate, and blood pressure will
more likely be increased in the client with acute pain. Diaphoresis is seen most likely in the
client in acute pain, not chronic pain.
Cognitive Level: Applying
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need: Physiological Integrity
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Learning Outcome: 8.2 Identify the physiology of pain
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Question 18
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Type: MCMA
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The nurse is caring for a 3-year-old child who has been hospitalized for internal fixation of a
fractured arm. The nurse is considering nonpharmacological pain management techniques to
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implement. What interventions should be included in the plan of care?
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Standard Text: Select all that apply.
1. Offer a glucose-coated pacifier.
2. Sit with the child and allow her to blow bubbles.
3. Explain to the child the cause of the pain.
4. Teach the use of guided imagery.
5. Hold the child.
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Correct Answer: 2,5
Rationale 1: Offer a glucose coated pacifier. The use of a glucose-coated pacifier is most
effective with an infant in the management of pain.
Rationale 2: Sit with the child and allow her to blow bubbles. Blowing bubbles is an ageappropriate activity for the preschool-age child. The child can be encouraged to blow the pain
away.
Rationale 3: Explain to the child the cause of the pain. A child at the age of 3 is too young to
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grasp a discussion of the causes of the pain being experienced.
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Rationale 4: Teach the use of guided imagery. Age-appropriate guided imagery is not a
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successful nonpharmacological means to manage pain in a preschool-age child. This may be
helpful for the school-age child.
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Rationale 5: Hold the child: The preschool-age child will find comfort in being held during the
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pain.
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Global Rationale: The use of a glucose-coated pacifier is most effective with an infant in the
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management of pain. Blowing bubbles is an age-appropriate activity for the preschool-age child.
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The child can be encouraged to blow the pain away. A child at the age of 3 is too young to grasp
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a discussion of the causes of the pain being experienced. Age-appropriate guided imagery is not
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a successful nonpharmacological means to manage pain in a preschool-age child. This may be
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the pain.
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helpful for the school-age child. The preschool-age child will find comfort in being held during
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.5: Describe techniques used for assessment of a client having pain.
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Question 19
Type: MCMA
A client has multiple fractures following a motor vehicle accident. One of the client outcomes of
the nurses plan of care includes reducing the perception of pain. Which of the following nursing
interventions would apply to reaching this outcome?
Standard Text: Select all that apply.
2. Assisting with guided imagery
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3. Administering Demerol (Meperidine) intravenously
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1. Offering a selection of musical CDs
4. Providing instruction on deep breathing techniques
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5. Administering an anti-inflammatory medication
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Correct Answer: 1,2,4
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Rationale 1: Offering a selection of musical CDs. The use of music is a means to assist the
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client to shift the focus from the pain to something else. This will help in reducing the perception
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of pain.
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Rationale 2: Assisting with guided imagery. Guided imagery allows the client to focus on a
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calmer, more positive place or sensation. This allows the focus to divert from the pain. This is a
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means to reduce the perception of pain.
Rationale 3: Administering Demerol (Meperidine) intravenously. The administration of
narcotic analgesics does not work to diminish the perception. These medications work to reduce
the transmission of the pain to the clients nerve sensors.
Rationale 4: Providing instruction on deep breathing techniques. The use of therapeutic
techniques will reduce the clients sensation of pain being experienced.
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Rationale 5: Administering an anti-inflammatory medication. The medication will reduce
discomfort by reducing the inflammation. This method does not reduce the perception of the
pain. The medications reduce inflammation, thus reducing the incidence of pain, not the
perception of it.
Global Rationale: The use of music, guided imagery, and deep breathing techniques are means
to assist the client to shift the focus from the pain to something else. This will help in reducing
the perception of pain. The administration of narcotic analgesics does not work to diminish the
perception. These medications work to reduce the transmission of the pain to the clients nerve
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sensors. Anti-inflammatory medication will reduce discomfort by reducing the inflammation.
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thus reducing the incidence of pain, not the perception of it.
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This method does not reduce the perception of the pain. The medications reduce inflammation,
Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 8.4: Discuss factors that influence pain.
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Type: MCSA
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Question 20
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A 45-year-old client continues to request intravenous pain medications 4 days after being placed
in skeletal traction due to a complex fracture of the hip. While giving report to the next shift, the
nurse who cared for the client during the day states, I just do not know why he still needs
medication 4 days after surgery. The client we had last month with the same type situation did
not need any medication after 2 days. Which of the following responses by a nursing peer is the
best example of being a client advocate?
1. I just think this client needs more because of his age.
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2. Have you tried getting the doctor to order oral pain medications to see if they work?
3. Wouldnt you want all of the pain medication you could have if you were in traction?
4. Everyone does not have the same pain perception or response to a similar injury.
Correct Answer: 4
Rationale 1: Pain threshold does not appear to change specifically with aging.
Rationale 2: Traditionally oral pain medications are used to manage less severe reports of pain.
The client in the scenario has uncontrolled pain. The client in the scenario has uncontrolled pain.
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The best course of action for the nurse is to educate the colleague about the individuality of the
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pain experience.
Rationale 3: A nurses personal attitudes or perceptions should not influence the care that is
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provided to a client.
Rationale 4: Based on the definition by McCaffery & Pasero pain is whatever the experiencing
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person says it is, existing whenever he or she says it does. This definition supports each clients
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need for individualized pain management approaches.
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Global Rationale: Based on the definition by McCaffery & Pasero, pain is whatever the
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experiencing person says it is, existing whenever he or she says it does. This definition supports
each clients need for individualized pain management approaches. Pain threshold does not
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appear to change with aging. Traditionally oral pain medications are used to manage less severe
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reports of pain. The client in the scenario has uncontrolled pain. The client in the scenario has
uncontrolled pain. The best course of action for the nurse is to educate the colleague about the
individuality of the pain experience. A nurses personal attitudes or perceptions should not
influence the care that is provided to a client.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.4: Discuss factors that influence pain
Question 21
Type: MCSA
A nursing student is reviewing the home medications of a client who has just been admitted with
chronic back pain. When asked by the nursing instructor why there is a tricyclic antidepressant
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on the clients list, which response by the student is most likely the accurate reason?
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2. It may be to prevent depression due to physical limitations.
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1. I would think having chronic pain would make the client depressed.
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3. This type of medication can help inhibit painful stimuli.
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4. The client is at risk for suicidal thoughts related to the chronic pain.
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Correct Answer: 3
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Rationale 1: This medication is not being used to prevent or manage depression.
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Rationale 2: This medication is not being used to prevent or manage depression.
Rationale 3: Tricyclic antidepressants can inhibit the reuptake of norepinephrine and serotonin.
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response.
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This would assist with the modulation phase of pain response by decreasing the pain stimuli
Rationale 4: This medication is not being used to reduce the incidence of suicidal thoughts.
Global Rationale: Tricyclic antidepressants can inhibit the reuptake of norepinephrine and
serotonin. This would assist with the modulation phase of pain response by decreasing the pain
stimuli response. This medication is not being used to prevent depression, manage depression, or
reduce the incidence of suicidal thoughts.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8.2: Identify the physiology of pain.
Question 22
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Type: MCSA
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The nursing student is discussing an assigned clients pain responses with the nursing instructor.
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The student reports feeling amazed about how the client has continued to avoid taking any
analgesics only hours after surgery. What response by the nursing instructor is indicated?
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1. Sometimes clients just dont need any analgesics.
2. Have you seen any nonverbal cues that might indicate the client is experiencing pain?
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3. We will need to contact the healthcare provider to report the clients continued refusal of
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analgesics.
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Correct Answer: 2
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4. Do the clients vital signs indicate the client is experiencing pain?
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Rationale 1: Sometimes clients just dont need any analgesics. A variety of factors will
influence a clients perception of pain and willingness to receive analgesics.
Rationale 2: Have you seen any nonverbal cues that might indicate the client is
experiencing pain? The nurse will need to promote a comprehensive assessment of the clients
pain experience. Nonverbal behaviors will need to be considered. Some clients may be stoic with
the pain experience.
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Rationale 3: We will need to contact the healthcare provider to report the clients continued
refusal of analgesics. There is no need to contact the healthcare provider at this time.
Rationale 4: Do the clients vital signs indicate the client is experiencing pain? The clients
vital signs should be considered in the assessment of pain but they are not the priority
consideration
Global Rationale: A variety of factors will influence a clients perception of pain and willingness
to receive analgesics. The nurse will need to promote a comprehensive assessment of the clients
pain experience. Nonverbal behaviors will need to be considered. Some clients may be stoic with
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the pain experience. There is no need to contact the healthcare provider at this time. The clients
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vital signs should be considered in the assessment of pain but they are not the priority
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consideration.
Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 8.4: Discuss factors that influence pain.
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Type: MCMA
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Question 23
The nurse is performing a physical assessment on a client with undiagnosed back pain. The client
is unable to communicate verbally. Which of the following vital sign values would indicate to
the nurse that the client is in acute pain?
Standard Text: Select all that apply.
1. Temperature of 100.6 degrees:
2. Pulse rate 94
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3. Respiratory rate 32
4. Blood pressure 158/92
5. Facial grimacing
Correct Answer: 2,3,4,5
Rationale 1: Temperature of 100.6 degrees. The client may be diaphoretic with acute pain, but
not directly as a result of a low-grade temperature.
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Rationale 2: Pulse rate 94. When in acute pain, a client will typically have sympathetic nervous
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system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure.
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Rationale 3: Respiratory rate 32. When in acute pain, a client will typically have sympathetic
nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood
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pressure.
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Rationale 4: Blood pressure 158/92. When in acute pain, a client will typically have
sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate,
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and blood pressure.
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experiencing acute pain.
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Rationale 5: Facial grimacing. Facial grimacing may be noted in the expressions of the client
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Global Rationale: The client may be diaphoretic with acute pain, but not directly as a result of a
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low-grade temperature. When in acute pain, a client will typically have sympathetic nervous
system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure.
Facial grimacing may be noted in the expressions of the client experiencing acute pain.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
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Learning Outcome: 8.2: Describe the physiology of pain.
Question 24
Type: MCSA
A client with a history of cardiac problems is brought to the emergency room by the paramedics
with a tentative diagnosis of myocardial infarction (MI, or heart attack). The paramedic tells the
nurse that the client had pain in the jaw area that was not relieved with nitroglycerin. The client
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asks the nurse how jaw pain is related to having a heart attack. The nurses best explanation is:
1. The doctors would rather treat you as a cardiac client until they find out why the nitroglycerin
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did not work.
2. Sometimes cardiac pain is not just in your chest, but in your jaws, arms or back.
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3. You may have been so stressed that you clenched your jaws and not realized if you had any
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chest pain or not.
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4. It may not be related, but cardiac pain is so serious to investigate and treat.
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Correct Answer: 2
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Rationale 1: It is inappropriate for the nurse to indicate the healthcare provider is treating the
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client in a manner without certainty.
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Rationale 2: Referred pain may result when pain is felt in tissues that are not in close proximity
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to the primary cause or site of the pain. This may be especially true of cardiac pain. It may be
exhibited in the jaw, shoulders, arms, or back.
Rationale 3: Clenching teeth would not be linked to chest pain.
Rationale 4: While cardiac pain is serious, this response does not meet the level of client
questioning.
Global Rationale: Referred pain may result when pain is felt in tissues that are not in close
proximity to the primary cause or site of the pain. This may be especially true of cardiac pain. It
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may be exhibited in the jaw, shoulders, arms, or back. It is inappropriate for the nurse to indicate
the healthcare provider is treating the client in a manner without certainty. Clenching teeth would
not be linked to chest pain. While cardiac pain is serious, this response does not meet the level of
client questioning.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Learning Outcome: 8.2: Identify the physiology of pain.
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Question 25
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Client Need Sub:
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Type: MCSA
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A 12-year-old client is brought to the emergency room after falling on his arm during a football
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game. When the nurse tells the client that she is going to administer pain medication through the
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intravenous line, the client begins to scream and wave his unhurt arm. The parents ask the nurse
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why their child is behaving this way. The nurses best response would be:
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1. He is just immature for his age.
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2. I am sure he is just scared.
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3. It looks like he may have hurt his head during the fall.
4. He may be remembering another time when he got a shot.
Correct Answer: 4
Rationale 1: There is no information to indicate that the client is immature for age.
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Rationale 2: Assuming the child is just scared is not something the nurse can be sure of, as it is
never safe to assume anything as a definite.
Rationale 3: There is no information to indicate the presence of a head injury.
Rationale 4: A clients nervous system responds to pain, but many times there are also behavioral
responses. A clients pain reaction may be a behavioral response to a similar or previous situation
when pain was experienced. This is a learned response and method of coping with the pain.
Many children remember getting a shot for pain, or getting an immunization. Seeing the syringe
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and/or needle may trigger this pain reaction.
Global Rationale: A clients nervous system responds to pain, but many times there are also
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behavioral responses. A clients pain reaction may be a behavioral response to a similar or
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previous situation when pain was experienced. This is a learned response and method of coping
with the pain. Many children remember getting a shot for pain, or getting an immunization.
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Seeing the syringe and/or needle may trigger this pain reaction. Assuming the child is just scared
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is not something the nurse can be sure of, as it is never safe to assume anything as a definite.
There is no information to indicate the presence of a head injury or that the client is immature for
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age.
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Chapter 8. Assessing the Skin, Hair, and Nails
Question 1
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Type: HOTSPOT
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The nurse has performed a focused interview with the client and is preparing to perform a skin
assessment while the student nurse observes. The student nurse asks, Where exactly is the
stratum basale located? Identify the stratum basale in the following figure by placing an arrow
pointing toward this area. [Please insert figure 11-1 from DAmico 2nd edition: Skin structure, 3dimensional view of skin.Remove all labels]
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Rationale : The epidermis is a layer of epithelial tissue that comprises the outermost portion of
the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the
feet, the epidermis consists of five layers (or strata). These five layers are, from deep to
superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and
stratum corneum.
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Global Rationale:
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Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.1: Identify the anatomy and physiology of the skin, hair, and nails.
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Question 2
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Type: HOTSPOT
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The nurse is assessing the clients nail. Identify the lunula by drawing an arrow pointing toward
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this area on the following figure.
Rationale : The lunula is a moon-shaped crescent that appears on the nail body over the
thickened nail matrix.
Global Rationale:
Cognitive Level: Remembering
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.1: Identify the anatomy and physiology of the skin, hair, and nails.
Question 3
Type: MCSA
The nurse is conducting a focused interview on the clients integumentary system and prepares to
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obtain data related to risk factors for the development of integumentary disorders. Which of the
following questions by the nurse would be unexpected based on the specific data the nurse is
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attempting to gain during the interview?
2. How do you care for your skin?
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3. Do you have any tattoos or body piercings?
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1. How much time do you spend outdoors?
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4. Have you noticed any drainage from your skin?
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Correct Answer: 4
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Rationale 1: The nurse can ask the client about the amount of time that the client spends outside.
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Spending time outside in the sunshine is a risk factor for the development of skin disorders, such
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as squamous cell carcinoma.
Rationale 2: The nurse can ask the client about the way that the client cares for the skin. There
may be something that the client is doing while caring for the skin that is a risk factor for the
development of an integumentary disorder.
Rationale 3: Tattoos and body piercings can increase the clients risk for developing an
integumentary disorder.
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Rationale 4: When the nurse asks the client about the presence of drainage from the skin, this
question is directed at determining the presence of a clinical manifestation of an integumentary
disorder. This question is not necessarily directed at gaining information about risk factors.
Global Rationale: When the nurse asks the client about the presence of drainage from the skin,
this question is directed at determining the presence of a clinical manifestation of an
integumentary disorder. This question is not necessarily directed at gaining information about
risk factors. The nurse can ask the client about the amount of time that the client spends outside.
Spending time outside in the sunshine is a risk factor for the development of skin disorders, such
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as squamous cell carcinoma. The nurse can ask the client about the way that the client cares for
the skin. There may be something that the client is doing while caring for the skin that is a risk
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the clients risk for developing an integumentary disorder.
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factor for the development of an integumentary disorder. Tattoos and body piercings can increase
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 11.2: Develop questions to be used when completing the focused interview.
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Type: MCSA
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Question 4
The nurse is completing a focused interview to assess the skin, hair, and nails of a pregnant
client. Which of the following questions would be most important for the nurse to include in the
interview?
1. Do you use any skin creams?
2. Do you try to avoid exposure to the sun?
3. Have you lost any hair during your pregnancy?
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4. Have you had any nail changes?
Correct Answer: 1
Rationale 1: Topical medications may be absorbed through the skin and harm the fetus. Those
that can cause birth defects include Retin A, antifungal agents, and minoxidil for hair growth.
Other topical medications that can harm the baby include antibiotics, steroids, and medication for
muscle pain.
Rationale 2: Client should avoid sun exposure to prevent skin damage.
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Rationale 3: Losing hair during pregnancy is not necessarily as important to assess as the clients
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use of skin creams. Topical medications may be absorbed through the skin and harm the fetus.
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Rationale 4: Nail changes can be assessed, but it is most important to assess the clients use of
skin creams. Topical medications may be absorbed through the skin and harm the fetus.
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Global Rationale: Topical medications may be absorbed through the skin and harm the fetus.
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Those that can cause birth defects include Retin A, antifungal agents, and minoxidil for hair
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growth. Other topical medications that can harm the baby include antibiotics, steroids, and
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Cognitive Level: Applying
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medication for muscle pain.
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.2: Develop questions to be used when completing the focused interview.
Question 5
Type: MCSA
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The nurse is preparing to assess the clients skin, hair, and nails. Which of the following
techniques will the nurse use initially during this assessment?
1. Percussion
2. Palpation
3. Auscultation
4. Inspection
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Correct Answer: 4
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Rationale 1: There is no need to use percussion to assess the clients skin, hair, and nails.
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Rationale 2: The nurse inspects then palpates during the assessment of the clients skin, hair, and
nails.
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Rationale 3: There is no need to use auscultation to assess the clients skin, hair, and nails.
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Rationale 4: Inspection is the nurses first step when assessing the clients skin, hair, and nails.
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Global Rationale: Physical assessment of the skin, hair, and nails is conducted by inspection
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and then with palpation. There is no need to use percussion to assess the clients skin, hair, and
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nails. There is no need to use auscultation to assess the clients skin, hair, and nails.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11.3: Explain client preparation for assessment of the skin, hair, and nails.
Question 6
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Type: MCMA
The client is visiting the healthcare providers office for a head-to-toe assessment. During the
nurses assessment of the clients skin, the nurse notes that the client is pale. Which of the
following findings may be related to the clients color?
Standard Text: Select all that apply.
1. Clients blood pressure is 96/62.
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4. The client states, I have been diagnosed with osteoporosis.
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3. The clients oxygen saturation level is 86% on room air.
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2. The client states, I just smoked a cigarette before I came in the office.
5. The client states, It is snowing again outside with a wind chill factor of 11 degrees Fahrenheit.
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Correct Answer: 1,2,3,5
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Rationale 1: Clients blood pressure is 96/62. Pallor may be seen in the client with hypotension.
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Rationale 2: The client states, I just smoked a cigarette before I came in the office. It can be
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produced by the sympathetic nervous stimulation that results in vasoconstriction due to smoking
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cigarettes.
Rationale 3: The clients oxygen saturation level is 86% on room air. The client with a
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decreased oxygen saturation level may exhibit pallor.
Rationale 4: The client states, I have been diagnosed with osteoporosis. Pallor is not normally
associated with osteoporosis.
Rationale 5: The client states, It is snowing again outside with a wind chill factor of 11
degrees Fahrenheit. A cold environment can produce vasoconstriction and pallor.
Global Rationale: Pallor may be seen in the client with hypotension. It can be produced by the
sympathetic nervous stimulation that results in vasoconstriction due to smoking cigarettes. The
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client with a decreased oxygen saturation level may exhibit pallor. A cold environment can
produce vasoconstriction and pallor. It is not normally associated with osteoporosis.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
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Question 7
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Type: MCSA
The nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and
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sclerae are yellowish in color. The nurse would correctly document this finding as which of the
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following?
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1. Uremia
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2. Cyanosis
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3. Jaundice
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4. Carotenemia
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Correct Answer: 3
Rationale 1: Uremic skin is pale and yellow, but is associated with renal, and not liver, disease.
The yellow tinge seen in the patient with uremic skin is very pale and does not affect
conjunctivae or mucous membranes.
Rationale 2: Cyanotic skin is bluish in color.
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Rationale 3: The nurses findings indicate jaundice, which is due to increased levels of bilirubin
in the blood. Jaundice is visible in the sclerae, oral mucosa, junction of hard and soft palate,
palms of the hands, and soles of the feet.
Rationale 4: Carotenemic skin has a yellow-orange tinge. The yellow-orange tinge seen in the
client with carotenemia is most visible in palms of the hands and soles of the feet. This client
would not exhibit yellowing of sclerae or mucous membranes.
Global Rationale: The nurses findings indicate jaundice, which is due to increased levels of
bilirubin in the blood. Jaundice is visible in the sclerae, oral mucosa, junction of hard and soft
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palate, palms of the hands, and soles of the feet. Uremic skin is pale and yellow, but is associated
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with renal, and not liver, disease. The yellow tinge seen in the patient with uremic skin is very
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pale and does not affect conjunctivae or mucous membranes. Cyanotic skin is bluish in color.
Carotenemic skin has a yellow-orange tinge. The yellow-orange tinge seen in the client with
carotenemia is most visible in palms of the hands and soles of the feet. This client would not
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exhibit yellowing of sclerae or mucous membranes.
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Client Need: Physiological Integrity
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Cognitive Level: Understanding
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
Question 8
Type: MCSA
The nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled
mass approximately 0.4 cm in size. The nurse would correctly document this finding as which of
the following?
1. Vesicle
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2. Macule
3. Papule
4. Tumor
Correct Answer: 1
Rationale 1: The area described is a vesicle and may be caused by herpetic lesions, poison ivy,
and small burn blisters.
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Rationale 3: A papule is an elevated, solid, palpable mass.
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Rationale 2: A macule is a flat, nonpalpable change in skin color.
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Rationale 4: Tumors are elevated, but solid, hard, or soft palpable and extend deeper into the
dermis.
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Global Rationale: The area described is a vesicle and may be caused by herpetic lesions, poison
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ivy, and small burn blisters. A macule is a flat, nonpalpable change in skin color. A papule is an
elevated, solid, palpable mass. Tumors are elevated, but solid, hard, or soft palpable and extend
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Cognitive Level: Remembering
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deeper into the dermis.
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
Question 9
Type: MCSA
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The nurse is caring for a client who has smoked for many years and documents that clubbing is
present. Which of the following techniques is the best way for the nurse to determine the
presence of clubbing?
1. Place two thumbs touching side-by-side.
2. Place two of the same fingers from each hand together.
3. Place two index fingers together tip-to-tip.
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4. Place the hands out straight with the palm sides down.
Correct Answer: 2
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Rationale 1: Placing the thumbs together side-by-side is not an appropriate way to determine the
presence of clubbing.
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Rationale 2: To assess for clubbing, the nurse can use the Schamroth technique in which the
nurse asks the client to bring the dorsal aspect of corresponding fingers together and if there is
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clubbing, a diamond is not formed and the distance increases at the fingertip.
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Rationale 3: Placing the index finger tip-to-tip is not an appropriate way to determine the
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presence of clubbing.
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Rationale 4: Placing the hands straight out with the palms facing downward is not an
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appropriate way to determine the presence of clubbing.
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Global Rationale: To assess for clubbing, the nurse can use the Schamroth technique in which
the nurse asks the client to bring the dorsal aspect of corresponding fingers together and if there
is clubbing, a diamond is not formed and the distance increases at the fingertip. Placing the
thumbs together side-by-side is not an appropriate way to determine the presence of clubbing.
Placing the index finger tip-to-tip is not an appropriate way to determine the presence of
clubbing. Placing the hands straight out with the palms facing downward is not an appropriate
way to determine the presence of clubbing.
Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
Question 10
Type: MCSA
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The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse, Why
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did this happen to me? Which of the following statements is the nurses best response?
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1. Your diet is not nutritionally balanced.
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2. You may have some hormone imbalances.
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3. Usually, there is not a known cause for this condition.
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4. You need to take vitamins.
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Correct Answer: 2
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Rationale 1: Hirsutism is not typically linked to nutrition.
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Rationale 2: Hirsutism is the occurrence of excess body hair in females on the face, chest,
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abdomen, arms, and legs, following the male pattern. It is typically due to endocrine or metabolic
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dysfunction, but may be idiopathic in nature.
Rationale 3: Hirsutism is typically due to endocrine or metabolic dysfunction.
Rationale 4: Clients with hirsutism do not need more vitamins, since hirsutism is often the result
of endocrine or metabolic dysfunction.
Global Rationale: Hirsutism is the occurrence of excess body hair in females on the face, chest,
abdomen, arms, and legs, following the male pattern. It is typically due to endocrine or metabolic
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dysfunction, but may be idiopathic in nature. Hirsutism is not typically linked to nutrition.
Hirsutism is typically due to endocrine or metabolic dysfunction. Clients with hirsutism do not
need more vitamins, since hirsutism is often the result of endocrine or metabolic dysfunction.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
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Question 11
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Type: MCSA
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The nurse is inspecting the fingernails of a client with a diagnosis of polycythemia. Which of the
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following findings would be expected with this diagnosis?
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2. Horizontal white bands
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1. Dark red nails
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3. Pale nail beds
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4. Spoon-shaped nails
Correct Answer: 1
Rationale 1: The client with polycythemia has nails that appear dark red due to a pathological
increase in red blood cells.
Rationale 2: Horizontal white bands in the nails are seen with the client who has been diagnosed
with chronic hepatitis.
Rationale 3: Pale nail beds are associated with anemia or peripheral circulatory disorders.
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Rationale 4: Spoon-shaped nails may be related to iron deficiency.
Global Rationale: The client with polycythemia has nails that appear dark red due to a
pathological increase in red blood cells. Horizontal white bands in the nails are seen with the
client who has been diagnosed with chronic hepatitis. Pale nail beds are associated with anemia
or peripheral circulatory disorders. Spoon-shaped nails may be related to iron deficiency.
Cognitive Level: Understanding
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need: Physiological Integrity
Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
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Question 12
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Type: MCSA
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The nurse is assessing the skin of a teenage male client and notes the presence of a musky odor.
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The client states that this is embarrassing for him and that he showers daily. Which of the
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following actions should the nurse take in this situation?
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1. Reassure the teen that this is normal.
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2. Notify the clients healthcare provider.
3. Obtain a dietary referral.
4. Educate the client regarding the importance of increased water intake.
Correct Answer: 1
Rationale 1: The apocrine glands are dormant until the onset of puberty when they become
active and produce secretion of water, salts, fatty acids, and proteins. This secretion is released
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into hair follicles primarily in auxiliary and anogenital areas and when mixed with bacteria on
skin surface produces a musky odor. This is a normal part of normal growth and development.
Rationale 2: The teenage clients healthcare provider does not need to be notified because this
odor is associated with normal growth and development.
Rationale 3: The nurse does not need to obtain a dietary referral because this odor is associated
with normal growth and development.
Rationale 4: Increasing fluid intake will not help prevent the occurrence of this odor. It is a
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normal part of normal growth and development.
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Global Rationale: The apocrine glands are dormant until the onset of puberty when they
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become active and produce secretion of water, salts, fatty acids, and proteins. This secretion is
released into hair follicles primarily in auxiliary and anogenital areas and when mixed with
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bacteria on skin surface produces a musky odor. This is a normal part of normal growth and
development. The teenage clients healthcare provider does not need to be notified because this
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odor is associated with normal growth and development. The nurse does not need to obtain a
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dietary referral because this odor is associated with normal growth and development. Increasing
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fluid intake will not help prevent the occurrence of this odor. It is a normal part of normal growth
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and development.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
Question 13
Type: MCSA
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The nurse is caring for a client complaining of a painful, hot area located on the clients leg.
Erythema and edema are present in the localized area. Which of the following actions should the
nurse perform next?
1. Palpate the area.
2. Place a heating pad on the area.
3. Notify the healthcare provider.
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4. Place client on bed rest.
Correct Answer: 3
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Rationale 1: The nurse would not palpate the area. Reddened, swollen, localized, painful areas
should not be palpated because these signs and symptoms indicate the presence of inflammation
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and possible infection. Disturbance may spread the infection into skin layers.
Rationale 2: The nurse would not apply a heating pad to this site. Disturbance may spread the
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infection into skin layers.
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Rationale 3: Reddened, swollen, localized, painful areas should not be palpated because these
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signs and symptoms indicate the presence of inflammation and possible infection. Disturbance
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may spread the infection into skin layers. The healthcare provider should be notified.
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Rationale 4: The nurse would not necessarily place the client on bed rest. The healthcare
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provider should be notified.
Global Rationale: Reddened, swollen, localized, painful areas should not be palpated because
these signs and symptoms indicate the presence of inflammation and possible infection.
Disturbance may spread the infection into skin layers. The healthcare provider should be
notified. The nurse would not palpate the area. The nurse would not apply a heating pad to this
site. The nurse would not necessarily place the client on bed rest.
Cognitive Level: Applying
Client Need: Physiological Integrity
www.mynursingtestprep.com
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
Question 14
Type: MCSA
The nurse is performing a skin assessment on a client and notes an oval-shaped, elevated, fluid-
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filled mass that is approximately 1.5 centimeter in size. The nurse would correctly document this
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finding as which of the following?
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1. Vesicle
2. Bulla
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3. Papule
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4. Tumor
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Correct Answer: 2
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Rationale 1: Vesicles are smaller than 0.5 centimeters but are also described as elevated, fluid-
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filled, round or oval-shaped, palpable mass with thin, translucent walls and circumscribed
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borders.
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Rationale 2: The area described is a bulla and may be caused by contact dermatitis, friction
blisters, and large burn blisters.
Rationale 3: A papule is an elevated, solid palpable mass with a circumscribed border. Papules
are smaller than 0.5 centimeters.
Rationale 4: Tumors are elevated, solid, hard, or soft palpable and extend deeper into the
dermis.
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Global Rationale: The area described is a bulla and may be caused by contact dermatitis,
friction blisters, and large burn blisters. Vesicles are smaller than 0.5 centimeters but are also
described as elevated, fluid-filled, round or oval-shaped, palpable mass with thin, translucent
walls and circumscribed borders. A papule is an elevated, solid palpable mass with a
circumscribed border. Papules are smaller than 0.5 centimeters. Tumors are elevated, but solid,
hard, or soft palpable and extend deeper into the dermis.
Cognitive Level: Understanding
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need: Physiological Integrity
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Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
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Question 15
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Type: MCSA
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The adult client is visiting the outpatient clinic. The client states, I have sores in my mouth and
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on my lips. The nurse notes the presence of crusted lesions on the lips and inside the clients
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mouth along the cheek. The client states that the lesions do not itch. These findings are most
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1. Chickenpox
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consistent with the development of which of the following conditions?
2. Contact dermatitis
3. Herpes simplex
4. Psoriasis
Correct Answer: 3
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Rationale 1: Chickenpox is a mild infectious disease caused by the herpes zoster virus. It begins
as groups of small, red, fluid-filled vesicles usually on the trunk, and progresses to the face,
arms, and legs. Vesicles erupt over several days, forming pustules, then crusts. The condition
may cause intense itching. It occurs mostly in children.
Rationale 2: Contact dermatitis is inflammation of the skin due to an allergy to a substance that
comes into contact with the skin, such as clothing, jewelry, plants, chemicals, or cosmetics. The
location of the lesions may help identify the allergen. It may progress from redness to hives,
vesicles, or scales, and is usually accompanied by intense itching.
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Rationale 3: The lesions described are typical for herpes simplex, which is a viral infection that
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produces such lesions.
Rationale 4: Psoriasis is thickening of the skin in dry, silvery, scaly patches. It occurs with
overproduction of skin cells resulting in buildup of cells faster than they can be shed. It may be
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triggered by emotional stress or generally poor health. It may be located on scalp, elbows and
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knees, lower back, and perianal area.
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Global Rationale: The lesions described are typical for herpes simplex, which is a viral
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infection that produces such lesions. Chickenpox is an infectious disease caused by the herpes
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zoster virus. It begins as groups of small, red, fluid-filled vesicles usually on the trunk, and
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progresses to the face, arms, and legs. Vesicles erupt over several days, forming pustules, then
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crusts. The condition may cause intense itching. It occurs mostly in children. Contact dermatitis
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is inflammation of the skin due to an allergy to a substance that comes into contact with the skin,
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such as clothing, jewelry, plants, chemicals, or cosmetics. The location of the lesions may help
identify the allergen. It may progress from redness to hives, vesicles, or scales, and is usually
accompanied by intense itching. Psoriasis is thickening of the skin in dry, silvery, scaly patches.
It occurs with overproduction of skin cells resulting in buildup of cells faster than they can be
shed. It may be triggered by emotional stress or generally poor health. It may be located on scalp,
elbows and knees, lower back, and perianal area.
Cognitive Level: Understanding
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
Question 16
Type: MCSA
The nurse is assessing a clients skin and notes that the color of the skin, nails, and the clients
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mucous membranes are very light. Which of the following descriptions would the nurse use
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when documenting this finding?
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1. Cyanosis
2. Pallor
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3. Erythema
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4. Jaundice
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Correct Answer: 2
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Rationale 1: Cyanotic skin is bluish in color.
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Rationale 2: Pallor is pale skin. It may occur with hypoxia, cold environment, stress, shock,
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hypotension, and anemia.
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Rationale 3: Erythema indicates that the skin is reddened.
Rationale 4: Jaundice is used to describe yellowish skin.
Global Rationale: Pallor, or paleness of the skin, may occur with hypoxia, cold environment,
stress, shock, hypotension, and anemia. Cyanotic skin is blue in color; erythema is redness of the
skin; and jaundiced skin has yellow undertones.
Cognitive Level: Understanding
www.mynursingtestprep.com
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
Question 17
Type: MCSA
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The client visits the outpatient clinic. During the assessment of the clients skin, the nurse notes
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document these lesions in which of the following ways?
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the presence of several abdominal lesions that appear in distinct clusters. The nurse would
1. Grouped
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2. Annular
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3. Discrete
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4. Confluent
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Correct Answer: 1
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Rationale 1: The lesions described are grouped lesions because they appear in clusters.
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Rationale 2: Annular lesions are lesions with a circular shape.
Rationale 3: Discrete lesions are lesions that are separate and discrete.
Rationale 4: Confluent lesions run together.
Global Rationale: The lesions described are grouped lesions because they appear in clusters.
Annular lesions are lesions with a circular shape. Discrete lesions are separate. Confluent lesions
run together.
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Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
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Question 18
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Type: MCMA
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The nurse has assessed the clients skin. The nurse is preparing to document the appearance of
herpetic lesions found over a clients nose and mouth region. The healthcare provider diagnosed
the client with herpes simplex. Which of the following are common words that are used to
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describe these types of lesions?
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Standard Text: Select all that apply.
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1. Vesicular
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2. Pustular
5. Crusty
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4. Ulcerated
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3. Pruritic
Correct Answer: 1,2,5
Rationale 1: Vesicular. Herpes simplex lesions may be described as vesicular.
Rationale 2: Pustular. Herpes simplex lesions may be described as pustular.
Rationale 3: Pruritic. Herpes simplex lesions are not associated with pruritis.
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Rationale 4: Ulcerated. Herpes simplex lesions are not typically ulcerated.
Rationale 5: Crusty. Herpes simplex lesions may be described as crusty.
Global Rationale: Herpes simplex lesions progress from vesicles to pustules, and then crusts.
They are not typically itchy (pruritic). They are not often described as being ulcerated.
Cognitive Level: Understanding
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Client Need: Physiological Integrity
Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
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Question 19
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Type: MCSA
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The student nurse assessed the clients skin. The student nurse documented +1 edema right lower
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leg. The experienced nurse expects to find which of the following based on the student nurses
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documentation?
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1. The presence of slight pitting, no obvious distortion
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2. Deep pitting, obvious distortion
3. Pitting is obvious, extremities are swollen
4. Moderate amount of edema
Correct Answer: 1
Rationale 1: Edema, or accumulation of fluid in the bodys tissues, is recorded as +1, +2, +3, or
+4. The designation +1 means the client has slight pitting in the right lower leg with no obvious
distortion.
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Rationale 2: Deep pitting with obvious distortion may be documented as +4 edema.
Rationale 3: Obvious pitting with swollen extremities may be described as +3 edema.
Rationale 4: A moderate amount of edema may be described as +2 to +3 edema.
Global Rationale: Edema, or accumulation of fluid in the bodys tissues, is recorded as +1, +2,
+3, or +4. The designation +1 means the client has slight pitting in the right lower leg with no
obvious distortion.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
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Question 20
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Type: MCSA
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During the assessment of a clients integumentary status the nurse notes vitiligo present bilateral
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hands. This documentation indicates which of the following information?
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1. Nodules with ulcerations
2. Dark, asymmetrical colored patches
3. Grouped vesicles
4. Abnormal loss of melanin in patches
Correct Answer: 4
Rationale 1: The term vitiligo does not indicate the presence of nodules with ulcerations.
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Rationale 2: The term vitiligo does not indicate the presence of dark, asymmetrical colored
patches.
Rationale 3: The term vitiligo does not indicate the presence of grouped vesicles.
Rationale 4: Vitiligo is an abnormal loss of melanin in patches, typically occurring over the
face, hands, or groin.
Global Rationale: Vitiligo is an abnormal loss of melanin in patches, typically occurring over
the face, hands, or groin. The term vitiligo does not indicate the presence of nodules with
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ulcerations. The term vitiligo does not indicate the presence of dark, asymmetrical colored
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patches. The term vitiligo does not indicate the presence of grouped vesicles.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.
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Question 21
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Type: MCSA
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The nurse is admitting a newly admitted client and notes skin vitiligo, which is highly visible
even from a distance. The client asks the nurse to place a No Visitors sign on the door the
patients room. The client states, I hate the way my skin looks. Some people just stare at me.
Which of the following nursing diagnoses should be incorporated into the clients plan of care?
1. Defensive coping
2. Risk for loneliness
3. Deficient knowledge
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4. Disturbed body image
Correct Answer: 4
Rationale 1: Defensive coping is not the best nursing diagnosis to apply to this client. This client
has a disturbed body image.
Rationale 2: The client does have a risk for loneliness but it is most likely due to the underlying
disturbed body image.
Rationale 3: There is nothing to indicate that the client has a deficient knowledge. This client is
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suffering from a disturbed body image due to the skins appearance.
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Rationale 4: This client has a visible skin disorder and is exhibiting signs that the client has a
disturbed body image.
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Global Rationale: A visible skin disorder may trigger psychosocial problems and a disturbed
body image. This client has vitiligo, which is a skin condition. The client will exhibit patchy
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depigmented areas over some or all of the following body areas: face, neck, hands, feet, and
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body folds. A client with vitiligo may suffer a severe disturbance in body image.
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Cognitive Level: Applying
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Client Need Sub:
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Client Need: Psychosocial Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
Question 22
Type: MCSA
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The nurse received a phone call from a mother who was discharged with her newborn several
days ago. The mother completed the infant care teaching prior to discharge. The nurse would
determine that the teaching had been effective if the mother reported which of the following?
1. Tiny, white facial bumps
2. Yellow skin and mucous membrane color
3. Irregular red patches on the back of the neck
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4. Dark spots on the sacral area
Correct Answer: 2
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Rationale 1: Milia are tiny, white facial papules due to sebum and will resolve within a few
weeks of birth.
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Rationale 2: Yellowing of skin and mucous membranes in an infant who is 34 days old is
temporary jaundice form of jaundice called physiological jaundice, but may require treatment
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with fluids and phototherapy.
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Rationale 3: Vascular markings are also called stork bites and may be located on the back of the
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neck.
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Rationale 4: Harmless skin markings requiring no intervention include gray, blue, or purple
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spots (Mongolian spots) on the buttocks or sacral area.
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Global Rationale: Yellowing of skin and mucous membranes in an infant who is 34 days old is
temporary form of jaundice called physiological jaundice, but may require treatment with fluids
and phototherapy. Milia are tiny, white facial papules due to sebum and will resolve within a few
weeks of birth. Vascular markings are also called stork bites and may be located on the back of
the neck. Harmless skin markings requiring no intervention include gray, blue, or purple spots
(Mongolian spots) on the buttocks or sacral area.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
Question 23
Type: MCSA
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The nurse is caring for a client with dark skin and needs to assess the skin for jaundice. Which of
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the following actions would be appropriate for the nurse in this situation?
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1. Use a bright lamp and a magnifying glass.
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2. Document unable to assess for skin changes.
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3. Assess the skin the same way you would inspect a client with lighter skin.
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4. Inspect the lips, oral mucosa, sclera, conjunctivae, and palms.
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Correct Answer: 4
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Rationale 1: A bright light may assist the nurse, but the nurse should inspect the clients lips, oral
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mucosa, sclera, conjunctivae, and palms when assessing for jaundice.
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jaundice.
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Rationale 2: It is not appropriate to document that the nurse is unable to assess the client for
Rationale 3: The nurse will not find it as useful to assess the client with darker skin in the same
way that the nurse would assess the client with lighter skin. The nurse should inspect areas of the
body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and
conjunctivae.
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Rationale 4: Changes in skin color may be difficult to discover when assessing clients with dark
skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral
mucosa, sclera, palms of the hand, and conjunctivae.
Global Rationale: Changes in skin color may be difficult to discover when assessing clients
with dark skin. The nurse should inspect areas of the body with less pigmentation such as the
lips, oral mucosa, sclera, palms of the hand, and conjunctivae. A bright light may assist the
nurse, but the nurse should inspect the clients lips, oral mucosa, sclera, conjunctivae, and palms
when assessing for jaundice. It is not appropriate to document that the nurse is unable to assess
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the client for jaundice. The nurse will not find it as useful to assess the client with darker skin in
the same way that the nurse would assess the client with lighter skin. The nurse should inspect
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areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand,
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and conjunctivae.
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Cognitive Level: Applying
ng
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental
Type: MCSA
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Question 24
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variations in assessment techniques and findings.
The nurse is assessing the skin of a newborn infant and notes a bright red, raised lesion on the
lateral aspect of the thigh. The lesion is 4.5 centimeters in diameter. When light pressure is
applied to the lesion, the site does not blanch. The mother expresses concern about the
appearance of this site, and asks the nurse if it should be removed. Which of the following would
be the best response for the nurse in this situation?
1. Your pediatrician can make a surgical referral for you.
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2. It really is not that noticeable.
3. You should be happy that your baby is healthy overall.
4. These types of lesions usually disappear by the time a child turns 10 years old.
Correct Answer: 4
Rationale 1: There is no reason for the nurse to speak with the pediatrician regarding a surgical
referral. These types of lesions usually disappear by the time a child turns 10 years old.
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Rationale 2: The nurse should not indicate that the lesion is not that noticeable. The nurse
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should educate the mother about the lesion.
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Rationale 3: The nurse should not state that the mother should be happy with the overall health
of the newborn. The mother is concerned about the appearance of the lesion and should be
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educated about the lesion and its normal course.
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Rationale 4: The lesion described is a hemangioma, which is a cluster of immature capillaries
that can be found on any part of the body. These lesions usually disappear by age 10, and no
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intervention is needed.
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Global Rationale: The lesion described is a hemangioma, which is a cluster of immature
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capillaries that can be found on any part of the body. These lesions usually disappear by age 10,
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and no intervention is needed. The nurse should educate the mother about the lesion. The mother
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does not require comments suggesting she should ignore the lesion or be happy that the infant
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does not have more serious problems. The nurse should not state that the mother should be happy
with the overall health of the newborn. The mother is concerned about the appearance of the
lesion and should be educated about the lesion and its normal course.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
Question 25
Type: MCSA
The nurse is performing a skin assessment on an African American client and notes an elevated,
irregular band of jagged tissue on the clients left arm. The client states, I had a burn here a long
time ago, but it seemed to keep on getting bigger. The nurse would correctly document this
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finding in which of the following ways?
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1. Ulcer
2. Keloid
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3. Fissure
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4. Scar
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Correct Answer: 2
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Rationale 1: An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or
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subcutaneous tissue. This tissue is best described as a keloid.
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Rationale 2: This is most likely a keloid, which is an elevated, irregular, darkened area of excess
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scar tissue caused by excessive collagen formation during healing. It extends beyond the site of
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the original injury. There is higher incidence in people of African descent.
Rationale 3: A fissure is a crack in the skin extending to the dermis. This tissue is best described
as a keloid.
Rationale 4: A scar is connective tissue left after healing, but is flat and usually linear. This is
most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused
by excessive collagen formation during healing. It extends beyond the site of the original injury.
There is higher incidence in people of African descent.
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Global Rationale: This is most likely a keloid, which is an elevated, irregular, darkened area of
excess scar tissue caused by excessive collagen formation during healing. It extends beyond the
site of the original injury. There is higher incidence in people of African descent. An ulcer is a
deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. A
fissure is a crack in the skin extending to the dermis. A scar is connective tissue left after healing,
but is flat and usually linear. This tissue is best described as a keloid.
Chapter 9. Assessing the Head, Face, Mouth, and Neck
Question 1
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Type: MCMA
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The nurse is assessing the clients temporomandibular joint. The client complains of chronic pain
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at this site. Which of the following may have occurred as a result of this condition?
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Standard Text: Select all that apply.
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1. The client has developed migraine headaches.
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2. The client is unable to chew well and has lost weight since the pain began.
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3. The client exhibits difficulty speaking clearly and enunciating words.
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4. The client has developed hyperparathyroidism.
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5. The client has developed torticollis.
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Correct Answer: 2,3,5
Rationale 1: The client has developed migraine headaches. Clients who have pain at the
temporomandibular joint will have difficulty moving this joint adequately. This can result in
difficulty speaking, problems chewing food, and weight loss. Clients with temporomandibular
joint pain are more likely to develop cluster or tension headaches.
Rationale 2: The client is unable to chew well and has lost weight since the pain began.
Clients who have pain at the temporomandibular joint will have difficulty moving this joint
adequately. This can result in difficulty speaking, problems chewing food, and weight loss.
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Rationale 3: The client exhibits difficulty speaking clearly and enunciating words. Clients
who have pain at the temporomandibular joint will have difficulty moving this joint adequately.
This can result in difficulty speaking, problems chewing food, and weight loss.
Rationale 4: The client has developed hyperparathyroidism. Clients who have pain at the
temporomandibular joint will have difficulty moving this joint adequately. This can result in
difficulty speaking, problems chewing food, and weight loss. Pain at the site of
temporomandibular joint is not associated with hyperparathyroidism.
Rationale 5: The client has developed torticollis. Clients who have pain at the
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temporomandibular joint will have difficulty moving this joint adequately. This can result in
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difficulty speaking, problems chewing food, and weight loss. The client with temporomandibular
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joint pain can also develop painful muscle spasms in the neck called torticollis.
Global Rationale: Clients who have pain at the temporomandibular joint will have difficulty
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moving this joint adequately. This can result in difficulty speaking, problems chewing food, and
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weight loss. Clients with temporomandibular joint pain are more likely to develop cluster or
tension headaches than migraine headaches. Pain at the site of temporomandibular joint is not
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associated with hyperparathyroidism. The client with temporomandibular joint pain can also
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Cognitive Level: Applying
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develop painful muscle spasms in the neck called torticollis.
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
neck.
Question 2
Type: HOTSPOT
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ng
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The nurse is assessing the clients neck. Draw an X over the location of the axis.
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Rationale : The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which
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support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis
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allows for movement of the head.
Global Rationale:
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
neck.
Question 3
Type: MCSA
The nurse is performing an assessment of the clients head and neck. The client requests
response?
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1. Sometimes, enlarged lymph nodes indicate an infection.
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information about the assessment of her lymph nodes. Which of the following is the best
2. All of your lymph nodes should be easily palpable.
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3. The lymph system makes antibiotics to treat infection.
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4. When one lymph node is identified as being enlarged, this is always an abnormal finding.
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Correct Answer: 1
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Rationale 1: The lymph nodes are part of the lymphatic system and provide the body with
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protection against infection. It is true that sometimes when the nurse is able to palpate enlarged
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lymph nodes this indicates that the client has developed an infection.
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Rationale 2: Lymph nodes should not be palpable.
Rationale 3: The lymph system does not make antibiotics; it makes antibodies and lymphocytes
to protect the client from infection.
Rationale 4: It is not necessarily abnormal to be able to palpate one enlarged lymph node.
Global Rationale: The head and neck are supplied by a large number of lymph nodes. The
lymph nodes are part of the lymphatic system and provide the body with protection against
infection. It is true that sometimes when the nurse is able to palpate enlarged lymph nodes this
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indicates that the client has developed an infection. Lymph nodes should not be palpable. The
lymph system does not make antibiotics; it makes antibodies and lymphocytes to protect the
client from infection. It is not necessarily abnormal to be able to palpate one enlarged lymph
node.
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
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neck.
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Question 4
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Type: MCSA
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The nurse is performing a physical examination on a 2-day-old infant and notes flattened areas
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on each side of the head. The mother expresses concern about the infants appearance. Which of
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the following responses would be appropriate for the nurse?
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1. The baby will likely need a neurologic evaluation.
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2. The baby will need plastic surgery.
3. This is normal and will resolve in a few days.
4. What shape is your husbands head?
Correct Answer: 3
Rationale 1: The infant will not require a neurologic evaluation because this is a normal finding.
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Rationale 2: The infants head will take on a more normal round shape in several days so plastic
surgery is not required.
Rationale 3: Infants born by vaginal delivery experience molding, which is shaping of the head
as it passes through the vaginal canal. This will resolve in several days.
Rationale 4: The shape of the infants head is normal after birth and is unrelated to the shape of
the fathers head.
Global Rationale: Infants born by vaginal delivery experience molding, which is shaping of the
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head as it passes through the vaginal canal. This will resolve in several days. The infant will not
require a neurologic evaluation because this is a normal finding. The infants head will take on a
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more normal round shape in several days. The shape of the infants head is normal after birth and
is unrelated to the shape of the fathers head.
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Cognitive Level: Applying
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
Type: MCSA
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Question 5
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neck.
The client has an enlarged lymph node in front of his right ear. In which of the following ways
should the nurse accurately document this finding?
1. Right-sided occipital lymph node enlarged
2. Right-sided submaxillary lymph node enlarged
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3. Right-sided deep cervical lymph node enlarged
4. Right-sided preauricular lymph node enlarged
Correct Answer: 4
Rationale 1: The occipital lymph nodes are located at the base of the skull.
Rationale 2: The submaxillary lymph nodes are located in the medial border of the mandible.
Rationale 3: The deep cervical lymph nodes are located behind and inferior to the
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sternocleidomastoid muscle.
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Rationale 4: The preauricular lymph node is located in front of the ear.
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Global Rationale: The occipital lymph nodes are located at the base of the skull. The
submaxillary lymph nodes are located in the medial border of the mandible. The deep cervical
lymph nodes are located behind and inferior to the sternocleidomastoid muscle. The preauricular
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lymph node is located in front of the ear.
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Client Need: Physiological Integrity
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Cognitive Level: Understanding
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
neck.
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Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
Question 6
Type: MCSA
Which of the following findings is normal regarding assessment of the fontanels?
1. The nurse notes that the 2-week-old infants fontanels are slightly pulsing.
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2. The 2-year-old childs anterior fontanel remains unclosed.
3. The 1-month-old infants posterior fontanel has closed.
4. The 10-month-old infants anterior fontanel is shaped like a triangle.
Correct Answer: 1
Rationale 1: The nurse may note that there are slight pulsations noted in the infants fontanels.
Rationale 2: The anterior fontanel should be fully closed by 18 months of age.
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Rationale 3: The posterior fontanel should close at approximately 2 months of age.
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Rationale 4: The anterior fontanel should be shaped like a diamond. The posterior fontanel
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should be shaped like a triangle.
Global Rationale: The nurse may note that there are slight pulsations noted in the infants
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fontanels. The anterior fontanel should be fully closed by 18 months of age. The posterior
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fontanel should close at approximately 2 months of age. The anterior fontanel should be shaped
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Cognitive Level: Understanding
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like a diamond. The posterior fontanel should be shaped like a triangle.
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
neck.
Question 7
Type: MCSA
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Which of the following information is true regarding the assessment of the thyroid or thyroid
function in an infant or child?
1. To accurately assess thyroid function, the nurse should assess the childs growth and
development in comparison to others in the childs age group.
2. The thyroid gland is easily palpable in an infant.
3. Assess the child for abnormal hair growth because this may indicate thyroid dysfunction.
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4. Assess the child for melasma because this will indicate thyroid dysfunction.
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Correct Answer: 1
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Rationale 1: The best way to assess thyroid function in an infant or child is to assess his growth
and development in comparison to other people in his age group
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Rationale 2: The thyroid gland is difficult to palpate in an infant.
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Rationale 3: Long facial hair is usually seen in older women who are making less reproductive
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hormones.
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Rationale 4: Melasma is found in pregnant women. Melasma occurs when the pregnant female
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develops large, blotchy, pigmented areas on her face.
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Global Rationale: The best way to assess thyroid function in an infant or child is to assess his
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growth and development in comparison to other people in his age group. Laboratory tests can
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also help the clinician determine thyroid function. The thyroid gland is difficult to palpate in an
infant. Long facial hair is usually seen in older women who are making less reproductive
hormones. Melasma is found in pregnant women. Melasma occurs when the pregnant female
develops large, blotchy, pigmented areas on her face.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
neck.
Question 8
Type: MCSA
The pregnant female has entered her third trimester. The client has developed hypertension and
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has been diagnosed with preeclampsia. Which of the following would the nurse also expect to
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find during the assessment of this client?
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1. Dehydration
3. Decreased reproductive hormone levels
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4. Lack of protein excretion in clients urine
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2. Complaints of increasing headaches
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Correct Answer: 2
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Rationale 1: Preeclampsia is associated with fluid retention, not dehydration.
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Rationale 2: Preeclampsia is associated with hypertension, fluid retention, complaints of
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headaches, increased hormone levels, and an increase amount of urinary protein excretion.
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Rationale 3: Preeclampsia is associated with increased hormone levels.
Rationale 4: Preeclampsia is associated with an increased amount of urinary protein excretion.
Global Rationale: This pregnant client has developed preeclampsia. This condition occurs after
20 weeks gestation. It is associated with hypertension, fluid retention, complaints of headaches,
increased hormone levels, and an increase amount of urinary protein excretion. Preeclampsia is
important to identify because it can result in restricted blood flow to the placenta and may harm
the developing fetus.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
neck.
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Question 9
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Type: MCSA
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the nurse from performing this portion of the exam?
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The client is preparing to examine the clients head. Which of the following clients may prohibit
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1. Caucasian from the United States
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2. African American
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4. Native American Indian
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3. Mexican American
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Correct Answer: 4
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Rationale 1: Touching the head is not a cultural taboo for this group.
Rationale 2: Touching the head is not a cultural taboo for this group.
Rationale 3: Touching the head is not a cultural taboo for this group.
Rationale 4: The cultural groups who may prohibit a thorough examination of their heads are
Native Americans, people from Southeast Asia, and some Latino cultures.
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Global Rationale: Some cultural groups believe that the touching of another persons head is
inappropriate and this type of examination would be unwelcome. They believe that the soul or
spirit resides within their heads.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
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neck.
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Question 10
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Type: MCMA
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The client is complaining of pain in his temporomandibular joint. During the nurses assessment
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of this client, which of the following pieces of information does the nurse expect to find?
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Standard Text: Select all that apply.
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1. The client has been under a great deal of stress due to a recent divorce.
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2. The client has developed hypothyroidism.
3. The client has lost tooth enamel due to nighttime teeth grinding.
4. The client has developed hypotension.
5. The client has developed severe tension headaches.
Correct Answer: 1,3,5
Rationale 1: The client has been under a great deal of stress due to a recent divorce. Stress
can produce unconscious jaw clenching that can result in temporomandibular joint pain.
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Rationale 2: The client has developed hypothyroidism. Temporomandibular joint pain is not
associated with hypothyroidism. Perhaps, the client with hyperthyroidism may experience more
stress related to sympathetic nervous system stimulation and this could possibly result in teeth
grinding and temporomandibular joint pain.
Rationale 3: The client has lost tooth enamel due to nighttime teeth grinding. Some clients
with temporomandibular joint pain grind their teeth at night and wear down their tooth enamel.
Rationale 4: The client has developed hypotension. Temporomandibular joint pain is not
associated with hypotension. The client with stress may develop hypertension and
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temporomandibular joint pain.
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Rationale 5: The client has developed severe tension headaches. Clients with
temporomandibular joint pain are more prone to tension headaches.
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Global Rationale: Stress can produce unconscious jaw clenching that can result in
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temporomandibular joint pain. Some clients with temporomandibular joint pain grind their teeth
at night and wear down their tooth enamel. Clients with temporomandibular joint pain are more
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prone to tension headaches. Temporomandibular joint pain is not associated with
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hypothyroidism. Perhaps, the client with hyperthyroidism may experience more stress related to
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sympathetic nervous system stimulation and this could possibly result in teeth grinding and
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temporomandibular joint pain. Temporomandibular joint pain is not associated with hypotension.
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The client with stress may develop hypertension and temporomandibular joint pain.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
neck.
Question 11
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Type: MCSA
Which of the following countries have decreased their populations risk of developing thyroid
disease by adding iodine to salt?
1. India
2. United States
3. Australia
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4. China
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Correct Answer: 2
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Rationale 1: People who live in India and China have a higher risk of developing thyroid disease
related to iodine deficiencies.
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Rationale 2: The use of iodized salt has reduced iodine defiencies and thyroid problems for
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people who live in the United States.
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Rationale 3: Australia, some areas in Eastern Europe, and South America have trouble with
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iodine deficiency due to their soil, which is typically poor in iodine.
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Rationale 4: People who live in India and China have a higher risk of developing thyroid disease
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related to iodine deficiencies.
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Global Rationale: Thyroid problems are common in areas where iodine is limited. The use of
iodized salt has reduced iodine defiencies and thyroid problems for people who live in the United
States. People who live in India and China have a higher risk of developing thyroid disease
related to iodine deficiencies. Australia, some areas in Eastern Europe, and South America have
trouble with iodine deficiency due to their soil, which is typically poor in iodine.
Cognitive Level: Remembering
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and
neck.
Question 12
Type: MCSA
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During a focused interview of a client, the nurse learns about an open lesion on theclients head
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that hasnt healed in several months. What might this indicate to the nurse?
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1. The client may have a thyroid disease.
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2. The client may have a malignancy.
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3. The client may be pregnant.
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4. The client may have meningitis.
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Correct Answer: 2
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Rationale 1: This finding doesnt necessarily indicate the client has a thyroid problem.
Rationale 2: Wounds or lesions that do not heal, swellings, or masses should be assessed
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because this finding may indicate the client has a malignancy.
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Rationale 3: Pregnancy does not make the body less likely to heal.
Rationale 4: This particular client does not exhibit symptoms of meningitis such as complaints
of a stiff neck and headache.
Global Rationale: Wounds or lesions that do not heal, swellings, or masses should be assessed
because this finding may indicate the client has a malignancy. This finding doesnt necessarily
indicate the client has a thyroid problem. Pregnancy does not make the body less likely to heal.
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This particular client does not exhibit symptoms of meningitis such as complaints of a stiff neck
and headache.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 12.2: Develop questions to be used when completing the focused interview.
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Question 13
Type: MCMA
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A client complains of daily headaches. Which of the following would the nurse include in the
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Standard Text: Select all that apply.
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focused interview?
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1. Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst.
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2. Tell me exactly where the pain is located.
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3. Is there anything that relieves the pain, like resting or medication?
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4. Is the pain sharp, dull, steady, or throbbing?
5. Have you had a recent cold or infection?
Correct Answer: 1,2,3,4,5
Rationale 1: Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst.
The nurse should gather as much information about the clients pain as possible. The nurse should
gather information about the pains intensity.
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Rationale 2: Tell me exactly where the pain is located. The nurse should gather as much
information about the clients pain as possible. The nurse should gather information about the
pains location.
Rationale 3: Is there anything that relieves the pain, like resting or medication? The nurse
should determine if there is anything that helps alleviate the clients pain, such as resting,
medication, or exercise.
Rationale 4: Is the pain sharp, dull, steady, or throbbing? It is important to assess the
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character of the pain.
Rationale 5: Have you had a recent cold or infection? Sometimes headaches can be associated
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with recent colds or infections.
Global Rationale: The nurse should gather as much information about the clients pain as
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possible. The nurse should gather information about the pains location, intensity, character, and
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location. The nurse should determine if there is anything that helps alleviate the clients pain,
such as resting, medication, or exercise. Sometimes headaches can be associated with recent
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Cognitive Level: Applying
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colds or infections.
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.2: Develop questions to be used when completing the focused interview.
Question 14
Type: MCSA
The nurse finds the clients thyroid gland is enlarged during the physical assessment. The client
states that she has had a history of a goiter in the past. Which of the following questions is a
priority to ask during the focused interview?
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1. Where do you purchase your medication?
2. What type of salt do you use in your diet?
3. Do you work around chemicals?
4. How long have you had this problem?
Correct Answer: 2
Rationale 1: Although this question is important to gain general information, the nurse needs to
assess whether the client is indeed using iodized salt, especially regarding the clients past history
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and present symptomatology.
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Rationale 2: Thyroid disease is common where iodine is limited and deficient amounts of iodine
can cause a goiter to develop. Use of iodized salt in the U.S. has generally eliminated iodine
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deficiencies.
Rationale 3: Although this question is important to gain general information, the nurse needs to
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assess whether the client is indeed using iodized salt, especially regarding the clients past history
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and present symptomatology.
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Rationale 4: Although this question is important to gain general information, the nurse needs to
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assess whether the client is indeed using iodized salt, especially regarding the clients past history
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and present symptomatology.
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Global Rationale: Thyroid disease is common where iodine is limited and deficient amounts of
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iodine can cause a goiter to develop. Use of iodized salt in the U.S. has generally eliminated
iodine deficiencies. Although the other questions are important to gain general information, the
nurse needs to assess whether the client is indeed using iodized salt, especially regarding the
clients past history and present symptomatology.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.2: Develop questions to be used when completing the focused interview.
Question 15
Type: MCSA
The nurse is assessing the 1-month-old infants fontanels. The infants fontanels are sunken. What
may this indicate to the nurse?
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1. Infection
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2. Thyroid disease
3. Dehydration
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4. Fetal Alcohol Syndrome
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Correct Answer: 3
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Rationale 1: Infection would result in bulging fontanels.
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Rationale 2: Thyroid disease would not necessarily alter the state of the fontanels.
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Rationale 3: Sunken or depressed fontanels in an infant can indicate dehydration.
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Rationale 4: Fetal Alcohol Syndrome results in specific facial malformations.
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Global Rationale: Sunken or depressed fontanels in an infant can indicate dehydration.
Infection would result in bulging fontanels. Thyroid disease would not necessarily alter the state
of the fontanels. Fetal Alcohol Syndrome results in specific facial malformations.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.2: Develop questions to be used when completing the focused interview.
Question 16
Type: MCSA
The nurse is assessing the clients head and neck. The nurse provides the client with a glass of
water. Which of the following structures will the nurse most likely need to assess as the client
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drinks?
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1. Temporomandibular joint
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2. Lymph nodes
3. Temporal artery
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4. Trachea
Correct Answer: 4
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Rationale 1: The temporomandibular joint should be inspected and palpated.
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Rationale 2: The lymph nodes are inspected and palpated.
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Rationale 3: The temporal artery can be inspected and palpated.
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Rationale 4: The nurse will ask the client to drink from the glass of water when the nurse is
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ready to assess the hyoid bone, tracheal cartilage, and thyroid as the client swallows.
Global Rationale: Physical assessment of the head and neck requires the use of inspection,
palpation, and auscultation. The nurse will ask the client to drink from the glass of water when
the nurse is ready to assess the hyoid bone, tracheal cartilage, and thyroid as the client swallows.
The temporomandibular joint should be inspected and palpated. The lymph nodes are inspected
and palpated. The temporal artery can be inspected and palpated.
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Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3: Describe the techniques required for assessment of the head and neck.
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Question 17
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Type: MCSA
1. The clients carotid arteries are visibly pulsating.
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2. The neck is symmetrical.
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The nurse is assessing the clients neck. Which of the following findings is abnormal?
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3. The tracheal cartilage does not move when the client swallows.
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4. The thyroid has no palpable nodules.
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Correct Answer: 3
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the neck.
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Rationale 1: It is normal to note that a clients carotid arteries visibly pulse during inspection of
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Rationale 2: The neck should be smooth and symmetrical.
Rationale 3: The tracheal cartilage should move when the client swallows.
Rationale 4: The thyroid should be free of any nodules and this would be noted during
palpation.
Global Rationale: It is normal to note that a clients carotid arteries visibly pulse during
inspection of the neck. The neck should be smooth and symmetrical. The thyroid should be free
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of any nodules and this would be noted during palpation. The tracheal cartilage should move
when the client swallows.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 12.3: Describe the techniques required for assessment of the head and neck.
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Question 18
Type: MCSA
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The nurse is assessing the function of the clients cranial nerves. The nurse finds that the client is
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unable to demonstrate the ability to chew. The nurse suspects that which of the following cranial
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nerves is not functioning properly?
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1. Cranial nerve III
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2. Cranial nerve V
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4. Cranial nerve VI
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3. Cranial nerve VII
Correct Answer: 2
Rationale 1: Cranial nerve III assists with controlling the movement of the eyes.
Rationale 2: Cranial nerve V stimulates the movement needed for chewing, which is also known
as mastication.
Rationale 3: Cranial nerve VII is responsible for controlling the clients facial movements.
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Rationale 4: Cranial nerve VI assists with controlling the movement of the eyes.
Global Rationale: Cranial nerve III assists with controlling the movement of the eyes. Cranial
nerve V stimulates the movement needed for chewing, which is also known as mastication.
Cranial nerve VII is responsible for controlling the clients facial movements. Cranial nerve VI
assists with controlling the movement of the eyes.
Cognitive Level: Applying
Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Client Need: Physiological Integrity
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Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
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of the head, neck, and related structures.
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Question 19
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Type: MCSA
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The nurse is auscultating the temporal artery and hears a soft blowing sound. How would the
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nurse correctly document this finding?
3. Stenosis
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2. Murmur
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1. Bruit
4. Occlusion
Correct Answer: 1
Rationale 1: A bruit can be heard through the bell of the stethoscope as a soft, blowing sound
and is indicative of narrowing of the vessel. This is an abnormal sound.
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Rationale 2: The sound described is not a murmur, which is heard when auscultating the heart.
Rationale 3: Stenosis is a medical diagnosis and the nurse should not document any conclusive
diagnoses from assessment findings.
Rationale 4: When a vessel is occluded, there is no associated sound because blood is not
flowing through the vessel.
Global Rationale: A bruit can be heard through the bell of the stethoscope as a soft, blowing
sound and is indicative of narrowing of the vessel. This is an abnormal sound. The sound
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described is not a murmur, which is heard when auscultating the heart, and the nurse should not
document any conclusive diagnoses from assessment findings. Stenosis is a medical diagnosis.
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When an artery is stenosed, it can create a bruit. When a vessel is occluded, there is no
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associated sound because blood is not flowing through the vessel.
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Cognitive Level: Understanding
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
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Question 20
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of the head, neck, and related structures.
Type: MCSA
The nurse is palpating an adult clients neck and does not note any palpable lymph nodes. The
nurse understands that this is:
1. probably due to an infection.
2. a normal finding in adults.
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3. reason for referral to an ear, nose, and throat specialist.
4. cause to inspect for further malformations.
Correct Answer: 2
Rationale 1: Lymph nodes of the head and neck are non-palpable in adults. If an infection were
present, the lymph nodes of the surrounding area may be tender and possibly enlarged.
Rationale 2: The lymph nodes that are located in the adult clients neck should not be able to be
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palpated.
Rationale 3: There is no reason to refer the client to a specialist or to inspect the client for
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further malformations in the neck because it is normal to be unable to palpate lymph nodes.
Rationale 4: There is no reason to refer the client to a specialist or to inspect the client for
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further malformations in the neck because it is normal to be unable to palpate lymph nodes.
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Global Rationale: Lymph nodes of the head and neck are nonpalpable in adults. If an infection
were present, the lymph nodes of the surrounding area may be tender and possibly enlarged. The
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lymph nodes that are located in the adult clients neck should not be able to be palpated. There is
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no reason to refer the client to a specialist or to inspect the client for further malformations in the
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neck because it is normal to be unable to palpate lymph nodes.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
of the head, neck, and related structures.
Question 21
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Type: MCMA
The nurse is examining a clients neck. Which of the following would the nurse use as the correct
method to palpate the trachea?
Standard Text: Select all that apply.
1. Palpate while the client is swallowing.
2. Slide the thumb and index finger upward on each side of the trachea.
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3. Palpate the midline of the neck to feel the cricoid cartilage.
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5. Stand behind the client and ask her to turn her head.
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4. Ask the client to open and close her mouth.
Correct Answer: 1,2,3
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Rationale 1: Palpate while the client is swallowing. The nurse should confirm that the hyoid
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bone and tracheal cartilages move up when the client swallows.
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Rationale 2: Slide the thumb and index finger upward on each side of the trachea. The
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fingers up the clients neck.
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nurse should use his thumb and index finger to identify the thyroid cartilage as he slides these
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Rationale 3: Palpate the midline of the neck to feel the cricoid cartilage. The trachea should
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be midline. The C rings are also called cricoid cartilage.
Rationale 4: Ask the client to open and close her mouth. The client should be asked to open
and close her mouth during inspected and palpation of the temporomandibular joint.
Rationale 5: Stand behind the client and ask her to turn her head. The range of motion of the
clients neck can be partially assessed in this manner.
Global Rationale: The nurse should use his thumb and index finger to identify the thyroid
cartilage as he slides these fingers up the clients neck. The nurse should confirm that the hyoid
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bone and tracheal cartilages move up when the client swallows. The trachea should be midline.
The C rings are also called cricoid cartilage. The client should be asked to open and close her
mouth during inspected and palpation of the temporomandibular joint. The range of motion of
the clients neck can be partially assessed by standing behind the client and asking her to turn her
head.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
of the head, neck, and related structures.
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Question 22
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Type: HOTSPOT
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where the nurse would palpate.
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The nurse needs to palpate the submental lymph node on a client. Draw an arrow to the spot
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Rationale : The submental lymph node is just below the chin and should be palpated with one
hand.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
www.mynursingtestprep.com
Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
of the head, neck, and related structures.
Question 23
Type: MCSA
The nurse is planning care for a client with hypothyroidism. Which of the following would be
the priority nursing diagnosis for this client?
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1. Risk for constipation related to metabolic imbalance
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4. Altered nutrition, less than body requirements
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3. Risk for injury related to confusion and lethargy
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2. Activity intolerance related to fatigue
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Correct Answer: 2
Rationale 1: While confusion, lethargy, and constipation are commonly associated with
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hypothyroidism, these are conditions that are not present according to the nursing diagnosis
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statement and therefore do not carry the same priority as those that are actually present.
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Rationale 2: Feeling tired, exhausted, and not having enough energy to perform even small tasks
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is a typical complaint from clients suffering from hypothyroidism.
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Rationale 3: While confusion, lethargy, and constipation are commonly associated with
hypothyroidism, these are conditions that are not present according to the nursing diagnosis
statement and therefore do not carry the same priority as those that are actually present.
Rationale 4: Typically, the client with hypothyroidism, though he may not have an appetite, may
be gaining weight.
Global Rationale: Feeling tired, exhausted, and not having enough energy to perform even
small tasks is a typical complaint from clients suffering from hypothyroidism. While confusion,
lethargy, and constipation are commonly associated with hypothyroidism, these are conditions
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that are not present according to the nursing diagnosis statement and therefore do not carry the
same priority as those that are actually present. Typically, the client with hypothyroidism, though
he may not have an appetite, may be gaining weight.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
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of the head, neck, and related structures.
Question 24
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Type: MCSA
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The client presents with unilateral facial paralysis and the nurse suspects Bells palsy. Which of
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the following statement by the nurse to the client may indicate that the nurse requires further
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education about Bells palsy?
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1. This may have occurred as a result of a viral infection.
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2. This will probably disappear on its own in several weeks.
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3. The onset of Bells palsy is very slow and the effects can linger for several months.
4. Your cranial nerve VII is not functioning appropriately.
Correct Answer: 3
Rationale 1: Bells palsy is believed to occur as a result of viral infection.
Rationale 2: The condition usually resolves spontaneously after several weeks.
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Rationale 3: The onset is sudden and there arent lingering effects after the condition resolves in
several weeks after onset.
Rationale 4: Cranial nerve VII is not functioning appropriately as a result of the viral infection.
This results in the unilateral facial paralysis associated with the condition.
Global Rationale: Bells palsy is believed to occur as a result of viral infection. The condition
usually resolves spontaneously after several weeks. The onset is sudden and there arent lingering
effects after the condition resolves in several weeks after onset. Cranial nerve VII is not
functioning appropriately as a result of the viral infection. This results in the unilateral facial
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paralysis associated with the condition.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
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of the head, neck, and related structures.
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Type: MCSA
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Question 25
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The nurse is auscultating the thyroid gland and notes a bruit. Which of the following would the
nurse associate with this finding?
1. Indicates stenosis of the thyroid artery.
2. Is a normal finding.
3. Indicates increased blood flow.
4. Occurs with hypothyroidism.
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Correct Answer: 3
Rationale 1: A bruit does not indicate stenosis, which is when blood flow is restricted through a
blood vessel.
Rationale 2: This is not a normal finding.
Rationale 3: If the thyroid is enlarged, blood flows through the arteries at an accelerated rate,
producing a soft, rushing sound and is detected with the bell of the stethoscope as a bruit.
Rationale 4: Hypothyroidism can produce a smaller than normal thyroid gland and decreased
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blood flow.
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Global Rationale: If the thyroid is enlarged, blood flows through the arteries at an accelerated
rate, producing a soft, rushing sound and is detected with the bell of the stethoscope as a bruit. A
bruit does not indicate stenosis, which is when blood flow is restricted through a blood vessel.
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This is not a normal finding. Hypothyroidism can produce a smaller than normal thyroid gland
Cognitive Level: Applying
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Client Need: Physiological Integrity
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and decreased blood flow.
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
of the head, neck, and related structures.
Question 26
Type: MCSA
The nurse is demonstrating palpation of the lymph nodes to a nursing student. Which of the
following methods would be correct for the nurse to use during this examination?
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1. First on one side, then on the other
2. Gentle, circular pressure
3. Strong, deep pressure
4. Always attempt to push the nodes into the muscle.
Correct Answer: 2
Rationale 1: Nodes should be palpated on both sides simultaneously for comparison.
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Rationale 2: Palpation of the lymph nodes should be done by exerting gentle, circular pressure
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using the fingerpads of both hands.
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Rationale 3: Strong, deep pressure can push the nodes into the muscle and underlying structures,
making them difficult to find.
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Rationale 4: It is not appropriate to exhibit enough pressure to push the lymph nodes into the
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clients neck muscles because it makes it more difficult to find the lymph nodes.
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Global Rationale: Palpation of the lymph nodes should be done by exerting gentle, circular
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pressure using the fingerpads of both hands. Strong, deep pressure can push the nodes into the
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muscle and underlying structures, making them difficult to find. Nodes should be palpated on
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both sides simultaneously for comparison. It is not appropriate to exhibit enough pressure to
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lymph nodes.
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push the lymph nodes into the clients neck muscles because it makes it more difficult to find the
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
www.mynursingtestprep.com
Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
of the head, neck, and related structures.
Question 27
Type: MCSA
The nurse is assessing a client with complaints of sudden, intermittent headaches for the past
several months. The client states that the headaches come after seeing flashes of lights and
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experiencing nausea. The nurse would suspect which of the following disorders?
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1. Migraine headaches
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2. Cluster headaches
3. Tension headaches
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4. Increased intracranial pressure
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Correct Answer: 1
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Rationale 1: Migraine headaches are often preceded by an aura during which the client may feel
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depressed, restless, or irritable; see spots or flashes of light; and feel nausea.
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Rationale 2: Cluster headaches come in waves over a period of time and then disappear and
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reappear.
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Rationale 3: Tension headaches occur gradually.
Rationale 4: The headache associated with increased intracranial pressure is usually sudden and
severe and is not intermittent.
Global Rationale: Migraine headaches are often preceded by an aura during which the client
may feel depressed, restless, or irritable; see spots or flashes of light; and feel nausea. Cluster
headaches come in waves over a period of time and then disappear and reappear. Tension
headaches occur gradually. Neither cluster nor tension headaches are precipitated by an aura.
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The headache associated with increased intracranial pressure is usually sudden and severe and is
not intermittent.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
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of the head, neck, and related structures.
Question 28
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Type: MCSA
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During a focused assessment and interview regarding the clients head and neck, the client states
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that she is currently suffering from a severe headache that has occurred intermittently over the
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course of 3 days. The client denies any aura. The pain is severe and unilateral over the right side
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of her face. Also, the client is complaining of nasal congestion. Which of the following is the
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1. Cluster headache
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most likely diagnosis?
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2. Classic migraine
3. Tension headache
4. Hydrocephalus
Correct Answer: 1
Rationale 1: Cluster headaches can occur over time. They have no associated aura. They are
often unilateral and can be excruciating. Nasal congestion is commonly associated with this type
of headache.
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Rationale 2: Migraine headaches are associated with an aura, nausea, tremors, and vertigo.
Rationale 3: Tension headaches are also known as a muscle contraction headache. The onset for
tension headaches is gradual and the pain is steady.
Rationale 4: Hydrocephalus is not a type of headache.
Global Rationale: Cluster headaches can occur over time. They have no associated aura. They
are often unilateral and can be excruciating. Nasal congestion is commonly associated with this
type of headache. Migraine headaches are associated with an aura, nausea, tremors, and vertigo.
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Tension headaches are also known as a muscle contraction headache. The onset for tension
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headaches is gradual and the pain is steady. Hydrocephalus is not a type of headache.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
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of the head, neck, and related structures.
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Question 29
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Type: MCSA
The nurse is assessing a newborn infant and notes that the infants head is enlarged with
prominent scalp veins visible. The nurse would correctly document this finding as which of the
following?
1. Craniosynostosis
2. Hydrocephalus
3. Acromegaly
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4. Fetal alcohol syndrome
Correct Answer: 2
Rationale 1: Craniosynostosis is early closure of the sutures, which causes head elongation.
Rationale 2: Hydrocephalus is enlargement of the head caused by inadequate drainage of
cerebrospinal fluid.
Rationale 3: Acromegaly is enlargement of the skull and cranial bones due to increased growth
hormone, which would not be the cause in an infant. Acromegaly is usually found in adult
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clients.
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Rationale 4: Fetal alcohol syndrome causes specific types of facial deformities such as a small
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head circumference, small widely spaced eyes, and a flat mid-facial area.
Global Rationale: Hydrocephalus is enlargement of the head caused by inadequate drainage of
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cerebrospinal fluid. Craniosynostosis is early closure of the sutures, which causes head
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elongation. Acromegaly is enlargement of the skull and cranial bones due to increased growth
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hormone, which would not be the cause in an infant. Acromegaly is usually found in adult
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clients. Fetal alcohol syndrome causes specific types of facial deformities such as a small head
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Cognitive Level: Applying
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circumference, small widely spaced eyes, and a flat mid-facial area.
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment
of the head, neck, and related structures.
Question 30
Type: MCMA
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The nurse is assessing an infant diagnosed with Down syndrome. Which of the following
characteristics would the nurse expect to find during the examination?
Standard Text: Select all that apply.
1. Slanted eyes
2. Cleft palate and lip
3. Protruding tongue
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4. Shortened neck
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5. Drooping eyelids
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Correct Answer: 1,3,4
Rationale 1: Slanted eyes: An associated characteristic of a client with Down syndrome is
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slanted eyes.
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Rationale 2: Cleft palate and lip: Down syndrome is not associated with a cleft palate and lip.
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Rationale 3: Protruding tongue: An associated characteristic of a client with Down syndrome
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is a protruding tongue.
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Rationale 4: Shortened neck: An associated characteristic of a client with Down syndrome is a
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shortened neck.
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Rationale 5: Drooping eyelids: Down syndrome is not associated with drooping eyelids.
Global Rationale: Associated characteristics of a client with Down syndrome are slanted eyes, a
protruding tongue, and a shortened neck. Cleft palate and lip and drooping eyelids are not
characteristics associated with Down syndrome.
Chapter 10. Assessing the Ears
Question 1
Type: HOTSPOT
A client is having difficulty maintaining equilibrium. The client is unable to ambulate without
pushing a wheelchair or using a walker. Draw an arrow indicating which part of the ear is not
functioning adequately.
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Correct Answer:
Rationale : The ear is divided into three areas: the external ear, the middle ear, and the inner ear.
All three are involved in hearing, but only the inner ear is involved in equilibrium. The vestibular
apparatus contained in the inner ear must be working adequately for the client to be able to
maintain a sense of balance.
Global Rationale:
Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and
throat.
Question 2
Type: MCSA
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The client is experiencing the effects of a recent cerebrovascular accident. The client is unable to
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hear out of the left ear. Which of the following cranial nerves was most likely affected?
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1. Cranial nerve I
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2. Cranial nerve XII
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3. Cranial nerve VIII
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4. Cranial nerve VII
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Correct Answer: 3
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Rationale 1: The sense of smell is controlled by cranial nerve I.
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Rationale 2: Tongue movement is controlled by cranial nerve XII.
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Rationale 3: Hearing and balance is controlled by cranial nerve VII.
Rationale 4: The sense of taste is controlled by cranial nerves VII and IX.
Global Rationale: Hearing and balance is controlled by cranial nerve VII. The sense of smell is
controlled by cranial nerve I. Tongue movement is controlled by cranial nerve XII. The sense of
taste is controlled by cranial nerves VII and IX.
Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and
throat.
Question 3
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Type: MCHS
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The nurse is assessing the clients vestibule of the oral cavity. The student nurse requests
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information regarding the vestibule and the mouth. Draw an arrow to the structure that separates
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the vestibule from the mouth.
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Correct Answer:
Rationale : The vestibule is made up of the lips, buccal mucosa, outer surface of the gums and
the teeth and cheeks. The mouth is separated from the vestibule by the teeth. The mouth is made
up of the tongue, hard and soft palate, uvula, mandibular arch, and axillary arch.
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Global Rationale:
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and
throat.
Question 4
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Type: MCSA
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The nurse educates the client about the major functions of the nose and sinuses. Which of the
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following structures is specifically responsible for filtering, moistening, and warming air that
enters the lower portion of the respiratory tract?
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1. Olfactory cells
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2. Columella
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3. Turbinates
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4. Nares
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Correct Answer: 3
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Rationale 1: The olfactory cells assist the client to smell.
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Rationale 2: The columella is located at the base of the nose and helps form the nares.
Rationale 3: The superior, middle, and inferior turbinates are specifically responsible for
warming, moistening, and filtering the air before it enters the trachea and lungs.
Rationale 4: The nares are structures that lead into the internal vestibule and nasal cavity.
Global Rationale: The superior, middle, and inferior turbinates are specifically responsible for
warming, moistening, and filtering the air before it enters the trachea and lungs. The olfactory
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cells assist the client to smell. The columella is located at the base of the nose and helps form the
nares. The nares are structures that lead into the internal vestibule and nasal cavity.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and
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throat.
Question 5
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Type: MCSA
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Which of the following structures attaches the tongue to the floor of the mouth?
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1. Hard palate
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2. Papillae
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4. Alveoli sockets
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3. Frenulum
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Correct Answer: 3
Rationale 1: The hard palate is the anterior portion of the roof of the mouth.
Rationale 2: The papillae contain the taste buds and assist with moving food within the mouth.
The papillae are located on the dorsal surface of the tongue.
Rationale 3: The frenulum connects the anterior portion of the tongue to the floor of the mouth.
Rationale 4: The alveoli sockets contain the teeth within the mandible and maxilla.
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Global Rationale: The frenulum connects the anterior portion of the tongue to the floor of the
mouth. The hard palate is the anterior portion of the roof of the mouth. The papillae contain the
taste buds and assist with moving food within the mouth. The papillae are located on the dorsal
surface of the tongue. The alveoli sockets contain the teeth within the mandible and maxilla.
Cognitive Level: Remembering
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and
throat.
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Question 6
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Type: MCMA
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The nurse is performing a focused interview with a client who has been cleaning the ears with a
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cotton-tipped applicator. The nurse should educate the client about which of the following
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complications that can occur as a result of this practice?
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Standard Text: Select all that apply.
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1. The client has a higher risk of developing otitis externa.
2. The client has a higher risk of developing tophi along the outer rim of the ears.
3. The client could perforate the tympanic membrane.
4. The client could require tympanostomy tubes.
5. The clients cerumen might become impacted.
Correct Answer: 3,5
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Rationale 1: The client has a higher risk of developing otitis externa. Otitis externa is an
infection of the clients outer ear. This client does not have an increased risk of developing otitis
externa.
Rationale 2: The client has a higher risk of developing tophi along the outer rim of the ears.
Tophi are small white nodules that are found on the helix or antihelix. These nodules are a sign
of gout and contain uric acid crystals.
Rationale 3: The client could perforate the tympanic membrane. This client is at risk for
perforating the tympanic membrane with the cotton-tipped applicator. The inside of the ear
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should not be cleaned. Cerumen moves to the outside of the ear canal naturally.
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Rationale 4: The client could require tympanostomy tubes. Tympanostomy tubes are placed
when clients develop repeated otitis media infections. These tubes help relieve middle ear
pressure and allow drainage that occurs as a result of the infection. This client does not require
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tympanostomy tubes.
Rationale 5: The clients cerumen might become impacted. This client is at risk for impacting
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the cerumen within the ears with the cotton-tipped applicator. The inside of the ear should not be
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cleaned. Cerumen moves to the outside of the ear canal naturally.
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Global Rationale: Otitis externa is an infection of the clients outer ear. This client does not have
an increased risk of developing otitis externa. Tophi are small white nodules that are found on
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the helix or antihelix. These nodules are a sign of gout and contain uric acid crystals. This client
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is at risk for perforating the tympanic membrane with the cotton-tipped applicator. The inside of
the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally.
Tympanostomy tubes are placed when clients develop repeated otitis media infections. These
tubes help relieve middle ear pressure and allow drainage that occurs as a result of the infection.
This client does not require tympanostomy tubes. This client is at risk for impacting the cerumen
within the ears with the cotton-tipped applicator. The inside of the ear should not be cleaned.
Cerumen moves to the outside of the ear canal naturally.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 14.2: Develop questions to be used when completing the focused interview.
Question 7
Type: MCSA
The nurse is performing a focused interview with the client. The nurse asks the client if the client
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has noticed any drainage from the ears, and the client states, Yes. Which of the following
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1. The ear canal itself is really red, raw, and sore.
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statements indicate that the client may have developed acute otitis media?
2. I noticed that the drainage looked clear, like water.
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4. It is kind of yellowish-reddish color.
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3. The drainage looks like what is draining from my nose, kind of clear and mucousy.
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Correct Answer: 4
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Rationale 1: When the client complains that the ear canal is inflamed, painful, and with
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erythema, this indicates that the client may have developed otitis externa.
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Rationale 2: Clear drainage from the ear may indicate that the client has developed a
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cerebrospinal fluid leak following trauma.
Rationale 3: Serous drainage can indicate that the client has developed drainage from the ears as
a result of allergies.
Rationale 4: The client with acute otitis media will state that he is experiencing drainage from
the ears that is purulent. Reddish-yellow drainage would be classified as purulent.
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Global Rationale: The client with acute otitis media will state that they are experiencing
drainage from the ears that is purulent. Reddish-yellow drainage would be classified as purulent.
When the client complains that the ear canal is inflamed, painful, and with erythema, this
indicates that the client may have developed otitis externa. Clear drainage from the ear may
indicate that the client has developed a cerebrospinal fluid leak following trauma. Serous
drainage can indicate that the client has developed drainage from the ears as a result of allergies.
Cognitive Level: Applying
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Client Need: Physiological Integrity
Learning Outcome: 14.2: Develop questions to be used when completing the focused interview.
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Question 8
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Type: MCMA
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The client was given several medications during a recent hospital admission. The client has come
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to the medical office with complaints of tinnitus and bilateral hearing loss. The nurse
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understands that which of the following medications are associated with hearing loss or tinnitus?
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1. Streptomycin
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Standard Text: Select all that apply.
2. Steroid inhalers
3. Aspirin
4. Neomycin
5. Acetaminophen
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Correct Answer: 1,3,4
Rationale 1: Streptomycin. Streptomycin is an antibiotic that can cause hearing loss.
Rationale 2: Steroid inhalers. Steroid inhalers are associated with Candida (yeast infections) in
the nasal mucosa.
Rationale 3: Aspirin. Aspirin can cause ringing in the ears.
Rationale 4: Neomycin. Neomycin is an antibiotic that can cause hearing loss.
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Rationale 5: Acetaminophen. Acetaminophen is not associated with hearing loss.
Global Rationale: Streptomycin is an antibiotic that can cause hearing loss. Steroid inhalers are
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associated with Candida (yeast infections) in the nasal mucosa. Aspirin can cause ringing in the
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ears. Neomycin is an antibiotic that can cause hearing loss. Acetaminophen is not associated with
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hearing loss.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of
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Question 9
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the ear, nose, mouth, and throat.
Type: MCSA
The client has developed anosmia. The healthcare provider educates the client about the possible
causes. The nurse recognizes that which of the following would be an unexpected explanation
for this condition?
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1. Commonly associated with gingivitis
2. Possibly linked to heredity
3. Related to a diet deficient in zinc
4. An indicator of a neurological problem
Correct Answer: 1
Rationale 1: Anosmia is the inability to smell. It is unrelated to gingivitis. Clients with gingivitis
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often complain of a bad taste in their mouth.
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Rationale 2: Anosmia is the inability to smell. Anosmia may be related to genetic makeup.
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Rationale 3: Anosmia is the inability to smell. Anosmia may be related to a diet that is deficient
in food containing zinc.
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Rationale 4: Anosmia is the inability to smell. Anosmia may be related to a neurological
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disorder.
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Global Rationale: Anosmia is the inability to smell. Anosmia may be related to a neurological
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disorder, genetic makeup, or a diet that is deficient in food containing zinc. It is unrelated to
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gingivitis. Clients with gingivitis often complain of a bad taste in their mouth.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of
the ear, nose, mouth, and throat.
Question 10
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Type: MCSA
The client has been brought via ambulance to the emergency room following a motor vehicle
accident. The nurse notes that the clients ear is draining clear fluid. What is the nurses priority
nursing action?
1. Request information from the client regarding any chronic allergies.
2. Test the drainage for glucose.
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3. Ask the patient if she has experienced a recent middle ear infection.
4. Irrigate the ear with warm mineral oil, peroxide, and flush with warm water.
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Correct Answer: 2
Rationale 1: Chronic allergies would not result in clear fluid draining from the clients ear.
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However, an acute allergic reaction may result in serous fluid that drains from the clients ear.
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Rationale 2: When a clients ear is draining clear fluid, this might indicate the client has a
cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in
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cerebrospinal fluid.
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Rationale 3: A recent middle ear infection may result in purulent or bloody drainage from the
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clients ear.
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Rationale 4: The ear should not be irrigated at this time. Irrigation with warm mineral oil,
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peroxide, and flushing with warm water is often used to remove cerumen. There is nothing to
suggest that the client has impacted cerumen.
Global Rationale: When a clients ear is draining clear fluid, this might indicate the client has a
cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in
cerebrospinal fluid. Chronic allergies would not result in clear fluid draining from the clients ear.
However, an acute allergic reaction may result in serous fluid that drains from the clients ear. A
recent middle ear infection may result in purulent or bloody drainage from the clients ear. The
ear should not be irrigated at this time. Irrigation with warm mineral oil, peroxide, and flushing
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with warm water is often used to remove cerumen. There is nothing to suggest that the client has
impacted cerumen.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of
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the ear, nose, mouth, and throat.
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Question 11
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Type: MCSA
The nurse is assessing the tympanic membrane of a client and notes the presence of a bluish
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color. The nurse would suspect which of the following?
2. Recent head trauma
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3. Blocked eustachian tubes
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1. Acute otitis media
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4. History of frequent middle ear infections
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Correct Answer: 2
Rationale 1: Acute otitis media is associated with a reddish or yellowish tinge on the tympanic
membrane.
Rationale 2: The presence of a bluish tinge on the tympanic membrane is most likely due to
blood in the middle ear and may be indicative of recent head trauma.
Rationale 3: A blocked eustachian tube will cause the tympanic membrane to retract.
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Rationale 4: Previous middle ear infections will result in white patches noted on the tympanic
membrane that indicate scarring.
Global Rationale: The presence of a bluish tinge on the tympanic membrane is most likely due
to blood in the middle ear and may be indicative of recent head trauma. Acute otitis media is
associated with a reddish or yellowish tinge on the tympanic membrane. A blocked eustachian
tube will cause the tympanic membrane to retract. Previous middle ear infections will result in
white patches noted on the tympanic membrane that indicate scarring.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 14.4: Explain the use of otoscope.
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Question 12
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Type: MCSA
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The nursing is performing an otoscopic examination on an adult client and is unable to visualize
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visualize this structure?
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the tympanic membrane. The nurse should perform which of the following steps to better
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1. Pull the pinna up and back, then reinsert the otoscope
2. Tell the client to move away from the speculum if they experience any pain as the otoscope is
advanced.
3. Reinsert the otoscope quickly and press against both sides of the inner auditory canal.
4. Pull the pinna down and back, then reinsert the otoscope.
Correct Answer: 1
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Rationale 1: To avoid trauma to the ear, the otoscope is to be removed and the pinna should be
pulled up and back for better visualization.
Rationale 2: The client should be instructed to state any feelings of discomfort or pain but not to
pull away because this may result in injury during this examination.
Rationale 3: The otoscope should not be inserted quickly and should not be pressed against
either side of the inner auditory canal because it would be painful for the client.
Rationale 4: Pulling down and back is recommended in children because of the shape of their
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auditory canal.
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Global Rationale: To avoid trauma to the ear, the otoscope is to be removed and the pinna
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should be pulled up and back for better visualization. The client should be instructed to state any
feelings of discomfort or pain but not to pull away because this may result in injury during this
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examination. The otoscope should not be inserted quickly and should not be pressed against
either side of the inner auditory canal because it would be painful for the client. Pulling down
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and back is recommended in children because of the shape of their auditory canal.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 14.4: Explain the use of otoscope.
Question 13
Type: MCMA
The nurse is examining a clients ears and notes that right ear is occluded with wax. The nurse
would choose which of the following to remove the earwax?
Standard Text: Select all that apply.
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1. Irrigation with warm mineral oil, peroxide, followed by warm water
2. A sharp instrument to break up the ear wax
3. Irrigation with a cold solution
4. A cerumen spoon to remove the wax
5. Irrigation with warm sudsy water
Correct Answer: 1,4
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Rationale 1: Irrigate the ear canal with warm mineral oil, peroxide, followed by warm
water. Care must be taken when removing cerumen. Warmed mineral oil and peroxide soften the
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earwax and the ear can be irrigated with warm water afterwards.
Rationale 2: A sharp instrument to break up the ear wax within the ear canal. Sharp
instruments should not be placed within the ear canal because it may injure the tympanic
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membrane.
Rationale 3: Irrigate the ear canal with a cold solution. Cold solutions may harden the ear
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wax, making it more difficult to remove.
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Rationale 4: A cerumen spoon can be placed in the ear canal to remove the wax. The
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cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to
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remove the wax safely without risking injury or perforation of the eardrum.
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Rationale 5: Irrigate the ear canal with warm sudsy water. Warm, sudsy solutions may
irritate the ear canal.
Global Rationale: Care must be taken when removing cerumen. Warmed mineral oil and
peroxide soften the earwax and the ear can be irrigated with warm water afterwards. Sharp
instruments should not be placed within the ear canal because it may injure the tympanic
membrane. Cold solutions may harden the ear wax, making it more difficult to remove. The
cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to
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remove the wax safely without risking injury or perforation of the eardrum. Warm, sudsy
solutions may irritate the ear canal.
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 14.4: Explain the use of otoscope.
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Question 14
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Type: MCMA
During the focused interview, the client admits to regularly abusing cocaine. Which of the
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following findings does the nurse expect to discover during the physical assessment of the clients
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Standard Text: Select all that apply.
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nose?
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1. The nurse notes that the nasal septum has perforated.
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2. Temporomandibular joint pain when the client opens and closes the mouth
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3. The septum is noted to be very pale in color.
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4. Yeast infection of nasal mucosa and in mouth
5. Difficulty swallowing water
Correct Answer: 1,3
Rationale 1: The nurse notes that the nasal septum has perforated. When a client is abusing
cocaine, the nurse may note that the nasal septum has broken down and has even perforated.
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Rationale 2: Temporomandibular joint pain when the client opens and closes the mouth.
Temporomandibular joint pain could be the result of otitis externa or might indicate
temporomandibular joint dysfunction. It is unrelated to cocaine use.
Rationale 3: The septum is noted to be very pale in color. When a client is abusing cocaine,
the nasal mucosa might appear vasoconstricted and very pale in color.
Rationale 4: Yeast infection of nasal mucosa and in mouth. Steroid inhalers can cause growth of
Candida in the nose, mouth, or throat. It is unrelated to cocaine use.
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Rationale 5: Difficulty swallowing water. If the client experiences difficulty in swallowing, this
may be due to a neurological or gastrointestinal problem, or it may be related to ill-fitting
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dentures or malocclusion.
Global Rationale: When a client is abusing cocaine, the nurse may note that the nasal septum
has broken down and has even perforated. Temporomandibular joint pain could be the result of
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otitis externa or might indicate temporomandibular joint dysfunction. It is unrelated to cocaine
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use. When a client is abusing cocaine, the nasal mucosa might appear vasoconstricted and very
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pale in color. Steroid inhalers can cause growth of Candida in the nose, mouth, or throat. It is
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unrelated to cocaine use. If the client experiences difficulty in swallowing, this may be due to a
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neurological or gastrointestinal problem, or it may be related to ill-fitting dentures or
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malocclusion.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
of the ear, nose, mouth, and throat.
Question 15
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Type: MCSA
The nurse is caring for a client who was admitted to the medical unit. The healthcare provider
states that the clients Romberg test was positive. As the nurse plans to meet the clients
elimination needs, the nurse would implement which of the following interventions?
1. Allow the client to walk independently.
2. Obtain an order for a catheter.
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3. Limit fluid intake.
4. Obtain a bedside commode.
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Correct Answer: 4
Rationale 1: A positive Romberg sign indicates problems with the vestibular apparatus that
controls balance. This client might experience difficult ambulating and has a higher risk of
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falling. The nurse must help the client eliminate safely.
Rationale 2: Catheter insertion is invasive and increases the clients risk of developing a urinary
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tract infection.
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Rationale 3: Restricting fluid intake is not indicated in this situation.
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Rationale 4: A positive Romberg sign indicates problems with the vestibular apparatus that
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controls balance. This client might experience difficult ambulating and has a higher risk of
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falling. The nurse must help the client eliminate safely. Obtaining a bedside commode for the
client will help prevent the client from falling while attempting to ambulate independently to and
from the bathroom.
Global Rationale: A positive Romberg sign indicates problems with the vestibular apparatus
that controls balance. This client might experience difficult ambulating and has a higher risk of
falling. The nurse must help the client eliminate safely. Obtaining a bedside commode for the
client will help prevent the client from falling while attempting to ambulate independently to and
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from the bathroom. Catheter insertion is invasive and increases the clients risk of developing a
urinary tract infection. Restricting fluid intake is not indicated in this situation.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 15. 5: Differentiate normal from abnormal findings in physical assessment
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of the ear, nose, mouth, and throat.
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Question 16
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Type: MCSA
A client with a fever is also complaining of difficulty hearing. The nurse realizes this client
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might be experiencing which of the following disorders?
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1. Sinusitis
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2. Otitis media
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4. Otitis externa
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3. Tonsillitis
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Correct Answer: 2
Rationale 1: Sinusitis is associated with facial pain, inflammation, and nasal discharge.
Rationale 2: Fever and hearing loss are clinical manifestations associated with otitis media.
Rationale 3: Tonsillitis is associated with reddened, inflamed tonsils and a fever.
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Rationale 4: Otitis externa is associated with a red, swollen auricle and ear canal. Clients with
otitis externa also might have a fever.
Global Rationale: Fever and hearing loss are clinical manifestations associated with otitis
media. Sinusitis is associated with facial pain, inflammation, and nasal discharge. Tonsillitis is
associated with reddened, inflamed tonsils and a fever. Otitis externa is associated with a red,
swollen auricle and ear canal. Clients with otitis externa also might have a fever.
Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
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of the ear, nose, mouth, and throat.
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Question 17
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Type: MCSA
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The emergency room triage nurse is assessing a child who has a history of a cough and nasal
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congestion for the last three days. When assessing patency of the nares, the nurse notes that the
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child is unable to breathe through the right nostril. The nurse would interpret these assessment
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findings as which of the following?
1. Produced by severe nasal inflammation or obstruction
2. Normal for a child
3. A result of chronic allergies
4. A result of sinusitis
Correct Answer: 1
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Rationale 1: If the client cannot breathe through each naris, severe inflammation or an
obstruction may be present.
Rationale 2: This is not a normal finding in an adult or a child.
Rationale 3: If nasal mucosa is pale and boggy or swollen, the client may have chronic allergies.
Due to the clients history, this is an acute problem and not associated with chronic allergies.
Rationale 4: The client with sinusitis will have tenderness over sinus cavities.
Global Rationale: If the client cannot breathe through each naris, severe inflammation or an
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obstruction may be present. This is not a normal finding in an adult or a child. If nasal mucosa is
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pale and boggy or swollen, the client may have chronic allergies. Due to the clients history, this
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is an acute problem and not associated with chronic allergies. The client with sinusitis will have
tenderness over sinus cavities.
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Cognitive Level: Applying
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
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Question 18
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of the ear, nose, mouth, and throat.
Type: MCSA
A client presents in the healthcare providers office with complaints of headache and malaise. The
nurse assesses the client and finds that the client has severe pain when the sinuses are palpated.
The nurse would suspect which of the following disorders?
1. Sinusitis
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2. Mastoiditis
3. Chronic allergies
4. Anemia
Correct Answer: 1
Rationale 1: Pain is a common finding during palpation of the sinuses when an infection or
inflammation is present in the sinuses.
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Rationale 2: Mastoiditis is associated with pain and tenderness over the mastoid process, which
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is located behind the clients ears.
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Rationale 3: The client with chronic allergies may have pale, boggy, or swollen nasal mucosa.
Rationale 4: Anemia would be associated with pale mucous membranes.
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Global Rationale: Pain is a common finding during palpation of the sinuses when an infection
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or inflammation is present in the sinuses. Mastoiditis is associated with pain and tenderness over
the mastoid process, which is located behind the clients ears. The client with chronic allergies
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may have pale, boggy, or swollen nasal mucosa. Anemia would be associated with pale mucous
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Cognitive Level: Applying
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membranes.
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
of the ear, nose, mouth, and throat.
Question 19
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Type: MCSA
The nurse is educating a group of teenagers in high school about the risks of chewing tobacco.
The nurse would include information about which of the following signs of oral cancer?
1. Bleeding and inflamed gums
2. Smooth and shiny tongue
3. Red, swollen tonsils
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4. Ulcerations on the lip or under the tongue
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Correct Answer: 4
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Rationale 1: Bleeding and inflamed gums are associated with gingivitis.
Rationale 2: A smooth, shiny tongue is associated with deficiencies of vitamin B and iron.
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Rationale 3: Red and swollen tonsils are associated with tonsillitis
Rationale 4: Oral cancers are most commonly found on the lower lip or the base of the tongue.
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They do not heal normally.
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Global Rationale: Oral cancers are most commonly found on the lower lip or the base of the
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tongue. They do not heal normally. Bleeding and inflamed gums are associated with gingivitis. A
smooth, shiny tongue is associated with deficiencies of vitamin B and iron. Red and swollen
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tonsils are associated with tonsillitis.
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Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
of the ear, nose, mouth, and throat.
Question 20
Type: MCMA
A client arrives in the emergency room with complaints of intermittent nosebleeds for the past
two days. Which of the following assessments would be a priority for the nurse is this situation?
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Standard Text: Select all that apply.
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1. Request information from the client regarding increased propensity for bruising or bleeding.
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2. Assess the tonsils for redness or swelling.
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3. Obtain a blood pressure.
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4. Check for deviated septum.
5. Request information from the client to determine if there was any recent thin, watery drainage
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from the nose.
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Correct Answer: 1,3,5
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Rationale 1: Request information from the client regarding increased propensity for
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bruising or bleeding. The client may have a blood coagulation disorder that may result in
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increased bruising or bleeding. This disorder may have produced the episodes of epistaxis.
Rationale 2: Assess the tonsils for redness or swelling. Red, swollen tonsils are associated with
tonsillitis. Tonsillitis is not associated with epistaxis.
Rationale 3: Obtain a blood pressure. Hypertension is a contributory factor to the occurrence
of nosebleeds. The nurse should assess the clients blood pressure to determine if it is elevated.
Rationale 4: Check for deviated septum. A deviated septum is not associated with epistaxis.
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Rationale 5: Request information from the client to determine if there was any recent thin,
watery drainage from the nose. Thin, watery drainage from the nose is associated with rhinitis.
Rhinitis is associated with epistaxis.
Global Rationale: The client may have a blood coagulation disorder that may result in increased
bruising or bleeding. This disorder may have produced the episodes of epistaxis. Red, swollen
tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis. Hypertension is
a contributory factor to the occurrence of nosebleeds. The nurse should assess the clients blood
pressure to determine if it is elevated. A deviated septum is not associated with epistaxis. Thin,
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watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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of the ear, nose, mouth, and throat.
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Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
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Question 21
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Type: MCSA
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The nurse is examining a 14-month-old child when the mother tells the nurse that the child cries
frequently, has a fever, and is pulling at both ears. The nurse suspects the child has which of the
following disorders from this assessment data?
1. Otitis media
2. Otitis externa
3. Hemotympanum
4. Tophi
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Correct Answer: 1
Rationale 1: The auditory canal of infants is shorter and has an upward curve that persists until
about the age of 3. In addition, their auditory tube is more horizontal than the adult, which leads
to easier migration of organisms from the throat to the middle ear. Infants and children with otitis
media often display the behavior of pulling at their ears.
Rationale 2: Otitis externa is an infection of the external auditory canal manifested by red,
swollen ear canal, fever, and purulent drainage.
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Rationale 3: Hemotympanum is a bluish tinge of the tympanic membrane indicating the
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presence of blood in the middle ear. It is usually associated with head trauma.
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Rationale 4: Tophi are small white nodules on the helix or antihelix. These nodules contain uric
acid crystals and are a sign of gout.
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Global Rationale: The auditory canal of infants is shorter and has an upward curve that persists
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until about the age of 3. In addition, their auditory tube is more horizontal than the adult, which
leads to easier migration of organisms from the throat to the middle ear. Infants and children
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with otitis media often display the behavior of pulling at their ears. Otitis externa is an infection
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of the external auditory canal manifested by red, swollen ear canal, fever, and purulent drainage.
Hemotympanum is a bluish tinge of the tympanic membrane indicating the presence of blood in
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the middle ear. It is usually associated with head trauma. Tophi are small white nodules on the
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helix or antihelix. These nodules contain uric acid crystals and are a sign of gout.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
of the ear, nose, mouth, and throat.
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Question 22
Type: MCSA
The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Based on
this finding, the nurse would implement which of the following actions first?
1. Administer IV fluids.
2. Provide oral hygiene.
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3. Administer oxygen.
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4. Provide a warm drink.
Correct Answer: 3
Rationale 1: There is no indication the client has an electrolyte or fluid imbalance at this time,
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making the administration of IV fluids inappropriate at this time.
Rationale 2: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate
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hypoxia. Providing oral hygiene is not an appropriate intervention because it will not increase the
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clients oxygenation levels.
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Rationale 3: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate
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hypoxia. The nurse should apply oxygen for the client.
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Rationale 4: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate
hypoxia. Providing a warm drink will not correct the clients oxygenation problem.
Global Rationale: Pallor and cyanosis of the oral cavity and lips are assessment findings that
indicate hypoxia. The nurse should apply oxygen for the client. There is no indication the client
has an electrolyte or fluid imbalance at this time, making the administration of IV fluids
inappropriate at this time. Providing oral hygiene is not an appropriate intervention because it
will not increase the clients oxygenation levels. Providing a warm drink will not correct the
clients oxygenation problem.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
of the ear, nose, mouth, and throat.
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Question 23
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Type: MCSA
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The nurse is assessing the clients nasal mucosa and notes the presence of a thin, watery
discharge. The client complains of sneezing and nasal congestion. The nurse would suspect
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1. Rhinitis
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2. Perforated septum
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3. Previous epistaxis
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4. Nasal polyps
Correct Answer: 1
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which of the following in this situation?
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Rationale 1: These clinical manifestations are associated with rhinitis. Rhinitis is inflammation
of the nasal mucosa due to a viral infection or allergy.
Rationale 2: A perforated septum is a hole in the septum caused by chronic infection, trauma, or
sniffing cocaine. It can be detected by shining a penlight through the naris on the other side.
Rationale 3: With a history of epistaxis, the nurse would note that there is old dried blood on the
nasal mucosa.
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Rationale 4: Nasal polyps are pale, round, firm, nonpainful overgrowth of nasal mucosa.
Global Rationale: These clinical manifestations are associated with rhinitis. Rhinitis is
inflammation of the nasal mucosa due to a viral infection or allergy. A perforated septum is a
hole in the septum caused by chronic infection, trauma, or sniffing cocaine. It can be detected by
shining a penlight through the naris on the other side. With a history of epistaxis, the nurse
would note that there is old dried blood on the nasal mucosa. Nasal polyps are pale, round, firm,
nonpainful overgrowth of nasal mucosa.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
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of the ear, nose, mouth, and throat.
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Question 24
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Type: MCSA
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The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on
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the tongue. Which of the following questions would be appropriate for the nurse to include when
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obtaining further assessment data?
1. Have you eaten licorice lately?
2. How often do you brush your tongue?
3. Have you recently taken antibiotics?
4. Have you ever had this happen before?
Correct Answer: 3
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Rationale 1: This finding is unrelated to food intake such as eating licorice.
Rationale 2: This finding is not related to poor oral hygiene practices.
Rationale 3: The presence of a black, furry-looking coating on the tongue is usually related to an
overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use.
Rationale 4: It may helpful for the nurse to determine if the condition has occurred previously
but it is not the most important question. The nurse should question the client regarding recent
antibiotic use.
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Global Rationale: The presence of a black, furry-looking coating on the tongue is usually
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related to an overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use. This
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finding is not related to poor oral hygiene practices. It is unrelated to food intake such as eating
licorice. It may helpful for the nurse to determine if the condition has occurred previously but it
is not the most important question. The nurse should question the client regarding recent
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antibiotic use.
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Client Need: Physiological Integrity
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Cognitive Level: Applying
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
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of the ear, nose, mouth, and throat.
Question 25
Type: MCSA
An elderly client says, I cant seem to hear as well as I could when I was younger. The nurse
suspects this client is experiencing which of the following disorders?
1. Presbycusis
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2. Mastoiditis
3. Otitis media
4. Otitis externa
Correct Answer: 1
Rationale 1: Age-related changes include loss of low- and high-frequency hearing, also known
as presbycusis.
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The client would complain of pain or tenderness behind the ear.
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Rationale 2: Mastoiditis is a complication of either a middle ear infection or a throat infection.
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Rationale 3: Otitis media is an infection of the middle ear producing a red, bulging eardrum,
fever, and hearing loss.
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Rationale 4: Otitis externa is an infection of the outer ear, often called swimmers ear. Otitis
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externa causes redness and swelling of the auricle and ear canal.
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Global Rationale: Age-related changes include loss of low- and high-frequency hearing, also
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known as presbycusis. Mastoiditis is a complication of either a middle ear infection or a throat
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infection. The client would complain of pain or tenderness behind the ear. Otitis media is an
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infection of the middle ear producing a red, bulging eardrum, fever, and hearing loss. Otitis
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externa is an infection of the outer ear, often called swimmers ear. Otitis externa causes redness
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and swelling of the auricle and ear canal.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment
of the ear, nose, mouth, and throat.
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Question 26
Type: MCSA
The nurse is assessing the oral mucosa of a pregnant female and notes enlargement of the gums.
The client states that regular oral hygiene is performed and that she does not understand why this
has occurred. Which of the following is the nurses best response?
1. You may have oral cancer.
3. You may have leukoplakia.
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4. You need to decrease the frequency of your oral hygiene.
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2. You are experiencing a normal change during pregnancy.
Correct Answer: 2
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Rationale 1: Early signs of oral cancer are manifested by ulcers in the lower lip and under the
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tongue that do not heal normally.
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Rationale 2: Gingival hyperplasia (enlargement of the gums) is a normal physiologic change
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associated with pregnancy. It is also seen in clients with leukemia and prolonged use of Dilantin.
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Rationale 3: Leukoplakia is a whitish thickening of the mucous membrane in the mouth or
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tongue. It cannot be scraped off. It is most often associated with heavy smoking or drinking, and
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it can be a precancerous condition.
Rationale 4: Advanced gingivitis and poor dental hygiene are manifested by swollen red gums
that will bleed when brushed, and will show separation of the gum from the tooth.
Global Rationale: Gingival hyperplasia (enlargement of the gums) is a normal physiologic
change associated with pregnancy. It is also seen in clients with leukemia and prolonged use of
Dilantin. Early signs of oral cancer are manifested by ulcers in the lower lip and under the tongue
that do not heal normally. Leukoplakia is a whitish thickening of the mucous membrane in the
mouth or tongue. It cannot be scraped off. It is most often associated with heavy smoking or
drinking, and it can be a precancerous condition. Advanced gingivitis and poor dental hygiene
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are manifested by swollen red gums that will bleed when brushed, and will show separation of
the gum from the tooth.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental
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variations in assessment techniques and findings.
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Question 27
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Type: MCMA
The nurse is discharging an 11-month-old child who was brought to the emergency room for the
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treatment of an ear infection and fever. The nurse would include which of the following
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statements in the discharge teaching to the parents?
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Standard Text: Select all that apply.
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1. The babys last bottle before bedtime should only contain water.
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2. It is important not to prop the babys bottle during feeding.
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3. You must rinse the babys mouth right after the baby falls asleep.
4. You must perform oral hygiene more frequently throughout the day.
5. The last bottle of the evening should not be given just before the baby goes to sleep.
Correct Answer: 2,5
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Rationale 1: The babys last bottle before bedtime should only contain water. Milk should
not be replaced with water because the baby may not receive enough nutrition. Bottles should not
be given just before bedtime.
Rationale 2: It is important not to prop the babys bottle during feeding. A primary source of
ear infection in infants and small children is the practice of propping the bottle with milk or
juice. The sugar in these liquids remains in the mouth and contributes to the potential for
infection in the throat, which travels through the shorter, narrower, and more horizontal auditory
tube.
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Rationale 3: You must rinse the babys mouth right after the baby falls asleep. This would
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not be appropriate and might be dangerous for the baby. Providing oral hygiene for children
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immediately before bedtime might be helpful to help reduce the risk of ear infections.
Rationale 4: You must perform oral hygiene more frequently throughout the day.
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Increasing the oral hygiene frequency throughout the day will not improve this situation if bottle
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propping is occurring or if the baby is given a bottle immediately prior to bedtime.
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Rationale 5: The last bottle of the evening should not be given just before the baby goes to
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sleep. A major source of ear infection in infants and small children is the practice of giving the
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baby a bottle at bedtime. The sugar in these liquids remains in the mouth and contributes to the
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potential for infection in the throat, which travels through the shorter, narrower, and more
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horizontal auditory tube.
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Global Rationale: Milk should not be replaced with water because the baby may not receive
enough nutrition. Bottles should not be given just before bedtime. A primary source of ear
infection in infants and small children is the practice of propping the bottle with milk or juice.
The sugar in these liquids remains in the mouth and contributes to the potential for infection in
the throat, which travels through the shorter, narrower, and more horizontal auditory tube. This
would not be appropriate and might be dangerous for the baby. Providing oral hygiene for
children immediately before bedtime might be helpful to help reduce the risk of ear infections.
Increasing the oral hygiene frequency throughout the day will not improve this situation if bottle
propping is occurring or if the baby is given a bottle immediately prior to bedtime. A major
source of ear infection in infants and small children is the practice of giving the baby a bottle at
bedtime. The sugar in these liquids remains in the mouth and contributes to the potential for
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infection in the throat, which travels through the shorter, narrower, and more horizontal auditory
tube.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental
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variations in assessment techniques and findings.
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Question 28
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Type: MCSA
The nurse is assessing the ears, nose and mouth of an Asian client with a student nurse. Which of
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the following statements made by the nurse to the student nurse about cultural differences is
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accurate?
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1. Asians are more likely to experience greater difficulty with otitis media than people from other
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cultures.
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2. Sometimes in Asians and Native Americans, their ear wax looks dry and dark.
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3. Asians have a higher risk of having issues associated with cleft lips and cleft palates.
4. Asians have a high incidence of tooth decay.
Correct Answer: 2
Rationale 1: Asians do not have a tendency to develop otitis media more than other cultures.
Rationale 2: Cerumen appears dry and gray to brown in Asians and Native Americans. Cerumen
found in Caucasians and African Americans looks moist and yellow-orange in color.
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Rationale 3: Cleft lip and palate occur with greatest frequency in Asians and least often in
African Americans.
Rationale 4: Caucasians have the highest incidence of tooth decay.
Global Rationale: Cerumen appears dry and gray to brown in Asians and Native Americans.
Cerumen found in Caucasians and African Americans looks moist and yellow-orange in color.
Asians do not have a tendency to develop otitis media more than other cultures. Cleft lip and
palate occur with greatest frequency in Asians and least often in African Americans. Caucasians
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have the highest incidence of tooth decay.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental
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variations in assessment techniques and findings.
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Question 29
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Type: MCSA
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The nurse is assessing several children in a pediatric clinic. Which of the following children
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might be experiencing delayed development?
1. The 6-year-old child has lost 2 deciduous teeth.
2. The 26-month-old child has one baby tooth.
3. The 4-month-old infant is drooling.
4. The 2-month-old infants salivary glands are not producing saliva.
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Correct Answer: 2
Rationale 1: Eruption of permanent teeth begins at around age 6 and continues through
adolescence.
Rationale 2: Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26month-old child might be expected to have more than one deciduous tooth.
Rationale 3: Drooling of saliva occurs for several months after saliva is produced (3 months old)
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until swallowing saliva is learned.
Rationale 4: Salivation begins at 3 months of age.
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Global Rationale: Eruption of permanent teeth begins at around age 6 and continues through
adolescence. Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26month-old child might be expected to have more than one deciduous tooth. Drooling of saliva
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learned. Salivation begins at 3 months of age.
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occurs for several months after saliva is produced (3 months old) until swallowing saliva is
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
Question 30
Type: MCMA
During the focused interview, the client provides information to the nurse regarding her
daughters recent diagnosis with cancer. The client is exhibiting clinical manifestations associated
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with anxiety. During the physical assessment, which of the following findings might be
expected?
Standard Text: Select all that apply.
1. The client complains of pain when the tragus is gently manipulated.
2. The client has several small ulcers on her lip.
3. Pale nasal mucosa
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4. Small sores are noted within the mouth.
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5. Perforated nasal septum
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Correct Answer: 1,2,4
Rationale 1: The client complains of pain when the tragus is gently manipulated. Pain that
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occurs with manipulation of the tragus may accompany temporomandibular joint dysfunction
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that may be associated with jaw clenching. Jaw clenching can accompany psychological stress.
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Rationale 2: The client has several small ulcers on her lip. Clients who are under a great deal
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of stress might bite their lips.
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hypoxia, and allergies.
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Rationale 3: Pale nasal mucosa. Pale nasal mucosa is associated with cocaine use, infection,
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Rationale 4: Small sores are noted within the mouth. Clients who are under a great deal of
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stress might present with ulcers in their mouth.
Rationale 5: Perforated nasal septum. A perforated nasal septum is associated with cocaine
use.
Global Rationale: Pain that occurs with manipulation of the tragus may accompany
temporomandibular joint dysfunction that may be associated with jaw clenching. Jaw clenching
can accompany psychological stress. Clients who are under a great deal of stress might bite their
lips. Pale nasal mucosa is associated with cocaine use, infection, hypoxia, and allergies. Clients
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who are under a great deal of stress might present with ulcers in their mouth. A perforated nasal
septum is associated with cocaine use.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental
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variations in assessment techniques and findings.
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Question 31
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Type: MCMA
The nurse is conducting a hearing assessment on an older adult client with impacted cerumen
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noted in the right ear canal. When performing the Weber test, the nurse would expect to learn
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which of the following?
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Standard Text: Select all that apply.
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1. Air conduction is longer than bone conduction.
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2. Bone conduction is longer than air conduction.
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3. Sound lateralized to the right ear.
4. The client is unable to maintain balance while standing.
5. The 4 year old placed a pea into his nose during lunch.
Correct Answer: 3
Rationale 1: The Rinne test, not the Weber test, compares air and bone conduction.
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Rationale 2: The Rinne test, not the Weber test, compares air and bone conduction.
Rationale 3: The Weber test uses bone conduction to evaluate hearing in a person who hears
better in one ear than in the other. With impacted cerumen, an ear infection, or a perforated
tympanic membrane, the sound will lateralize to the affected ear during the Weber test.
Rationale 4: The Romberg test is used to determine equilibrium and the clients ability to
maintain balance while standing.
Rationale 5: The 4 year old placed a pea into his nose during lunch. Children are more likely
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to introduce foreign objects into their mouth and nose. This behavior is not associated with gum
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or oral mucosa problems.
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Global Rationale: The Rinne test compares air and bone conduction. Normally, the sound is
heard twice as long by air conduction than by bone conduction after bone conduction stops. The
Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than
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in the other. With impacted cerumen, an ear infection, or a perforated tympanic membrane, the
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sound will lateralize to the affected ear during the Weber test. The Romberg test is used to
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determine equilibrium and the clients ability to maintain balance while standing.
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Cognitive Level: Applying
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.8: Apply critical thinking in selected simulations related to physical
assessment of the structures of the ear, nose, mouth, and throat.
Question 32
Type: MCSA
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The nurse is performing the Weber test. The nurse documents that the sound lateralized to the
clients right ear. The student nurse observing the assessment asks the nurse about the meaning of
this documentation. Which of the following is the nurses best response?
1. This just means that I am unable to visualize the clients tympanic membrane.
2. It refers to the clients inability to hear whispered statements.
3. The client is able to hear bone-conducted sound longer than air conducted sound.
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4. The client is able to hear bone-conducted sound better through the impaired ear.
Correct Answer: 4
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Rationale 1: While it is possible that the nurse is unable to visualize the tympanic membrane due
to cerumen and this is the reason for sound lateralizing to one ear during the Weber test, this is
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not the nurses best response.
Rationale 2: The clients ability to hear whispered statements at 12 feet away is assessed during
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the whisper test.
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Rationale 3: The Weber test is performed to determine if during bone conduction, with the use
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of a tuning fork, the client hears the sound in one ear better than the other. If there is impaired
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conduction in one ear, the sound will lateralize to that ear during the Weber test.
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fork.
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Rationale 4: The Rinne test compares air and bone conduction of sound with the use of a tuning
Global Rationale: While it is possible that the nurse is unable to visualize the tympanic
membrane due to cerumen and this is the reason for sound lateralizing to one ear during the
Weber test, this is not the nurses best response. The Weber test is performed to determine if
during bone conduction, with the use of a tuning fork, the client hears the sound in one ear better
than the other. If there is impaired conduction in one ear, the sound will lateralize to that ear
during the Weber test. The clients ability to hear whispered statements at 12 feet away is
assessed during the whisper test. The Rinne test compares air and bone conduction of sound with
the use of a tuning fork.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 14.8: Apply critical thinking in selected simulations related to physical
assessment of the structures of the ear, nose, mouth, and throat.
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Question 33
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Type: MCSA
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The client admits to cleaning his ears with a cotton-tipped applicator. As a consequence, the
client has developed impacted cerumen and unilateral hearing loss. As the nurse prepares the
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clients plan of care, which of the following nursing diagnoses is most applicable?
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1. Acute pain
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2. Knowledge deficit
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3. Acute confusion
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Correct Answer: 2
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4. Unilateral neglect
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Rationale 1: Acute pain would be appropriate if the client had perforated the tympanic
membrane with the cotton-tipped applicator. However, there are no data to suggest this.
Rationale 2: Of the choices, the best nursing diagnosis for this client is knowledge deficit
regarding how to adequately care for his ears. Another possible nursing diagnosis that would be
applicable for this client is disturbed sensory perception because he will be unable to hear well
out of the ear that is impacted with cerumen.
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Rationale 3: Acute confusion is not an appropriate nursing diagnosis. This client will not
develop confusion as a result of unilateral hearing loss.
Rationale 4: The client will not neglect one side as a result of unilateral hearing loss.
Global Rationale: Of the choices, the best nursing diagnosis for this client is knowledge deficit
regarding how to adequately care for his ears. Another possible nursing diagnosis that would be
applicable for this client is disturbed sensory perception because he will be unable to hear well
out of the ear that is impacted with cerumen. Acute pain would be appropriate if the client had
perforated the tympanic membrane with the cotton-tipped applicator. However, there are no data
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to suggest this. Acute confusion is not an appropriate nursing diagnosis. This client will not
develop confusion as a result of unilateral hearing loss. The client will not neglect one side as a
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result of unilateral hearing loss.
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Chapter 11. Assessing the Eyes
Question 1
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Type: MCMA
The nurse is assessing a client who is 34 weeks pregnant. Which of the following visual changes
are usually normal in this stage in pregnancy and should disappear at some point after delivery?
Standard Text: Select all that apply.
1. The client is complaining that her eyes feel very dry.
2. She states that she is experiencing blurry vision.
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3. Periorbital edema is noted.
Correct Answer: 1,2,5
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5. She has been unable to wear her contact lenses.
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4. Cataracts are noted.
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Rationale 1: The client is complaining that her eyes feel very dry. The pregnant client may
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complain of dry eyes. This symptom is usually not significant and disappears after childbirth.
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Rationale 2: She states that she is experiencing blurry vision. The pregnant client may
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describe visual changes such as blurry vision due to shifting fluid within the eye. Blurriness or
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trimester of pregnancy.
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distorted vision can occur because of temporary changes in the shape of the eye during the last
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Rationale 3: Periorbital edema is noted. Eyelid edema is not a common problem associated
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with pregnancy. Periorbital edema may signal an underlying problem.
Rationale 4: Cataracts are noted. Cataracts are not commonly associated with pregnancy.
Rationale 5: She has been unable to wear her contact lenses. Pregnant women often
discontinue wearing their contact lenses during their pregnancy as a result of fit and comfort.
Global Rationale: The pregnant client may complain of dry eyes. This symptom is usually not
significant and disappears after childbirth. The pregnant client may describe visual changes such
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as blurry vision due to shifting fluid within the eye. Blurriness or distorted vision can occur
because of temporary changes in the shape of the eye during the last trimester of pregnancy.
Pregnant women often discontinue wearing their contact lenses during their pregnancy as a result
of fit and comfort. Eyelid edema is not a common problem associated with pregnancy.
Periorbital edema may signal an underlying problem. Cataracts are not commonly associated
with pregnancy.
Cognitive Level: Applying
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.
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Question 2
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Type: MCSA
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The nurse noted that the client was unable to control the amount of light that came into her eye.
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The dysfunction of which of the following structures is the most likely cause of this problem?
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1. Cornea
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3. Conjunctiva
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2. Sclera
4. Iris
Correct Answer: 4
Rationale 1: The cornea is the window of the eye. It is the clear, transparent part of the sclera
and forms the anterior one sixth of the eye.
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Rationale 2: The sclera supports and protects the structures of the eye.
Rationale 3: The conjunctiva protects the eye and produces a lubricating fluid that prevents the
eye from becoming too dry.
Rationale 4: The iris responds to the light coming through the cornea by making the pupil larger
or smaller, thereby controlling the amount of light that enters the eye.
Global Rationale: The cornea is the window of the eye. It is the clear, transparent part of the
sclera and forms the anterior one sixth of the eye. The sclera supports and protects the structures
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of the eye. The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye
from becoming too dry. The iris responds to the light coming through the cornea by making the
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pupil larger or smaller, thereby controlling the amount of light that enters the eye.
Cognitive Level: Remembering
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.
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Type: MCMA
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Question 3
The nurse is examining the eye. The client asks about the specific structures within the eye that
are responsible for refraction of light rays. The nurse accurately states that the following
structures are involved in this process:
Standard Text: Select all that apply.
1. Lens
2. Macula
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3. Cornea
4. Iris
5. Optic disc
Correct Answer: 1,3
Rationale 1: Lens. The lens is located directly behind the pupil and is used to refract light
through the eye.
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Rationale 2: Macula. The macula is located within the retina and does not assist with light
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refraction.
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Rationale 3: Cornea. The cornea is a transparent part of the eye and located anteriorly. It allows
light to enter the eye and assists with refraction.
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Rationale 4: Iris. The iris controls the amount of light that enters the eye, but is not associated
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with refraction.
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Rationale 5: Optic disc. The optic disc is where the optic nerve and retina meet. It is where the
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vascular network enters the eye. This structure is not associated with refraction.
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Global Rationale: The lens is located directly behind the pupil and is used to refract light
through the eye. The macula is located within the retina and does not assist with light refraction.
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The cornea is a transparent part of the eye and located anteriorly. It allows light to enter the eye
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and assists with refraction. The iris controls the amount of light that enters the eye, but is not
associated with refraction. The optic disc is where the optic nerve and retina meet. It is where the
vascular network enters the eye. This structure is not associated with refraction.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.
Question 4
Type: MCSA
The nurse taught the client how to self-administer eye drops and the client was performing a
return demonstration. During this time, the client inadvertently touched the applicator to their
cornea, which caused the client to blink and produce tears. The nurse may document this
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response as which of the following?
1. Abnormal and should be reported to the healthcare provider
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2. Hyperactive
3. A medication side effect
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4. A normal response
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Correct Answer: 4
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Rationale 1: When the cornea is touched, the eyelids blink and tears are produced. The cornea
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This is not an abnormal response.
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contains many nerve endings and this action would produce a painful sensation for the client.
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Rationale 2: This would not be noted as a hyperactive response.
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Rationale 3: This is not due to a medication side effect.
Rationale 4: This is a normal response because the cornea is very sensitive.
Global Rationale: When the cornea is touched, the eyelids blink and tears are produced. The
cornea contains many nerve endings and this action would produce a painful sensation for the
client. This is not an abnormal response. This would not be noted as a hyperactive response. This
is not due to a medication side effect. This is a normal response because the cornea is very
sensitive.
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Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.
Question 5
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Type: MCHS
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Draw an arrow pointing to the location of the occipital lobe.
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The client requests information about where visual information is processed within the brain.
Correct Answer:
Rationale : Optic tracts encircle the brain and the impulses are transmitted to the occipital lobe
of the brain for interpretation.
Global Rationale:
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Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.
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Question 6
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Type: MCMA
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The nurse is assessing the clients eyes during a comprehensive health assessment. Which of the
following pieces of information should the nurse also gather?
1. The client is 62 years old.
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2. The clients parents were born in Spain.
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Standard Text: Select all that apply.
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4. The client is a welder.
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3. The clients annual income is below the poverty level.
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5. The client recently attempted to commit suicide after his wife died in an automobile accident.
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Correct Answer: 1,2,3,4,5
Rationale 1: The client is 62 years old. During a comprehensive health assessment, it is
important to gather objective information such as the clients age.
Rationale 2: The clients parents were born in Spain. During a comprehensive health
assessment, it is important to gather information about the clients ethnicity and race. Ethnicity
may influence how a client performs self-care activities. Hispanics have higher rates of visual
impairments than other races.
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Rationale 3: The clients annual income is below the poverty level. During a comprehensive
health assessment, it is important to gather information about the clients socioeconomic status.
This may affect how often the client will visit a health care provider for his health care needs and
routine screening activities.
Rationale 4: The client is a welder. During a comprehensive health assessment, it is important
to gather information about the clients occupation. People who work in some settings are more
likely to experience eye injuries.
Rationale 5: The client recently attempted to commit suicide after his wife died in an
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automobile accident. During a comprehensive health assessment, it is important to gather
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information about the clients emotional well-being.
Global Rationale: During a comprehensive health assessment, it is important to gather objective
information such as the clients age. It is also important to gather information about the clients
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ethnicity and race. Ethnicity may influence how a client performs self-care activities. Hispanics
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have higher rates of visual impairments than other races. It is important to gather information
about the clients socioeconomic status. This may affect how often the client will visit a health
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care provider for his health care needs and routine screening activities. It is important to gather
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information about the clients occupation. People who work in some settings are more likely to
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experience eye injuries. It is important to gather information about the clients emotional well-
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being.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.
Question 7
Type: MCSA
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The nurse is interviewing the mother of a three-week-old Caucasian infant. Which statement by
the mother indicates she requires further education about her infants eyes?
1. Its normal for my baby not to produce tears when she cries.
2. At this stage, my baby should be able to fixate on a bright light or something that moves.
3. My babys eyes are blue and definitely will stay blue.
4. It was normal for my babys eyes to be swollen after birth.
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Correct Answer: 3
Rationale 1: At this stage, the baby may not be able to produce tears. By the fourth week, the
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baby will begin to produce tears.
Rationale 2: At six weeks, the baby will begin to develop binocular vision. At this stage, the
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baby will fixate on a bright light or a moving object.
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Rationale 3: Light-skinned infants are born with blue eyes. By about the third month of age, the
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color of the eyes begins to change to a more permanent shade.
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Rationale 4: At birth, many infants have edematous eyelids.
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Global Rationale: At this stage, the baby may not be able to produce tears. By the fourth week,
the baby will begin to produce tears. At six weeks, the baby will begin to develop binocular
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vision. At this stage, the baby will fixate on a bright light or a moving object. Light-skinned
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infants are born with blue eyes. By about the third month of age, the color of the eyes begins to
change to a more permanent shade. Before six weeks of age, infants will fixate on a bright or
moving object. At birth, many infants have edematous eyelids.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.
Question 8
Type: MCSA
The nurse is assessing the eyes of an 82-year-old client. Which of the following findings are
expected by the nurse based on the clients age?
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2. There is a noticeable increase in fat within the orbit of the eye.
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1. The client is easily able to read from a paper held at close range without corrective glasses.
3. The client states that she feels her tear production has increased over the years.
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4. The pupillary light reflex is slower bilaterally.
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Correct Answer: 4
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Rationale 1: The lens of the older clients eye is less elastic and the clients ciliary muscles will
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become weaker. This results in a decreased ability to focus on objects that are held at close
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range.
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Rationale 2: There is a decrease in the amount of fat in the orbit of the eye, which produces a
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drooping appearance of the eye.
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Rationale 3: Older adults experience a decrease in lacrimal secretions.
Rationale 4: The pupillary light reflex slows with age.
Global Rationale: The lens of the older clients eye is less elastic and the clients ciliary muscles
will become weaker. This results in a decreased ability to focus on objects that are held at close
range. There is a decrease in the amount of fat in the orbit of the eye, which produces a drooping
appearance of the eye. Older adults experience a decrease in lacrimal secretions. The pupillary
light reflex slows with age.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.
Question 9
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Type: MCSA
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The nurse is performing a visual examination on a client due to the clients complaints of black
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dots appearing in the visual field. Which of the following statement is the nurses best response to
the client?
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1. The black dots are known as floaters and are usually normal.
2. We need to refer you to an eye surgeon immediately.
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Correct Answer: 1
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4. You may have a cataract.
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3. You may have glaucoma.
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Rationale 1: Black dots or spots are known as floaters. Floaters are considered normal unless
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they obstruct vision, so they should not be immediately referred to a healthcare provider.
Rationale 2: Floaters are considered normal unless they obstruct vision, so they should not be
immediately referred to a healthcare provider.
Rationale 3: Halos around lights are associated with glaucoma.
Rationale 4: Floaters are not seen with cataracts.
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Global Rationale: Black dots or spots are known as floaters. Floaters are considered normal
unless they obstruct vision, so they should not be immediately referred to a healthcare provider.
Halos around lights are associated with glaucoma. Floaters are not seen with cataracts.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 13.2: Develop questions to be used when completing the focused interview.
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Question 10
Type: MCSA
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The nurse is completing a focused interview with assessment of the eye. Which of the following
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1. The client graduated from college.
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is most helpful to the nurse during the focused interview?
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2. The client interacts easily with the nurse.
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3. The client is an African American male.
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4. The client is 23 years old.
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Correct Answer: 2
Rationale 1: It is important to determine the clients educational level.
Rationale 2: The clients ability to communicate is most essential to the interview. The nurse
must determine how well the client will be able to participate in the focused interview and follow
directions during the physical assessment.
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Rationale 3: It is important to assess the clients race because this may influence what types of
eye conditions the client is at risk for developing.
Rationale 4: The clients age is important to assess because anatomical and physiologic changes
can occur in the eye across the lifespan.
Global Rationale: The clients ability to communicate is most essential to the interview. The
nurse must determine how well the client will be able to participate in the focused interview and
follow directions during the physical assessment. It is important to determine the clients
educational level. It is important to assess the clients race because this may influence what types
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of eye conditions the client is at risk for developing. The clients age is important to assess
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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because anatomical and physiologic changes can occur in the eye across the lifespan.
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 13.2: Develop questions to be used when completing the focused interview.
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Type: MCSA
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Question 11
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A client was referred to the clinic with complaints of blurred vision. The initial question for the
nurse to ask the client would be which of the following?
1. Would you please tell me about your vision today?
2. Do you experience double vision?
3. Have you had any eye pain?
4. What kinds of activities do you perform at work?
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Correct Answer: 1
Rationale 1: The best way to start the focused interview is to begin with open-ended questions
that provide the client with an opportunity to describe his own perceptions about his vision.
Rationale 2: Information about double vision is important, but not the best way to start the
interview.
Rationale 3: Information about eye pain is important, but not the best way to start the interview.
Rationale 4: Information about work activities is important, but not the best way to start the
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interview.
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Global Rationale: The best way to start the focused interview is to begin with open-ended
questions that provide the client with an opportunity to describe his own perceptions about his
vision. All of the other questions are appropriate to ask at some point during the focused
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interview but are not the best way to start the interview. It is important to determine if the client
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has experienced double vision. Double vision can be caused by muscle or nerve problems and
some types of medications. It is important to determine if the client is experiencing eye pain
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because it can be associated with glaucoma or other eye problems. It is important to determine
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the clients occupation because some types of occupations put the client at risk for eye injury or
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eyestrain.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 13.2: Develop questions to be used when completing the focused interview.
Question 12
Type: MCSA
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During an eye assessment, a 24-year-old client reports difficulty seeing items well at close range.
The nurse realizes this finding is consistent with:
1. aging.
2. presbyopia.
3. hyperopia.
4. astigmatism.
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Correct Answer: 3
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Rationale 1: Aging can produce changes in the eye but this client is 24 years old.
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Rationale 2: Presbyopia is an age-related condition. The lens loses its ability to accommodate
viewing items at close range.
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Rationale 3: Younger clients who are unable to see items well at close range have a condition
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called hyperopia. This condition is also referred to as farsightedness.
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Rationale 4: Astigmatism occurs when light is refracted over a wide area rather than on a
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distinct area of the retina.
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Global Rationale: Younger clients who are unable to see items well at close range have a
condition called hyperopia. This condition is also referred to as farsightedness. Aging can
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produce changes in the eye but this client is 24 years old. Presbyopia is an age-related condition.
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The lens loses its ability to accommodate viewing items at close range. Astigmatism occurs
when light is refracted over a wide area rather than on a distinct area of the retina.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.
Question 13
Type: MCSA
The nurse notices that a clients pupils constrict when reading the consent form for medical
treatment. This observation would lead the nurse to consider which of the following?
1. The room is too dark.
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2. The client is able to read.
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3. This is a normal response.
4. The client requires glasses for reading.
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Correct Answer: 3
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Rationale 1: When a room is dark, the clients pupils should dilate in response.
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Rationale 2: Pupil constriction occurs as the client focuses on the paper. It does not indicate the
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client can read.
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read what is on the paper.
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Rationale 3: This is a normal finding. The clients pupils should constrict in response to trying to
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glasses.
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Rationale 4: Pupil constriction would not lead the nurse to believe the client needs reading
Global Rationale: When a room is dark, the clients pupils should dilate in response. Pupil
constriction occurs as the client focuses on the paper. It does not indicate the client can read.
This is a normal finding. The clients pupils should constrict in response to trying to read what is
on the paper. Pupil constriction would not lead the nurse to believe the client needs reading
glasses.
Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.
Question 14
Type: MCMA
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During an eye examination, the nurse requests that the client read letters located on the Snellen E
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chart. The clients vision is determined to be 20/200. Which of the following is true regarding
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these findings?
Standard Text: Select all that apply.
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1. The client is legally blind.
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3. The client is found to be farsighted.
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2. The client is unable to read from a paper at close range.
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4. The client is myopic.
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5. This is common in clients who are over 45 years old.
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Correct Answer: 1,4
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Rationale 1: The client is legally blind. When a clients vision is found to be 20/200, the client
is legally blind.
Rationale 2: The client is unable to read from a paper at close range. The Snellen E chart
assists with determining if the client is able to see items in the distance.
Rationale 3: The client is found to be farsighted. Clients who are farsighted are able to see
things in the distance. This client is unable to see distant objects.
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Rationale 4: The client is myopic. Clients who are myopic are unable to see objects in the
distance.
Rationale 5: This is common in clients who are over 45 years old. Presbyopia is the inability
to see items at close range. This condition is more common in people who are over 45 years old.
Global Rationale: When a clients vision is found to be 20/200, the client is legally blind. The
Snellen E chart assists with determining if the client is able to see items in the distance. Clients
who are farsighted are able to see things in the distance. This client is unable to see distant
objects.
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Clients who are myopic are unable to see objects in the distance. Presbyopia is the inability to
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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see items at close range. This condition is more common in people who are over 45 years old.
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.
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Type: MCSA
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Question 15
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The nurse is assessing a clients visual fields by confrontation. Which of the following nursing
actions indicates that the nurse requires further education regarding this test?
1. The nurse asks the client to cover one of her eyes with a card.
2. The nurse uses a penlight to assist with performing the test.
3. The nurse asks the client to sit 20 feet away.
4. The client tells the nurse when she first sees the object.
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Correct Answer: 3
Rationale 1: Confrontation to test visual fields is done by asking the client to cover one eye with
a cover while the nurse covers the eye opposite to the client.
Rationale 2: The nurse and client sit 23 feet away from each other, at eye level. An object such
as a pen or penlight is advanced from the periphery to the midline. Both the client and the nurse
should be able to see the object at the same time.
Rationale 3: The nurse and client should sit only 23 feet away from each other.
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Rationale 4: The client should tell the nurse when she first sees the object in her peripheral
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vision.
Global Rationale: Confrontation to test visual fields is done by asking the client to cover one
eye with a cover while the nurse covers the eye opposite to the client. The nurse and client sit 23
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feet away from each other, at eye level. An object such as a pen or penlight is advanced from the
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periphery to the midline. Both the client and the nurse should be able to see the object at the
same time. The nurse and client should sit only 23 feet away from each other. The client should
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Cognitive Level: Applying
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tell the nurse when she first sees the object in her peripheral vision.
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.
Question 16
Type: HOTSPOT
The nurse is assessing the clients corneal reflex. Draw an arrow pointing to the area of the eye
that the nurse should test for the presence of this reflex.
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : The nurse should use a lateral approach and gently touch the clients cornea on the
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outer aspect.
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Global Rationale:
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.
Question 17
Type: MCSA
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The nurse is assessing the clients eye with an ophthalmoscope. The nurse is preparing to focus
on the fundus and rotates the lens diopter wheel into the negative numbers. Based on this
information, which of the following conditions does the client most likely have?
1. Hyperopia
2. Presbyopia
3. Myopia
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4. Astigmatism
Correct Answer: 3
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Rationale 1: The diopter is rotated toward the positive numbers when the client is hyperopic.
Rationale 2: For presbyopia the diopter wheel is rotated until the fundus can be visualized
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adequately.
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Rationale 3: The diopter wheel is rotated into the negative numbers when the client is myopic.
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Rationale 4: For astigmatism the diopter wheel is rotated until the fundus can be visualized
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adequately.
Global Rationale: The diopter is rotated to help the nurse focus on the clients fundus. The
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diopter is rotated toward the positive numbers when the client is hyperopic. The diopter wheel is
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rotated into the negative numbers when the client is myopic. For any other condition such as
adequately.
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presbyopia or astigmatism, the diopter wheel is rotated until the fundus can be visualized
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 13.4: Explain the use of the ophthalmoscope.
Question 18
Type: HOTSPOT
The nurse is assessing the clients retina. Draw an arrow pointing toward the location of the optic
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disc.
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Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : The optic disc can be identified by following the path of the blood vessels. As they
grow larger, they lead to the optic disc which is located on the nasal side of the retina. The optic
disc normally looks like a round or oval yellow-orange depression with a distinct margin. This is
the site where the optic nerve and blood vessels exit from the eye.
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Global Rationale:
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 13.4: Explain the use of the ophthalmoscope.
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Question 19
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Type: MCSA
The nurse is assessing the fundus of the elderly clients eye with an ophthalmoscope. The nurse
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determines that there is a cyst within the macula. Which of the following client symptoms may
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1. Impaired central vision
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be associated with this finding?
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2. Impaired peripheral vision
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3. Consistently elevated serum glucose levels
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4. Uncontrolled hypertension
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Correct Answer: 1
Rationale 1: Degeneration of the macula can be related to cysts located in this area. It is more
common in older adults and results in impaired central vision.
Rationale 2: Impaired peripheral vision can be related to problems with the rods that are located
in the retina.
Rationale 3: Elevated serum glucose levels may be associated with diabetic retinopathy.
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Rationale 4: Uncontrolled hypertension can be associated with hypertensive retinopathy.
Global Rationale: Degeneration of the macula can be related to cysts located in this area. It is
more common in older adults and results in impaired central vision. Impaired peripheral vision
can be related to problems with the rods that are located in the retina. Elevated serum glucose
levels may be associated with diabetic retinopathy. Uncontrolled hypertension can be associated
with hypertensive retinopathy.
Cognitive Level: Applying
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Learning Outcome: 13.4: Explain the use of the ophthalmoscope
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Question 20
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Type: MCSA
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The nurse is preparing to assess the clients eye with an ophthalmoscope while a student nurse is
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observing. Which of the following statements by the nurse to the student nurse is accurate
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regarding this portion of the assessment?
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1. Im going to examine the clients right eye with my left eye.
2. Im going to advance the ophthalmoscope until the instrument touches the clients cornea.
3. Im going to begin with the lens set to the 0 diopter.
4. I can see the red reflex as the light reflects off of the clients lens.
Correct Answer: 3
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Rationale 1: The nurse should prepare to assess the clients eye with an ophthalmoscope by
examining the clients right eye with the nurses right eye.
Rationale 2: The nurse should advance the ophthalmoscope only until it almost touches the
clients eyelashes. The cornea contains many nerve endings and this would be painful for the
client.
Rationale 3: The nurse should always begin with the lens set to the 0 diopter.
Rationale 4: The red reflex is seen as light reflects off of the clients retina, not his lens.
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Global Rationale: The nurse should always begin with the lens set to the 0 diopter. The nurse
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should prepare to assess the clients eye with an ophthalmoscope by examining the clients right
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eye with the nurses right eye. The nurse should advance the ophthalmoscope only until it almost
touches the clients eyelashes. The cornea contains many nerve endings and this would be painful
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for the client. The red reflex is seen as light reflects off of the clients retina, not his lens.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Question 21
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Learning Outcome: 13.4: Explain the use of the ophthalmoscope.
Type: MCSA
The nurse is assessing a clients eyes during a comprehensive health assessment. The nurse
knows that the client who demonstrates clinical manifestations of which of the following
conditions will require immediate intervention?
1. Acute glaucoma
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2. Blepharitis
3. Periorbital edema
4. Anisocoria
Correct Answer: 1
Rationale 1: Acute glaucoma results from a sudden increase in intraocular pressure caused by a
blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate
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interventions to prevent further eye damage.
Rationale 2: Blepharitis is when the eyelid becomes inflamed. The eye burns, itches, and tears
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but does not require an immediate intervention.
Rationale 3: Periorbital edema is when the eyelid becomes puffy and swollen. It can be related
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to crying, infection, or systemic problems. It does not require an immediate intervention.
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Rationale 4: Anisocoria refers to unequal pupil size, which may be a normal finding or it may
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indicate that the client has a central nervous system disease.
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Global Rationale: Acute glaucoma results from a sudden increase in intraocular pressure caused
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by a blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate
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interventions to prevent further eye damage. Blepharitis is when the eyelid becomes inflamed.
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The eye burns, itches, and tears but does not require an immediate intervention. Periorbital
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edema is when the eyelid becomes puffy and swollen. It can be related to crying, infection, or
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systemic problems. It does not require an immediate intervention. Anisocoria refers to unequal
pupil size, which may be a normal finding or it may indicate that the client has a central nervous
system disease.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.
Question 22
Type: MCSA
The nurse is performing the cover test and notes inward turning of the eye. Which of the
following ways will the nurse accurately document this finding?
1. Exophoria
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2. Strabismus
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3. Esophoria
4. Mydriasis
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Correct Answer: 3
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Rationale 1: Exophoria is when the eye turns outward during the cover test.
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Rationale 2: Strabismus is when the axes of the eye cannot be directed at the same object.
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Rationale 3: Esophoria is when the eye turns inward during the cover test.
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Rationale 4: Mydriasis refers to fixed and dilated pupils.
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Global Rationale: Exophoria is when the eye turns outward during the cover test. Strabismus is
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when the axes of the eye cannot be directed at the same object. Esophoria is when the eye turns
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inward during the cover test. Mydriasis refers to fixed and dilated pupils.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.
Question 23
Type: MCSA
A client is found to need corrective lenses for myopia. Which of the following explanations
would the nurse provide to this client?
1. Your glasses will help you to see objects in the distance.
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2. Your glasses will help you to see objects that are very close to you.
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3. Your glasses will help you to improve your eyes ability to focus and reduce your blurred
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vision.
4. Your age has made it more difficult to read items that are at close range. Your new glasses
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will help.
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Correct Answer: 1
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Rationale 1: Myopia is the inability to see objects in the distance.
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Rationale 2: Hyperopia is the inability to see objects at close range.
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Rationale 3: Astigmatism causes blurred or double vision when the eyes attempt to focus.
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Rationale 4: Presbyopia causes the client to experience difficulty focusing on items that are at
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close range. Presbyopia affects people who are over 45 years old.
Global Rationale: Myopia is the inability to see objects in the distance. Hyperopia is the
inability to see objects at close range. Astigmatism causes blurred or double vision when the eyes
attempt to focus. Presbyopia causes the client to experience difficulty focusing on items that are
at close range. Presbyopia affects people who are over 45 years old.
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.
Question 24
Type: MCSA
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The nurse is assessing the clients pupillary responses. The client is found to have no consensual
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1. Cranial nerve III may not be functioning appropriately.
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response. The finding indicates which of the following to the nurse?
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2. This is a normal finding.
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3. This is evidence of increased intracranial pressure.
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4. This is evidence of optic nerve damage.
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Correct Answer: 1
Rationale 1: When evaluating pupillary response, the unilluminated, or consensual, pupil should
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also constrict. When this does not occur, it may be indicative of problems associated with cranial
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nerve III.
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Rationale 2: This is not a normal finding.
Rationale 3: Increased intracranial pressure is associated with pupils that are unequal and
irregularly shaped.
Rationale 4: This is not evidence that optic nerve damage has occurred. Optic nerve damage can
produce changes in the clients visual fields.
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Global Rationale: When evaluating pupillary response, the unilluminated, or consensual, pupil
should also constrict. When this does not occur, it may be indicative of problems associated with
cranial nerve III. This is not a normal finding. Increased intracranial pressure is associated with
pupils that are unequal and irregularly shaped. This is not evidence that optic nerve damage has
occurred. Optic nerve damage can produce changes in the clients visual fields.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.
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Question 25
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Type: MCSA
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During the assessment of a clients eyes, the nurse suspects the client has entropian. Which of the
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1. Eversion of the lower eyelid
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following did the nurse most likely find while assessing this client?
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2. Inversion of the lid and eyelashes
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3. Swollen, red hair follicles
4. Firm, nontender nodule on the eyelid
Correct Answer: 2
Rationale 1: Ectropian is eversion of the lower eyelid caused by muscle weakness.
Rationale 2: Entropian is inversion of the lid and lashes caused by a muscle spasm of the eyelid.
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Rationale 3: A stye causes swelling and redness in the affected eye. A stye is a result of a
staphylococcal infection of hair follicles on the margin of the lids.
Rationale 4: A chalazion is a firm, nontender nodule on the eyelid.
Global Rationale: Entropian is inversion of the lid and lashes caused by a muscle spasm of the
eyelid. Ectropian is eversion of the lower eyelid caused by muscle weakness. A stye causes
swelling and redness in the affected eye. A stye is a result of a staphylococcal infection of hair
follicles on the margin of the lids. A chalazion is a firm, nontender nodule on the eyelid.
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Chapter 12. Assessing the Respiratory System
Question 1
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Type: HOTSPOT
The client aspirated a pea during a meal. The healthcare provider noted that the pea was in the
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bronchus. Draw an arrow to the most likely site of the pea.
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Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : The right main bronchus is shorter, wider, and more vertical than the left bronchus;
therefore, aspirated objects are more likely to enter the right lung.
Global Rationale:
Cognitive Level: Applying
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
Learning Outcome: 15.1: Identify the anatomy and physiology of the respiratory system.
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Question 2
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Type: MCSA
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The nurse is examining a client who has been diagnosed with a fracture of one floating rib. Of
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the following ribs, which does the nurse suspect to be fractured?
3. 9
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2. 5
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1. 1
4. 12
Correct Answer: 4
Rationale 1: Anteriorly, the first seven pairs of ribs articulate directly to the sternum.
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Rationale 2: Anteriorly, the first seven pairs of ribs articulate directly to the sternum.
Rationale 3: The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7.
Rationale 4: The rib pairs of 11 and 12 are free floating and do not articulate anteriorly.
Global Rationale: The 12 pairs of ribs circle the body, form the lateral aspects of the thorax, and
are attached to the vertebrae and sternum. Anteriorly, the first seven pairs of ribs articulate
directly to the sternum. The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7,
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whereas the pairs of 11 and 12 are free floating and do not articulate anteriorly.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 15.1: Identify the anatomy and physiology of the respiratory system.
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Question 3
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Type: HOTSPOT
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Draw an arrow that points to the right anterior axillary line (AAL).
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Standard Text: Select the correct area on the image.
Correct Answer:
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Rationale : The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are
right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend
along the anterior lateral aspects of the thoracic cage to the twelfth rib.
Global Rationale:
Cognitive Level: Remembering
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory
system.
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Question 4
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Type: MCSA
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The nurse wants to assess the apex of a clients right lung. Which of the following locations
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should the nurse place the stethoscope to assess this area on the client?
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1. Intercostal space 6th rib near the sternum
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2. Intercostal space 4th rib near the axillary line
3. Below the scapula
4. Near the right clavicle
Correct Answer: 4
Rationale 1: The apex of each lung is slightly superior to the inner third of the clavicle.
Rationale 2: The apex of each lung is slightly superior to the inner third of the clavicle.
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Rationale 3: The apex of each lung is slightly superior to the inner third of the clavicle.
Rationale 4: The apex of each lung is slightly superior to the inner third of the clavicle.
Global Rationale: The apex of each lung is slightly superior to the inner third of the clavicle
whereas the base of each lung rests on the diaphragm.
Cognitive Level: Remembering
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Client Need: Physiological Integrity
Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory
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system.
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Question 5
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Type: MCSA
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During the respiratory assessment of a client the nurse wishes to locate the angle of Louis. This
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structure can be identified by using which of the following landmarks?
3. First rib
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2. Sternum
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1. Clavicle
4. Vertebral column
Correct Answer: 2
Rationale 1: The angle of Louis is the horizontal ridge formed by the intersection of the
manubrium and the body of the sternum.
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Rationale 2: The angle of Louis is the horizontal ridge formed by the intersection of the
manubrium and the body of the sternum.
Rationale 3: The angle of Louis is the horizontal ridge formed by the intersection of the
manubrium and the body of the sternum.
Rationale 4: The angle of Louis is the horizontal ridge formed by the intersection of the
manubrium and the body of the sternum.
Global Rationale: The angle of Louis is the horizontal ridge formed by the intersection of the
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manubrium and the body of the sternum.
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Cognitive Level: Understanding
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory
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system.
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Type: MCSA
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Question 6
While assessing the client, the nurse notes that the client has a moist cough. The nurse would
include which of the following questions in the focused interview?
1. Have you been losing weight?
2. How long have you been sick?
3. Are you wheezing?
4. Are you coughing up any mucus or phlegm?
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Correct Answer: 4
Rationale 1: At this point, the client should not be questioned about weight loss.
Rationale 2: The client may not necessarily be sick.
Rationale 3: The client should be questioned about the cough during the focused interview and
not about wheezing.
Rationale 4: The nurse must determine if the cough is productive or nonproductive. A moist
(sputum) is associated with specific diseases or problems
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cough is often associated with lung infections. The color and odor of any mucus or phlegm
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Global Rationale: The nurse must determine if the cough is productive or nonproductive. A
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moist cough is often associated with lung infections. The color and odor of any mucus or phlegm
(sputum) is associated with specific diseases or problems. At this point, the client should not be
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questioned about weight loss. The client may not necessarily be sick. The client should be
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questioned about the cough during the focused interview and not about wheezing.
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Client Need: Physiological Integrity
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Cognitive Level: Applying
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Question 7
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Learning Outcome: 15.3: Develop questions to be used when completing the focused interview.
Type: MCSA
The nurse is assessing the clients respiratory system. Which of the following methods will result
in the most accurate assessment of the clients respiratory rate?
1. The nurse should place a hand on the clients chest to count respirations accurately.
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2. The nurse should inform the client that the nurse is counting the clients respirations.
3. The nurse should count only the respirations that are audible.
4. The nurse should count the respirations in an unobtrusive manner without informing the client.
Correct Answer: 4
Rationale 1: Though laying a hand on the clients chest allows the nurse to feel the rise and fall
of the chest, this may be considered an intrusive move and might increase the clients level of
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anxiety, which may affect the respiratory rate.
Rationale 2: The nurse should not inform the client about this portion of the assessment.
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Rationale 3: Not all clients have audible respiratory cycles, and this would not be an effective
method for accuracy.
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Rationale 4: If a client knows his respirations are being counted, it may alter the normal
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breathing pattern.
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Global Rationale: If a client knows his respirations are being counted, it may alter the normal
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breathing pattern. Though laying a hand on the clients chest allows the nurse to feel the rise and
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fall of the chest, this may be considered an intrusive move and might increase the clients level of
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anxiety, which may affect the respiratory rate. The nurse should not inform the client about this
portion of the assessment. Not all clients have audible respiratory cycles, and this would not be
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an effective method for accuracy.
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Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.4: Explain client preparation for assessment of the respiratory system.
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Question 8
Type: SEQ
The nurse is preparing to assess the clients respiratory system. Rank in order according to how
the nurse should proceed.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Auscultation
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Choice 2. Inspection
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Choice 3. Percussion
Choice 4. Client survey
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Choice 5. Palpation
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Correct Answer: 4,2,5,3,1
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Rationale 1: The fifth step in physical assessment of the respiratory system is auscultation.
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Rationale 2: The second step of respiratory assessment is inspection of the anterior and posterior
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thorax.
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Rationale 3: The fourth step in physical assessment of the respiratory system is percussion of the
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anterior and posterior thorax.
Rationale 4: The first step in any physical assessment is the client survey.
Rationale 5: The third step in respiratory assessment is palpation of the structures of the anterior
and posterior thorax.
Global Rationale: The physical assessment of the respiratory system follows an organized
pattern. It begins with the client survey, then inspection of the anterior and posterior thorax. The
assessment ends with palpation, percussion, and auscultation of the anterior thorax.
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Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory
system.
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Question 9
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Type: HOTSPOT
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Draw an arrow to the area where tracheal breath sounds can be auscultated.
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : Tracheal breath sounds are heard over the trachea when the client inhales and
exhales. They are harsh and high-pitched.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory
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system.
Question 10
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Type: MCSA
The client was brought to the Emergency Department. The nurse administered a breathing
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treatment for the client earlier. The nurse is preparing the client for a procedure. The nurse notes
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that the client is breathing in a shallow manner and the clients hands are trembling. Which of the
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following actions will help decrease the clients level of anxiety?
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1. The nurse should explain all procedures in a calm and reassuring voice.
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2. Request the immediate presence of the healthcare provider.
3. Provide oxygen for the client.
4. Postpone the procedure.
Correct Answer: 1
Rationale 1: Clients experiencing anxiety may demonstrate trembling hands and a shallow
breathing pattern. Certain drugs, such as bronchodilators, are used in the treatment of respiratory
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conditions and may cause the hands to tremble visibly. The nurse should not confuse this sign
with nervousness. Even mild respiratory distress is frightening for the client and family.
Proceeding in a calm and reassuring manner helps reduce the clients fear.
Rationale 2: At this time, there is no reason to request the presence of the healthcare provider.
Rationale 3: There is not enough information about the information to assume the client requires
oxygen.
Rationale 4: The nurse does not need to postpone the procedure.
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Global Rationale: Clients experiencing anxiety may demonstrate trembling hands and a shallow
breathing pattern. Certain drugs, such as bronchodilators, are used in the treatment of respiratory
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conditions and may cause the hands to tremble visibly. The nurse should not confuse this sign
with nervousness. Even mild respiratory distress is frightening for the client and family.
Proceeding in a calm and reassuring manner helps reduce the clients fear. At this time, there is
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no reason to request the presence of the healthcare provider. There is not enough information
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about the information to assume the client requires oxygen. The nurse does not need to postpone
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the procedure.
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Cognitive Level: Analyzing
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Client Need: Psychosocial Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory
system.
Question 11
Type: MCSA
The nursing instructor is observing a student nurse assess the clients respiratory system. The
student demonstrates proper technique for auscultation when moving the stethoscope:
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1. From base to apices of lungs.
2. First up one side of the thorax, then up the other.
3. First down one side of the thorax, then down the other.
4. From side to side.
Correct Answer: 4
Rationale 1: The usual movement is from apices to the bases.
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Rationale 2: Auscultation should follow the same pattern as for percussion, from side to side,
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because comparison of sounds is an important step in respiratory assessment.
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Rationale 3: Auscultation should follow the same pattern as for percussion, from side to side,
because comparison of sounds is an important step in respiratory assessment.
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Rationale 4: Auscultation should follow the same pattern as for percussion, from side to side,
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because comparison of sounds is an important step in respiratory assessment.
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Global Rationale: Auscultation should follow the same pattern as for percussion, from side to
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side, because comparison of sounds is an important step in respiratory assessment. Auscultate
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through the entire respiratory cycle, inspiration and expiration. The student nurse should ask the
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client to breathe deeply through the mouth each time the stethoscope is placed on the chest. The
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usual movement is from apices to the bases.
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Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory
system.
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Question 12
Type: MCMA
The nurse is preparing to auscultate a clients lungs. Which of the following breath sounds would
be considered abnormal?
Standard Text: Select all that apply.
1. Crackles
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2. Vesicular
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3. Bronchovesicular
4. Wheezes
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5. Bronchial
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Correct Answer: 1,4
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collapsed or fluid-filled alveoli.
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Rationale 1: Crackles. Crackles are adventitious, or abnormal, lung sounds produced by
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Rationale 2: Vesicular. Vesicular sounds are normal and can be heard over the apices.
Rationale 3: Bronchovesicular. Bronchovesicular sounds are normal sounds that can be
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auscultated over the bronchi.
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Rationale 4: Wheezes. Wheezes are the result of blocked airflow as in asthma, infection, or due
to a foreign body.
Rationale 5: Bronchial. Bronchial sounds are normal and can be heard to the right and left of
the trachea over the bronchi.
Global Rationale: Crackles are adventitious, or abnormal, lung sounds produced by collapsed or
fluid-filled alveoli. Vesicular sounds are normal and can be heard over the apices.
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Bronchovesicular sounds are normal sounds that can be auscultated over the bronchi. Wheezes
are the result of blocked airflow as in asthma, infection, or due to a foreign body. Bronchial
sounds are normal and can be heard to the right and left of the trachea over the bronchi.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
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Question 13
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Type: MCSA
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The nurse is assessing the client. The nurse hears low-pitched, continuous respiratory sounds that
have a snoring quality while auscultating the clients lungs. The nurse would correctly document
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these findings as which of the following?
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1. Rales
4. Wheezes
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3. Rhonchi
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2. Crackles
Correct Answer: 3
Rationale 1: Rales are intermittent, non-musical brief sounds.
Rationale 2: Coarser and louder rales are referred to as crackles.
Rationale 3: There are two types of continuous respiratory sounds that may be heard during the
respiratory cycle. Rhonchi are low-pitched and have a snoring quality.
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Rationale 4: There are two types of continuous respiratory sounds that may be heard during the
respiratory cycle. Wheezes are high-pitched with a shrill quality.
Global Rationale: There are two types of continuous respiratory sounds that may be heard
during the respiratory cycle. Rhonchi are low-pitched and have a snoring quality, while wheezes
are high-pitched with a shrill quality. Rales are intermittent, nonmusical, brief sounds. Coarser
and louder rales are referred to as crackles.
Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment
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Question 14
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Type: MCMA
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While palpating respiratory expansion on a client in the emergency room the nurse notes
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movement on only one side of the chest. Which of the following conditions may produce this
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finding?
1. Atelectasis
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Standard Text: Select all that apply.
2. Chronic bronchitis
3. Lobar pneumonia
4. Pleural effusion
5. Congestive heart failure
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Correct Answer: 1,3,4
Rationale 1: Atelectasis. Atelectasis is a condition in which there is an obstruction of airflow.
Lung tissue may collapse from airway obstruction, such as a mucous plug, lack of surfactant, or
a compressed chest wall. Atelectasis will result in decreased lung expansion on the clients
affected side.
Rationale 2: Chronic bronchitis. Chronic inflammation of the tracheobronchial tree leads to
increased mucous production and blocked airways. It does not result in decreased lung expansion
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on one side.
Rationale 3: Lobar pneumonia. It is due to an infection that causes fluid, bacteria, and cellular
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debris to fill the alveoli. It may result in decreased lung expansion on the clients affected side.
Rationale 4: Pleural effusion. This condition refers to fluid accumulating in the pleural space. It
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may result in decreased lung expansion on the clients affected side.
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Rationale 5: Congestive heart failure. This is when increased pressure in the pulmonary veins
causes interstitial edema around the alveoli and may cause edema of the bronchial mucosa. It
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does not result in decreased lung expansion on one side.
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Global Rationale: Atelectasis is a condition in which there is an obstruction of airflow. Lung
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tissue may collapse from airway obstruction, such as a mucous plug, lack of surfactant, or a
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compressed chest wall. Atelectasis will result in decreased lung expansion on the clients affected
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side. Chronic bronchitis results in chronic inflammation of the tracheobronchial tree, which leads
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to increased mucous production and blocked airways. It does not result in decreased lung
expansion on one side. Lobar pneumonia is due to an infection that causes fluid, bacteria, and
cellular debris to fill the alveoli. It may result in decreased lung expansion on the clients affected
side. Pleural effusion refers to fluid accumulating in the pleural space. It may result in decreased
lung expansion on the clients affected side. Congestive heart failure occurs when increased
pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause
edema of the bronchial mucosa. It does not result in decreased lung expansion on one side.
Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment
Question 15
Type: MCMA
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The nurse is assessing a client with a severe left pleural effusion. Which of the following
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findings are expected?
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Standard Text: Select all that apply.
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1. Absent breath sounds on the left side
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2. Tracheal shift to the right
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3. Hyperresonance upon percussion.
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4. Bronchial breath sounds of the right side
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Correct Answer: 1,2,5
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5. Pleural friction rub auscultated.
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Rationale 1: Absent breath sounds on the left side. In this condition, fluid accumulates in the
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pleural space and may result in absent breath sounds on the affected side.
Rationale 2: Tracheal shift to the right. In this condition, fluid accumulates in the pleural
space. The trachea may shift to the unaffected side.
Rationale 3: Hyperresonance upon percussion. The trapping of air in the alveoli will produce
a sound of hyperresonance upon percussion. This is not a typical finding in someone who has
been diagnosed with a pleural effusion.
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Rationale 4: Bronchial breath sounds of the right side. This is not a typical finding in
someone who has been diagnosed with a pleural effusion.
Rationale 5: Pleural friction rub auscultated. In this condition, fluid accumulates in the
pleural space, and a pleural friction rub may be present during auscultation.
Global Rationale: In this condition, fluid accumulates in the pleural space and may result in
absent breath sounds on the affected side, a tracheal shift to the unaffected side, and a pleural
friction rub. The trapping of air in the alveoli will produce a sound of hyperresonance upon
percussion. This is not a typical finding in someone who has been diagnosed with a pleural
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effusion. Bronchial breath sounds of the right side is not a typical finding in someone who has
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been diagnosed with a pleural effusion.
Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
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Question 16
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Type: MCSA
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The nurse is assessing the clients respiratory pattern and notes periods of deep breathing
alternating with periods of apnea. Which of the following terms would the nurse use to document
this finding?
1. Tachypnea
2. Obstructive breathing
3. Hypoventilation
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4. Cheyne-Stokes
Correct Answer: 4
Rationale 1: The client who has tachypnea exhibits rapid and shallow respirations.
Rationale 2: Clients with obstructive breathing have prolonged expirations.
Rationale 3: Hypoventilation is irregular and shallow breathing.
Rationale 4: The breathing described is a Cheyne-Stokes pattern.
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Global Rationale: The breathing described is a Cheyne-Stokes pattern. The client who has
tachypnea exhibits rapid and shallow respirations. Clients with obstructive breathing have
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prolonged expirations. Hypoventilation is irregular and shallow breathing.
Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
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Type: MCSA
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Question 17
During the assessment of a clients voice sounds, the nurse hears louder sounds over the clients
right lower lobe. This finding would be consistent with:
1. Atelectasis.
2. Lobar pneumonia.
3. Asthma.
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4. Pleural effusion.
Correct Answer: 2
Rationale 1: Voice sounds are decreased or absent over areas of atelectasis.
Rationale 2: Voice sounds are increased and clearer over areas affected by lobar pneumonia.
Rationale 3: Voice sounds are decreased or absent over areas of asthma.
Rationale 4: Voice sounds are decreased or absent over areas of pleural effusion.
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Global Rationale: Voice sounds are decreased or absent over areas of atelectasis, asthma,
pleural effusion, and pneumothorax. Voice sounds are increased and clearer over areas affected
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by lobar pneumonia.
Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
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Question 18
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Type: MCSA
The nurse percusses the lungs and determines that there is an area of hyperresonance. This
finding is consistent with which of the following conditions?
1. Pneumonia
2. Atelectasis
3. Pneumothorax
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4. Pleural effusion
Correct Answer: 3
Rationale 1: When percussing a client with pneumonia the nurse would hear dullness over the
affected area.
Rationale 2: When percussing a client with atelectasis the nurse would hear dullness over the
affected area.
overinflated lungs such as emphysema and with pneumothorax.
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Rationale 3: Hyperresonance can be auscultated in clients with conditions that involve
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Rationale 4: When percussing a client with a pleural effusion, the nurse would hear dullness
over the affected area.
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Global Rationale: Hyperresonance can be auscultated in clients with conditions that involve
overinflated lungs such as emphysema and with pneumothorax. When percussing a client with
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pneumonia, atelectasis, or a pleural effusion, the nurse would hear dullness over the affected
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Cognitive Level: Understanding
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area.
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
Question 19
Type: MCSA
While the client sleeps, the nurse notes that the clients respirations periodically stop. This finding
would be documented as:
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1. Tachypnea.
2. Bradypnea.
3. Apnea.
4. Atelectasis.
Correct Answer: 3
Rationale 1: Tachypnea is a term used to describe rapid, shallow respirations that are greater
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than 24 per minute.
Rationale 2: Bradypnea is a term used to describe slow, regular respirations that are less than 10
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per minute.
Rationale 3: Apnea is the cessation of breathing lasting from a few seconds to a few minutes.
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Rationale 4: The findings do not indicate atelectasis, which is alveolar or lung collapse.
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Global Rationale: Apnea is the cessation of breathing lasting from a few seconds to a few
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minutes. Tachypnea is a term used to describe rapid, shallow respirations that are greater than 24
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per minute. Bradypnea is a term used to describe slow, regular respirations that are less than 10
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Cognitive Level: Applying
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per minute. The findings do not indicate atelectasis, which is alveolar or lung collapse.
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
Question 20
Type: MCSA
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The nurse documents that the clients respirations are shallow and rapid. The clients respiratory
rate is 30 per minute. From this finding, the nurse is concerned the client is:
1. Fatigued.
2. Anxious.
3. Normal.
4. Bored.
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Rationale 1: Fatigue does not usually result in tachypnea.
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Correct Answer: 2
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Rationale 2: Tachypnea, or rapid, shallow respirations, are greater than 24 per minute and may
be caused by fever, fear, exercise, respiratory insufficiency, pleuritic pain, alkalosis, or
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pneumonia.
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Rationale 3: Normal respirations are even and regular. A normal respiratory rate is over 10 and
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under 24 respirations per minute.
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Rationale 4: The bored client may exhibit a slower respiratory rate.
Global Rationale: Tachypnea, or rapid, shallow respirations, are greater than 24 per minute and
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may be caused by fever, fear, exercise, respiratory insufficiency, pleuritic pain, alkalosis, or
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pneumonia. Fatigue does not usually result in tachypnea. Normal respirations are even and
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regular. A normal respiratory rate is over 10 and under 24 respirations per minute. The bored
client may exhibit a slower respiratory rate.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
www.mynursingtestprep.com
Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
Question 21
Type: MCSA
During the assessment of a clients respiratory system, the nurse determines that the clients
expiration phase is the same length as the inspiration phase. The clients respiratory rate is 14 per
minute. The nurse would document this finding as:
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1. obstructive breathing.
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2. bradypnea.
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3. respiratory distress.
4. normal.
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Correct Answer: 4
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Rationale 1: A client exhibiting obstructive breathing will have a prolonged expiration.
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Rationale 2: Bradypnea is a term used to describe slow, regular respirations that are less than 10
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per minute.
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Rationale 3: These findings do not indicate that the client is experiencing respiratory distress.
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Rationale 4: The finding describes eupnea, which is a normal breathing pattern.
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Global Rationale: The finding describes eupnea, which is a normal breathing pattern.
Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute.
A client exhibiting obstructive breathing will have a prolonged expiration. These findings do not
indicate that the client is experiencing respiratory distress.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
Question 22
Type: MCSA
The nurse is preparing to assess an elderly client with emphysema. Which of the following
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anatomical changes would the nurse expect to find in this client?
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1. Funnel chest
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2. Barrel chest
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3. Pigeon chest
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4. Scoliosis
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Correct Answer: 2
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and adjacent costal cartilage.
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Rationale 1: Funnel chest is a congenital deformity characterized by depression of the sternum
Rationale 2: Clients with chronic obstructive pulmonary disease often have barrel chests. Aging
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can result in a barrel chest.
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Rationale 3: Pigeon chest is a congenital deformity that is characterized by forward
displacement of the sternum with depression of the adjacent costal cartilage.
Rationale 4: Scoliosis is a condition in which there is lateral curvature and rotation of the
thoracic and lumbar spine.
Global Rationale: Clients with chronic obstructive pulmonary disease often have barrel chests.
Aging can result in a barrel chest. Funnel chest is a congenital deformity characterized by
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depression of the sternum and adjacent costal cartilage. Pigeon chest is a congenital deformity
that is characterized by forward displacement of the sternum with depression of the adjacent
costal cartilage. Scoliosis is a condition in which there is lateral curvature and rotation of the
thoracic and lumbar spine.
Cognitive Level: Understanding
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
Question 23
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Type: MCSA
A client is demonstrating a diminished ability to exhale. The nurse realizes this client is at risk
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for developing:
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1. Pleurisy.
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2. Congestive heart failure.
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3. Increased carbon dioxide levels.
4. Reduced oxygen capacity.
Correct Answer: 3
Rationale 1: Pleurisy results in pleuritic pain.
Rationale 2: This client is not at risk for developing congestive heart failure.
Rationale 3: During expiration, the carbon dioxide is expelled. Poor exhalation leads to retention
of carbon dioxide.
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Rationale 4: The clients oxygen capacity at this time is increased.
Global Rationale: During expiration, the carbon dioxide is expelled. Poor exhalation leads to
retention of carbon dioxide. Pleurisy results in pleuritic pain. This client is not at risk for
developing congestive heart failure. The clients oxygen capacity at this time is increased.
Cognitive Level: Remembering
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
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Question 24
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Type: MCSA
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A client with chronic bronchitis has been admitted to the hospital. The nurse inspects the client
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while assessing the clients respiratory system. Which of the following would be an expected
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finding?
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1. Fever
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2. Decreased respiratory rate
3. Use of accessory muscles
4. Dry cough
Correct Answer: 3
Rationale 1: The client will not typically experience a fever. Fevers are associated with
infections.
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Rationale 2: The respiratory rate may be elevated to compensate for the inability to breathe
properly.
Rationale 3: Chronic inflammation of the tracheobronchial tree leads to increased mucous
production and blocked airways, causing decreased air movement in and out of the alveoli,
which in turn causes the clients respiratory rate to increase in order to compensate. The muscles
of the chest wall work harder to try to pull more air into the alveoli, which causes increased chest
wall expansion. The use of accessory muscles to breathe may be noted.
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Rationale 4: This client will most likely exhibit a chronic productive cough.
Global Rationale: Chronic inflammation of the tracheobronchial tree leads to increased mucous
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production and blocked airways, causing decreased air movement in and out of the alveoli,
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which in turn causes the clients respiratory rate to increase in order to compensate. The muscles
of the chest wall work harder to try to pull more air into the alveoli, which causes increased chest
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wall expansion. The use of accessory muscles to breathe may be noted. The client will not
typically experience a fever. Fevers are associated with infections. The respiratory rate may be
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elevated to compensate for the inability to breathe properly. This client will most likely exhibit a
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Cognitive Level: Applying
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chronic productive cough.
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.
Question 25
Type: MCSA
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A 4-year-old childs respiratory rate is 30 per minute. The mother states, That seems like a really
high number. My healthcare provider told me my respiratory rate is only 16 per minute. Which
of the following is the nurses best response?
1. This is a normal finding for your childs age.
2. Your child is exhibiting a sign of a respiratory infection.
3. Your child requires further assessment.
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4. Your child may simply be anxious.
Correct Answer: 1
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Rationale 1: It is normal for children up to the age of 5 to have respiratory rates of up to 35 per
minute.
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Rationale 2: This child is not exhibiting a sign of a respiratory infection.
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Rationale 3: This respiratory rate is normal for this childs age. The child does not require further
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assessment.
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Rationale 4: This respiratory rate is normal for this childs age. The childs respiratory rate will
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increase with anxiety and the child may exhibit tachypnea.
Global Rationale: It is normal for children up to the age of 5 to have respiratory rates of up to
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35 per minute. The other explanations are not appropriate for this situation. This child is not
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exhibiting a sign of a respiratory infection. This respiratory rate is normal for this childs age. The
child does not require further assessment. The childs respiratory rate will increase with anxiety
and the child may exhibit tachypnea.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
Question 26
Type: MCSA
The client is 36 weeks pregnant. The nurse is assessing the clients respiratory system and finds
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that her respiratory rate is 24 breaths per minute. The client states that she sometimes
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1. You have developed asthma during your pregnancy.
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experiences shortness of breath. Which of the following is the nurses best response?
2. During your last trimester, it is normal for you to feel short of breath and to have a faster
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respiratory rate.
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3. Im going to have to notify your healthcare provider right now about these findings.
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4. You have been infected with tuberculosis.
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Correct Answer: 2
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Rationale 1: The pregnant client has not developed asthma. Asthma is a chronic hyperreactive
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condition resulting in bronchospasm, mucosal edema, and increased mucus secretion. Usually
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occurs in response to inhaled irritants or allergens.
Rationale 2: Shortness of breath, dyspnea, and an increased respiratory are normal findings
during the last trimester of pregnancy as the womans chest expands to accommodate the growing
baby.
Rationale 3: These are normal findings for this pregnant client and the healthcare provider
would not need to be notified.
Rationale 4: The client has not developed tuberculosis.
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Global Rationale: Shortness of breath, dyspnea, and an increased respiratory are normal
findings during the last trimester of pregnancy as the womans chest expands to accommodate the
growing baby. The pregnant client has not developed asthma. Asthma is a chronic hyperreactive
condition resulting in bronchospasm, mucosal edema, and increased mucus secretion. Usually
occurs in response to inhaled irritants or allergens. These are normal findings for this pregnant
client and the healthcare provider would not need to be notified. The client has not developed
tuberculosis.
Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental
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variations in assessment techniques and findings.
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Question 27
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Type: MCSA
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The nurse is percussing the anterior chest of an elderly client. Which of the following would the
2. Dullness
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1. Flatness
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nurse expect to find in this client?
3. Tympany
4. Hyperresonance
Correct Answer: 4
Rationale 1: Percussion over bone will yield flat sounds.
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Rationale 2: Percussion over solid organs or bones will yield a dull sound.
Rationale 3: Tympany is heard when percussion is performed over an air bubble.
Rationale 4: As a client ages, the function of the respiratory system becomes less efficient. The
older adults lungs lose their elasticity, muscles begin to weaken, and bones lose their density.
Trapping of air in the alveoli will produce a hyperresonance sound upon percussion of the chest.
Global Rationale: As a client ages, the function of the respiratory system becomes less efficient.
The older adults lungs lose their elasticity, muscles begin to weaken, and bones lose their
density. Trapping of air in the alveoli will produce a hyperresonance sound upon percussion of
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the chest. Percussion over bone will yield flat sounds. Tympany is heard when percussion is
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performed over an air bubble. Percussion over solid organs or bones will yield a dull sound.
Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental
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Type: MCSA
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Question 28
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variations in assessment techniques and findings.
The nurse is caring for a teenager recently hospitalized with asthma. Several peers are preparing
to visit the client and have brought gifts for the client. The nurse intervenes and prevents which
of the following items from being brought into the patients room?
1. Magazines
2. Candy
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3. MP3 player
4. Fresh flowers
Correct Answer: 4
Rationale 1: Magazines would be an appropriate gift for this client.
Rationale 2: Candy would be an appropriate gift for this client.
Rationale 3: An MP3 player would be an appropriate gift for this client.
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Rationale 4: Limiting exposure to allergens, pollutants, and irritants in the clients environment is
important to control and limit problems associated with respiratory health. Assessment must
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identify exposure to irritants such as dust, tobacco, smoke, pollen, smog, asbestos, and vapors
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from household cleaners. The clients friends should be prevented from bringing anything in the
room that may expose the client to anything that is known to be a trigger for the condition.
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Global Rationale: Limiting exposure to allergens, pollutants, and irritants in the clients
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environment is important to control and limit problems associated with respiratory health.
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Assessment must identify exposure to irritants such as dust, tobacco, smoke, pollen, smog,
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asbestos, and vapors from household cleaners. The clients friends should be prevented from
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bringing anything in the room that may expose the client to anything that is known to be a trigger
for the condition. Objects void of any irritant would be the best selection for a gift. Magazines,
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candy, and an MP3 player would all be appropriate gifts for this client.
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Chapter 13. Assessing the Cardiovascular System
Question 1
Type: MCSA
The nurse who works on a cardiac unit is teaching the student nurse about heart sounds. The
student nurse asks how the S1 heart sound is produced. Which of the following is the nurses best
response?
1. It results from the closure of the semilunar valves.
2. It is heard when the aortic valve closes just slightly faster than the pulmonic valve.
3. It results from the closure of the atrioventricular valves.
4. It is caused by atrial contraction and ejection of blood into the ventricles in late diastole.
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Correct Answer: 3
Rationale 1: The S2 sounds results from the closure of the semilunar valves. The semilunar
valves include the aortic and pulmonic valves.
Rationale 2: A splitting of the S2 occurs toward the end of inspiration in some individuals. This
results from a slight difference between the time the aortic and pulmonic valves close.
Rationale 3: The S1 heart sound results from closure of the atrioventricular (AV) valves.
Rationale 4: The S4 sound may be heard in children, well-conditioned athletes, and healthy
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elderly individuals without cardiac disease. It is caused by atrial contraction and ejection of
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blood into the ventricles in late diastole.
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Global Rationale: The S2 sounds results from the closure of the semilunar valves. The
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semilunar valves include the aortic and pulmonic valves. A splitting of the S2 occurs toward the
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end of inspiration in some individuals. This results from a slight difference between the time the
aortic and pulmonic valves close. The S1 heart sound results from closure of the atrioventricular
(AV) valves. The S4 sound may be heard in children, well-conditioned athletes, and healthy
elderly individuals without cardiac disease. It is caused by atrial contraction and ejection of
blood into the ventricles in late diastole.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 17.1: Identify the anatomy and physiology of the cardiovascular system.
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Question 2
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Type: HOTSPOT
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The clients healthcare provider determines that the clients left ventricle is functioning
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adequately. Identify the left ventricle by drawing an arrow to it.
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Standard Text: Select the correct area on the image.
Correct Answer:
Rationale :
Global Rationale:
Cognitive Level: Remembering
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Client Need: Physiological Integrity
Learning Outcome: 17.1: Identify the anatomy and physiology of the cardiovascular system.
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Question 3
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Type: FIB
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The clients stroke volume is 72 ml/beat. The clients heart rate is 82 beats per minute.
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What is the clients cardiac output?
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Standard Text:
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Correct Answer: 5904 mL per minute.
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Rationale: Stroke volume describes the amount of blood that is ejected with every heartbeat.
Normal stroke volume is 55 to 100 ml/beat. Cardiac output describes the amount of blood ejected
from the left ventricle over 1 minute. Normal adult cardiac output is 4 to 8 liters per minute. The
formula for calculating cardiac output is: cardiac output = stroke volume multiplied by heart rate
for 1 minute.
72 ml/ beat x 82 beats/ minute= 5904 mL/ minute
Global Rationale:
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.1: Identify the anatomy and physiology of the cardiovascular system.
Question 4
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Type: HOTSPOT
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clients chest. Draw an arrow pointing to this area.
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The nurse is performing a cardiac assessment and prepares to palpate the clients heartbeat on the
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : The point of maximal impulse or PMI is located at the fifth intercostal space at the
midclavicular line.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 17.2: Recognize landmarks that guide assessment of the cardiovascular
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system.
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Question 5
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Type: HOTSPOT
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The nurse is reviewing the clients chart. The clients blood pressure has been consistently
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elevated over the last eight years. The client has been noncompliant with lifestyle changes and
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medication use designed to reduce the clients blood pressure. Today, the nurse is able to palpate
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a heave on the clients chest. Draw an arrow to the most likely location that the nurse is able to
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palpate the heave.
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : Pulsations or heaves palpated at the right sternal border in the second intercostal
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space are associated with systemic hypertension.
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Global Rationale:
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 17.2: Recognize landmarks that guide assessment of the cardiovascular
system.
Question 6
Type: MCMA
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During the focused interview, the client answers the nurses questions. Which of the following
statements by the client suggests that the client has an increased risk of developing
cardiovascular disease?
Standard Text: Select all that apply.
1. I have been stressed out since my divorce last year.
2. Im what you call a Type C personality.
4. On my new diet, I can eat only grains and vegetables.
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5. I think about my job all of the time.
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3. I went on this new diet because I gained 30 pounds in the last 9 months.
Correct Answer: 1,3,4,5
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Rationale 1: I have been stressed out since my divorce last year. Psychosocial problems and
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excessive stress can increase the clients risk for developing cardiovascular disease.
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Rationale 2: Im what you call a Type C personality. Type A personalities tend to develop
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cardiovascular disease more often than people with other personality types.
Rationale 3: I went on this new diet because I gained 30 pounds in the last 9 months.
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Obesity and a high percentage of body fat are risk factors for cardiovascular disease. Weight gain
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may accompany physical problems including systemic diseases such as diabetes, which increases
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this clients risk for developing cardiovascular disease.
Rationale 4: On my new diet, I can eat only grains and vegetables. The nurse must note if the
client has been dieting to reduce weight. Many diets deplete valuable electrolytes and subject the
client to potential complications. Muscle wasting may occur if the diet is deficient in protein.
Lack of protein may compromise cardiac function.
Rationale 5: I think about my job all of the time. Stress increases the stimulation of the clients
sympathetic nervous system and can increase the clients risk for developing cardiovascular
disease.
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Global Rationale: Psychosocial problems and excessive stress can increase the stimulation of
the clients sympathetic nervous system, thereby increasing the clients risk for developing
cardiovascular disease. Type A personalities tend to develop cardiovascular disease more often
than people with other personality types. Obesity and a high percentage of body fat are risk
factors for cardiovascular disease. Weight gain may accompany physical problems including
systemic diseases such as diabetes, which increases this clients risk for developing
cardiovascular disease. The nurse must note if the client has been dieting to reduce weight. Many
diets deplete valuable electrolytes and subject the client to potential complications. Muscle
wasting may occur if the diet is deficient in protein. Lack of protein may compromise cardiac
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function.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 17.3: Develop questions to be used when completing the focused interview.
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Question 7
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Type: MCSA
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During the focused interview, the client makes the following statements. Which of the following
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statements indicates that the client has an increased risk of developing cardiovascular disease?
1. I was diagnosed with hypothyroidism about 5 years ago.
2. My doctor always tells me when I come in that my blood pressure is low.
3. I know my grandmother had diabetes, but every time it has been checked mine has been
normal.
4. My total cholesterol has always been around 170.
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Correct Answer: 1
Rationale 1: Hypothyroidism may increase the clients risk for developing cardiovascular
disease.
Rationale 2: Hypertension, not hypotension, is associated with the development of
cardiovascular disease.
Rationale 3: Normal serum glucose levels indicate that the client does not currently have
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diabetes and so this clients risk is not necessarily increased.
Rationale 4: The clients total cholesterol level is within normal limits. High cholesterol levels
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would increase the clients risk for developing cardiovascular disease.
Global Rationale: Hypothyroidism may increase the clients risk for developing cardiovascular
disease. Hypertension, not hypotension, is associated with the development of cardiovascular
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disease. Normal serum glucose levels indicate that the client does not currently have diabetes and
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so this clients risk is not necessarily increased. The clients total cholesterol level is within normal
limits. High cholesterol levels would increase the clients risk for developing cardiovascular
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Cognitive Level: Applying
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disease.
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 17.3: Develop questions to be used when completing the focused interview.
Question 8
Type: MCSA
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The nurse is performing a focused interview with an adult male client who recently experienced
a myocardial infarction. The nurse requests information about how he felt during the time of the
myocardial infarction. Which of the following client statements would be unexpected?
1. I couldnt catch my breath.
2. My chest didnt actually ever hurt.
3. My wife said I looked like someone poured water all over me.
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4. I got so sick to my stomach.
Correct Answer: 2
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Rationale 1: Typically males who are experiencing a myocardial infarction will complain of
dyspnea.
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Rationale 2: Typically males who are experiencing a myocardial infarction will complain of
chest pain that is prolonged, dull, and radiates to the shoulder or jaw. Females are more likely to
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experience nausea and vomiting, indigestion, shortness of breath or extreme fatigue, without
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actual chest pain.
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Rationale 3: In males, the pain of MI is often accompanied by diaphoresis.
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Rationale 4: In males, the pain of MI is often accompanied by nausea.
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Global Rationale: Typically males who are experiencing a myocardial infarction will complain
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of dyspnea, and chest pain that is prolonged, dull, and radiates to the shoulder or jaw. In males,
the pain is often accompanied by diaphoresis and they may complain of nausea. Females are
more likely to experience nausea and vomiting, indigestion, shortness of breath or extreme
fatigue, without actual chest pain.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 17.3: Develop questions to be used when completing the focused interview.
Question 9
Type: MCSA
The nurse is interviewing a client who has recently been diagnosed with atherosclerosis in the
clients coronary arteries. Which of the following questions by the nurse has the highest priority
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to help the nurse determine the clients most important risk factor for this condition?
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2. Have you ever been diagnosed with rheumatic fever?
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1. Can you please tell me about the vitamins or supplements that you take?
3. Do you smoke or are you exposed to secondhand smoke?
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4. Have you ever had a diagnostic test, such as an electrocardiogram, stress test, or
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echocardiogram, or a surgical procedure for a cardiovascular problem?
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Correct Answer: 3
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Rationale 1: Information about vitamin and supplement use is important but is not specifically
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related to atherosclerosis and coronary artery disease.
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Rationale 2: A history of rheumatic fever can increase the clients risk for valvular problems but
disease.
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does not necessarily increase the clients risk for developing atherosclerosis and coronary artery
Rationale 3: The most important question regarding this clients history and recent diagnosis is
about exposure to cigarettes smoke. The chemical contained in the cigarette smoke injures the
inner wall of arterial vessels and contributes to the subsequent development of a coronary artery
plaque.
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Rationale 4: Diagnostic testing may help the nurse determine if there was a previous suspicion
that the client had developed a cardiovascular problem, but is not specifically related to coronary
artery disease and atherosclerosis.
Global Rationale: Information about vitamin and supplement use is important but is not
specifically related to atherosclerosis and coronary artery disease. A history of rheumatic fever
can increase the clients risk for valvular problems but does not necessarily increase the clients
risk for developing atherosclerosis and coronary artery disease. The most important question
regarding this clients history and recent diagnosis is about exposure to cigarettes smoke. The
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chemical contained in the cigarette smoke injures the inner wall of arterial vessels and
contributes to the subsequent development of a coronary artery plaque. The question regarding
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diagnostic testing may help the nurse determine if there was a previous suspicion that the client
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had developed a cardiovascular problem, but is not specifically related to coronary artery disease
and atherosclerosis.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 17.3: Develop questions to be used when completing the focused interview.
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Question 10
Type: MCMA
The nurse is preparing to assess the female clients cardiovascular system during the clients visit
to the healthcare providers office. Which of the following items should the nurse have available
in the room in order to complete the examination?
Standard Text: Select all that apply.
1. Ruler (metric)
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2. Stethoscope
3. Lamp
4. Client gown and a drape
5. Doppler
Correct Answer: 1,2,3,4,5
Rationale 1: Ruler (metric). The nurse will require a metric ruler to determine distention of
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blood vessels.
Rationale 2: Stethoscope. The nurse will require a stethoscope to auscultate the clients heart and
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arteries.
Rationale 3: Lamp. The nurse will require a lamp or adequate lighting in the room for the
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inspection process of the assessment.
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Rationale 4: Client gown and a drape. Female clients should be provided with a gown and a
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drape for this examination in order to maintain privacy and avoid overexposure.
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Rationale 5: Doppler. A Doppler device can be used to determine the presence of a pulse if the
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nurse is unable to adequately palpate the pulse.
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Global Rationale: The nurse will require a metric ruler to determine distention of blood vessels.
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The nurse will require a stethoscope to auscultate the clients heart and arteries. The nurse will
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require a lamp or adequate lighting in the room for the inspection process of the assessment.
Female clients should be provided with a gown and a drape for this examination in order to
maintain privacy and avoid overexposure. A Doppler device can be used to determine the
presence of a pulse if the nurse is unable to adequately palpate the pulse.
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.4: Explain client preparation for assessment of the cardiovascular
system.
Question 11
Type: MCMA
The nurse is preparing to assess the clients cardiovascular system. Which of the following
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positions will the nurse need to place the client in during the assessment?
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Standard Text: Select all that apply.
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1. Dorsal recumbent
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2. Leaning forward
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3. Right lateral position
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4. Left lateral position
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Correct Answer: 1,2,4,5
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5. Sitting upright
Rationale 1: Dorsal recumbent. The client will be asked to remain in a supine position or
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dorsal recumbent position for part of the examination. The nurse may be able to auscultate
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murmurs better while the client is in this position.
Rationale 2: Leaning forward. The client will be asked to lean forward during auscultation of
the heart. The nurse should listen to the clients heart while the client is leaning forward.
Rationale 3: Right lateral position. This is not a common position to place the client in during
this type of examination.
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Rationale 4: Left lateral position. The client will be asked to lie on the left side during part of
this examination. In obese clients, heart sounds are best heard at the apical area with the client in
the left lateral position.
Rationale 5: Sitting upright. The nurse will most likely begin this examination while the client
is in this position. This is the position the nurse should ask the client to assume when beginning
chest auscultation.
Global Rationale: The nurse will most likely begin this examination with the client sitting
upright. This is the position the nurse should ask the client to assume when beginning chest
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auscultation. The client will be asked to remain in a supine position or dorsal recumbent position
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for part of the examination. The nurse may be able to auscultate murmurs better while the client
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is in this position. The client will be asked to lean forward during auscultation of the heart. The
nurse should listen to the clients heart while the client is leaning forward. The client will be
asked to lie on the left side during part of this examination. In obese clients, heart sounds are best
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heard at the apical area with the client in the left lateral position. Right lateral position is not a
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common position to place the client in during this type of examination.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.4: Explain client preparation for assessment of the cardiovascular
system.
Question 12
Type: SEQ
The nurse is preparing to perform a cardiac assessment on a client. Rank the following pieces of
the assessment in order of occurrence.
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Standard Text: Click and drag the options below to move them up or down.
Choice 1. Auscultation of the clients heart, apical pulse, and carotid arteries
Choice 2. Inspection of the clients head and neck, chest, abdomen, and extremities
Choice 3. Percussion of the clients chest
Choice 4. Palpation of the precordium and pulses
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Correct Answer: 2,4,3,1
Rationale 1: The fourth of these steps is auscultation. Auscultation includes the heart in five
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areas with the diaphragm and the bell of the stethoscope. The carotid arteries and the apical pulse
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are auscultated.
Rationale 2: The first of these steps is inspection of the clients head and neck. The upper
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extremities, chest, abdomen, and lower extremities are also inspected.
Rationale 3: The third of these steps is percussion, which is conducted to determine the cardiac
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borders.
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Rationale 4: The second of these steps is palpation. Palpation includes the precordium and
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carotid pulses.
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Global Rationale: Physical assessment of the cardiovascular system follows an organized
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pattern. It begins with inspection of the clients head and neck. The upper extremities, chest,
abdomen, and lower extremities are also inspected. Palpation includes the precordium and
carotid pulses. Percussion of the chest is conducted to determine the cardiac borders.
Auscultation includes the heart in five areas with the diaphragm and the bell of the stethoscope.
The carotid arteries and the apical pulse are auscultated.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.5: Describe the techniques required for assessment of the cardiovascular
system.
Question 13
Type: MCMA
The student nurse is assessing the clients cardiovascular system while the experienced nurse
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observes. The employment of which of the following techniques by the student nurse indicate the
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need for further education?
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Standard Text: Select all that apply.
1. The client complains of discomfort while lying flat. The student nurse auscultates the clients
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chest quickly while the client continues to lie flat.
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2. The student nurse determines that the apical impulse is located at the fifth intercostal space at
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the midclavicular line.
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3. The student nurse examines the clients legs and notes that the clients hair is evenly distributed.
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4. The student nurse gently palpates the clients carotid arteries simultaneously to determine pulse
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strength, rhythm, and rate.
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5. The student nurse examines the clients hands and fingers and notes the presence of clubbing.
Correct Answer: 1,4
Rationale 1: The client complains of discomfort while lying flat. The student nurse
auscultates the clients chest quickly while the client continues to lie flat. If the client
complains of any discomfort during the examination, the nurse should pause the examination and
the client should be assisted into a more comfortable position for the rest of the examination. Not
all clients will be able to assume every position associated with this examination.
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Rationale 2: The student nurse determines that the apical impulse is located at the fifth
intercostal space at the midclavicular line. This is normally where the point of maximal
impulse can be palpated.
Rationale 3: The student nurse examines the clients legs and notes that the clients hair is
evenly distributed. This is an appropriate part of the examination. Patchy hair distribution can
indicate that there is a circulatory problem.
Rationale 4: The student nurse gently palpates the clients carotid arteries simultaneously to
determine pulse strength, rhythm, and rate. The carotid pulses must never be palpated
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simultaneously since this may obstruct blood flow to the brain, resulting in severe bradycardia or
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asystole.
Rationale 5: The student nurse examines the clients hands and fingers and notes the
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existence of peripheral circulatory problems.
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presence of clubbing. It is appropriate to examine the clients hands and fingers to determine the
Global Rationale: If the client complains of any discomfort during the examination, the nurse
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should pause the examination and the client should be assisted into a more comfortable position
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for the rest of the examination. Not all clients will be able to assume every position associated
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with this examination. If the student nurse has determined the apical impulse to be located at the
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fifth intercostal space at the midclavicular line, this is normal. Examining the clients legs and
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noting that the clients hair is evenly distributed is an appropriate part of the examination. Patchy
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hair distribution can indicate that there is a circulatory problem. The carotid pulses must never be
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palpated simultaneously since this may obstruct blood flow to the brain, resulting in severe
bradycardia or asystole. It is appropriate to examine the clients hands and fingers to determine
the existence of peripheral circulatory problems.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 17.5: Describe the techniques required for assessment of the cardiovascular
system.
Question 14
Type: HOTSPOT
The client has a history of rheumatic fever. Draw an arrow pointing to the layer of the heart that
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is most at risk for damage due to this infection.
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Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : Strep infections can cause rheumatic fever. Rheumatic fever can damage the clients
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endocardium. The endocardium makes up the innermost layer of the heart and valve tissue.
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Global Rationale:
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Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.
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Question 15
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Type: MCSA
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The nurse is percussing the clients anterior chest and notes a dull sound over an area where lung
tissue is normally found. Which of the following would the nurse associate with this finding?
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1. This is a normal finding.
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4. The client has a pulse deficit.
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3. The client has developed a murmur.
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2. The clients heart may be enlarged.
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Correct Answer: 2
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Rationale 1: This is not a normal finding. When the nurse percusses over lung tissue, the sound
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should be described as resonant.
Rationale 2: An enlarged heart emits a dull sound on percussion over a larger area than a heart
of normal size.
Rationale 3: Murmurs can be determined during auscultation of the heart.
Rationale 4: A pulse deficit is present when the apical pulse is greater than the carotid pulse.
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Global Rationale: This is not a normal finding. When the nurse percusses over lung tissue, the
sound should be described as resonant. An enlarged heart emits a dull sound on percussion over
a larger area than a heart of normal size. Murmurs can be determined during auscultation of the
heart. A pulse deficit is present when the apical pulse is greater than the carotid pulse.
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.
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Question 16
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Type: MCSA
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The nurse is performing a cardiac assessment on a 70-year-old client admitted with hypertension.
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The nurse determines that the apical impulse can be palpated in an area 2 cm in diameter at the
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point of maximal impulse. The nurse suspects that the client may have developed which of the
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following problems?
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1. Left ventricular hypertrophy
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2. Aortic stenosis
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3. Right ventricular volume overload
4. Enlarged left atrium
Correct Answer: 1
Rationale 1: If the apical impulse can be palpated in an area greater than 1 cm in diameter or is
laterally displaced, the conditions that may be present include left ventricular hypertrophy,
severe left ventricular volume overload, or severe aortic regurgitation.
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Rationale 2: Clients with aortic stenosis often have heaves present at the right sternal border,
second intercostal space.
Rationale 3: The presence of heaves or thrills in the subxiphoid area suggests the presence of
right ventricular volume overload.
Rationale 4: Pulsations or heaves in the left sternal border, second intercostal space, are
associated with an enlarged left atrium.
Global Rationale: If the apical impulse can be palpated in an area greater than 1 cm in diameter
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or is laterally displaced, the conditions that may be present include left ventricular hypertrophy,
severe left ventricular volume overload, or severe aortic regurgitation. Clients with aortic
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stenosis often have heaves present at the right sternal border, second intercostal space. The
presence of heaves or thrills in the subxiphoid area suggests the presence of right ventricular
volume overload. Pulsations or heaves in the left sternal border, second intercostal space, are
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Client Need: Physiological Integrity
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Cognitive Level: Applying
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associated with an enlarged left atrium.
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Question 17
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Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.
Type: MCSA
A 39-year-old client has been admitted to the hospital with complaints of increasing fatigue. The
history is remarkable for rheumatic fever as a child. The nurse hears a diastolic murmur at the
apex when the client is in the left lateral position. The murmur is described as a rumble without
radiation. This description is most consistent with:
1. tricuspid regurgitation.
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2. mitral regurgitation.
3. mitral stenosis.
4. pulmonic stenosis.
Correct Answer: 3
Rationale 1: The murmur associated with tricuspid regurgitation is often described as systolic,
blowing, high-pitched, and may radiate.
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Rationale 2: Mitral regurgitation is a high-pitched, blowing, harsh, systolic murmur with
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radiation to the left axilla.
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Rationale 3: The murmur associated with mitral stenosis is best heard with the bell of the
stethoscope at the apex while the client is placed in the left lateral position. It is a low-frequency
diastolic murmur, which does not radiate. It is often caused by rheumatic fever or a cardiac
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infection.
Rationale 4: The murmur associated with pulmonic stenosis is often described as a harsh,
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systolic murmur heard best over the pulmonic area with radiation to the neck.
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Global Rationale: The murmur associated with tricuspid regurgitation is often described as
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systolic, blowing, high-pitched, and may radiate. Mitral regurgitation is a high-pitched, blowing,
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harsh, systolic murmur with radiation to the left axilla. The murmur associated with mitral
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stenosis is best heard with the bell of the stethoscope at the apex while the client is placed in the
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left lateral position. It is a low-frequency diastolic murmur, which does not radiate. It is often
caused by rheumatic fever or a cardiac infection. The murmur associated with pulmonic stenosis
is often described as a harsh, systolic murmur heard best over the pulmonic area with radiation to
the neck.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
www.mynursingtestprep.com
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.
Question 18
Type: MCSA
During the cardiac assessment of a client, the nurse hears a loud rumbling during diastole that
increases toward the end of the sound. This sound is heard with the bell of the stethoscope over
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the lower left sternal border. The nurse would suspect which of the following in this client?
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1. Aortic stenosis
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2. Tricuspid stenosis
3. Mitral regurgitation
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4. Pulmonic stenosis
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Correct Answer: 2
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Rationale 1: The type of murmur heard with aortic stenosis occurs midsystole and is crescendo-
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decrescendo.
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Rationale 2: The sound heard in this scenario is most likely a murmur related to tricuspid
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stenosis. Tricuspid stenosis may produce a loud rumbling sound during diastole. The sound
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increases towards the end of the sound.
Rationale 3: With mitral regurgitation, the sound is heard in systole and is continuous.
Rationale 4: With pulmonary stenosis, the midsystolic sound is heard over the right sternal
border in the second intercostal space.
Global Rationale: The type of murmur heard with aortic stenosis occurs midsystole and is
crescendo-decrescendo. The sound heard in this scenario is most likely a murmur related to
tricuspid stenosis. Tricuspid stenosis may produce a loud rumbling sound during diastole. The
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sound increases toward the end of the sound. With mitral regurgitation, the sound is heard in
systole and is continuous. With pulmonary stenosis, the midsystolic sound is heard over the right
sternal border in the second intercostal space.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.
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Question 19
Type: MCSA
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The Intensive Care Unit nurse is performing a cardiac assessment on a newly admitted 72-year-
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old client and notes the following findings: peripheral edema, jugular venous distention of 5 cm
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above the sternal angle when the client is at a 45 degree angle, and an enlarged liver. These
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findings are most consistent with which of the following disorders?
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1. Pulmonary edema
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2. Left-sided heart failure
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3. Myocardial infarction
4. Right-sided heart failure
Correct Answer: 4
Rationale 1: Left-sided heart failure results in pulmonary congestion and pulmonary edema as
blood backs up into the pulmonary system.
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Rationale 2: Left-sided heart failure results in pulmonary congestion and pulmonary edema as
blood backs up into the pulmonary system.
Rationale 3: Heart failure may be caused by a myocardial infarction. However, the clinical
manifestations associated with heart failure are not always the result of a myocardial infarction.
Rationale 4: With right-sided heart failure, the right ventricle is ineffective as a pump, which
leads to congestion as blood backs up into the systemic circulation. Right-sided heart failure
results in increased jugular vein distention. This is a reflection of the increased pressure in the
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right atrium. Right-sided heart failure also results in peripheral edema and liver enlargement.
Global Rationale: Left-sided heart failure results in pulmonary congestion and pulmonary
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edema as blood backs up into the pulmonary system. Heart failure may be caused by a
myocardial infarction. However, the clinical manifestations associated with heart failure are not
always the result of a myocardial infarction. With right-sided heart failure, the right ventricle is
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ineffective as a pump, which leads to congestion as blood backs up into the systemic circulation.
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Right-sided heart failure results in increased jugular vein distention. This is a reflection of the
increased pressure in the right atrium. Right-sided heart failure also results in peripheral edema
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Cognitive Level: Understanding
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and liver enlargement.
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.
Question 20
Type: MCSA
The nurse is assessing a client and notes a loud, blowing sound over the right carotid artery. The
nurse would suspect the client has developed which of the following disorders?
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1. Mitral stenosis
2. Aortic regurgitation
3. Atrial septal defect
4. Stricture of the carotid
Correct Answer: 4
Rationale 1: Mitral stenosis is a narrowing of the left mitral valve. In a client with mitral
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stenosis, there is often a murmur heard at the apical area with the client in left lateral position.
Rationale 2: Aortic regurgitation is the backflow of blood from the aorta into the left ventricle.
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With aortic regurgitation, a murmur may be heard when the client is leaning forward, at the
second intercostal space.
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Rationale 3: With an atrial septal defect, there is an opening between the right and left atrium.
Regurgitation occurs through this defect resulting in a harsh, loud, high-pitched murmur heard at
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the left sternal border at the second intercostal space.
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Rationale 4: A bruit, which is a loud swishing or blowing sound, is most often associated with a
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narrowing or stricture of the carotid artery. The most common cause for this is atherosclerosis.
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Global Rationale: Mitral stenosis is a narrowing of the left mitral valve. In a client with mitral
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stenosis, there is often a murmur heard at the apical area with the client in left lateral position.
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Aortic regurgitation is the backflow of blood from the aorta into the left ventricle. With aortic
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regurgitation, a murmur may be heard when the client is leaning forward, at the second
intercostal space. With an atrial septal defect, there is an opening between the right and left
atrium. Regurgitation occurs through this defect resulting in a harsh, loud, high-pitched murmur
heard at the left sternal border at the second intercostal space. A bruit, which is a loud swishing
or blowing sound, is most often associated with a narrowing or stricture of the carotid artery. The
most common cause for this is atherosclerosis.
Cognitive Level: Remembering
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.
Question 21
Type: MCMA
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nurse would suspect which of the following cardiac conditions?
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The nurse is caring for a client admitted with a grade 3 heart murmur heard during systole. The
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Standard Text: Select all that apply.
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1. Mitral regurgitation
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2. Mitral stenosis
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3. Aortic stenosis
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4. Pulmonic stenosis
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Correct Answer: 1,3,4
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5. Tricuspid stenosis
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Rationale 1: Mitral regurgitation. A grade 3 murmur can be heard clearly and the nurse should
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be able to categorize the murmur easily. The murmur associated with mitral regurgitation can be
heard during systole.
Rationale 2: Mitral stenosis. The murmur associated with mitral stenosis can be heard during
diastole.
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Rationale 3: Aortic stenosis. Midsystolic murmurs are associated with semilunar valve
disorders. This murmur is heard during midsystole and this can be associated with aortic
stenosis.
Rationale 4: Pulmonic stenosis. Midsystolic murmurs are associated with semilunar valve
disorders. This murmur is heard during midsystole and this can be associated with pulmonic
stenosis.
Rationale 5: Tricuspid stenosis. The murmur associated with tricuspid stenosis can be heard
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during diastole.
Global Rationale: The murmur associated with mitral regurgitation can be heard during systole.
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Midsystolic murmurs are associated with semilunar valve disorders. This murmur is heard during
midsystole and this can be associated with pulmonic or aortic stenosis. The murmur associated
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tricuspid stenosis can be heard during diastole.
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Client Need: Physiological Integrity
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with mitral or tricusid stenosis can be heard during diastole. The murmur associated with
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Question 22
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Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.
Type: MCMA
The nurse is assessing a 20-year-old client and notes the presence of bilateral earlobe creases.
The nurse would choose which of the following actions?
Standard Text: Select all that apply.
1. Refer the client to a plastic surgeon.
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2. Document this finding as normal.
3. Document the finding and notify the healthcare provider.
4. Ask the client about any history of injuries to his ears.
5. Assess the clients risk factors for coronary artery disease.
Correct Answer: 3,4,5
Rationale 1: Refer the client to a plastic surgeon. The client may have an increased risk for
developing coronary artery disease. At this point, the client does not need to be referred to a
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plastic surgeon.
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Rationale 2: Document this finding as normal. This is an abnormal finding and the client
should be carefully monitored for the development of coronary artery disease.
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Rationale 3: Document the finding and notify the healthcare provider. The nurse should
document the finding, request information from the client regarding any injuries to the ears, and
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notify the healthcare provider about the presence of the bilateral earlobe creases.
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Rationale 4: Ask the client about any history of injuries to his ears. The nurse should
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determine if the client has sustained any injuries to the ears that could account for the bilateral
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earlobe creases.
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Rationale 5: Assess the clients risk factors for coronary artery disease. The nurse should
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artery disease.
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assess the client for any other clinical manifestations and risk factors associated with coronary
Global Rationale: This is an abnormal finding and the client should be carefully monitored for
the development of coronary artery disease. The nurse should document the finding, request
information from the client regarding any injuries to the ears, and notify the healthcare provider
about the presence of the bilateral earlobe creases. The nurse should assess the client for any
other clinical manifestations and risk factors associated with coronary artery disease. At this
point, the client does not need to be referred to a plastic surgeon.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.
Question 23
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Type: MCMA
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The nurse is performing a cardiac assessment on a healthy elderly adult client. Which of the
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following findings may be expected when compared to when the client was middle-aged?
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Standard Text: Select all that apply.
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1. Systolic murmur
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4. Increased stroke volume
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3. Increased systolic blood pressure
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2. Increased cardiac output
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5. Slight decrease in heart rate
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Correct Answer: 1,3,4,5
Rationale 1: Systolic murmur. Systolic murmurs become more common as people age,
especially because of aortic stenosis.
Rationale 2: Increased cardiac output. In the healthy older adult, cardiac output remains
relatively stable.
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Rationale 3: Increased systolic blood pressure. The clients systolic blood pressure may
increase.
Rationale 4: Increased stroke volume. Stroke volume may increase slightly when the client is
at rest and during exercise.
Rationale 5: light decrease in heart rate. The healthy older adult may have an insignificant
decrease in heart rate.
Global Rationale: Systolic murmurs become more common as people age, especially because of
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aortic stenosis. In the healthy older adult, cardiac output remains relatively stable. The older
clients systolic blood pressure may increase. Stroke volume may increase slightly when the older
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client is at rest and during exercise. The healthy older adult may have an insignificant decrease in
heart rate.
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Cognitive Level: Applying
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental
Type: MCSA
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Question 24
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variations in assessment techniques and findings.
The nurse is assessing a client who is 7 months pregnant. The nurse would document which of
the following cardiac findings as normal in this client?
1. Increased systolic and diastolic blood pressures when standing
2. Point of maximal impulse palpated at fourth intercostal space and left of midclavicular line
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3. Bradycardia
4. Diastolic murmur
Correct Answer: 2
Rationale 1: At this stage of the clients pregnancy, the blood pressure should be normal when
compared to pre-pregnancy values.
Rationale 2: During pregnancy, the heart is displaced to the left and upward and so it would be
normal to palpate the point of maximal impulse left of the midclavicular line at the fourth
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intercostal space.
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Rationale 3: The pregnancy usually results in an increase in the clients heart rate from pre-
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pregnancy values.
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Rationale 4: It is not normal to find a diastolic murmur.
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Global Rationale: At this stage of the clients pregnancy, the blood pressure should be normal
when compared to pre-pregnancy values. During pregnancy, the heart is displaced to the left and
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upward and so it would be normal to palpate the point of maximal impulse left of the
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midclavicular line at the fourth intercostal space. The pregnancy usually results in an increase in
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the clients heart rate from pre-pregnancy values. It is not normal to find a diastolic murmur.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
Question 25
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Type: MCSA
The nurse is assessing a full-term African American newborn that is 18 hours old. The nurse
would document which of the following as a normal finding?
1. Lethargy
2. Heart rate 115120
3. Bulging of the precordium
Correct Answer: 2
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Rationale 1: The infant should be easily aroused and alert.
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4. Pale conjunctiva
Rationale 2: The heart rate of a newborn initially may be as high as 175180 beats per minute but
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should decrease over the next 6 to 8 hours to about 115120 beats per minute.
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Rationale 3: Precordial bulging should always be evaluated and is never considered a normal
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finding.
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Rationale 4: The skin should demonstrate perfusion with pink quality in the nail beds, mucous
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membranes, and conjunctiva regardless of the babys race.
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Global Rationale: The infant should be easily aroused and alert. The heart rate of a newborn
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initially may be as high as 175180 beats per minute but should decrease over the next 6 to 8
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hours to about 115120 beats per minute. Precordial bulging should always be evaluated and is
never considered a normal finding. The skin should demonstrate perfusion with pink quality in
the nail beds, mucous membranes, and conjunctiva regardless of the babys race.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
Question 26
Type: MCSA
The nurse notes the pregnant clients blood pressure has dropped from 122/70 taken during her
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second month of pregnancy to 118/64 during her fifth month of pregnancy. Which of the
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following actions by the nurse is most appropriate?
2. Document the blood pressure as a normal finding .
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3. Consult the healthcare provider.
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1. Assess for signs of hemorrhage.
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4. Tell the client to come in the next day so the nurse can recheck her blood pressure.
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Correct Answer: 2
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Rationale 1: This small drop in blood pressure is expected and the nurse does not need to assess
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the client for signs of hemorrhage.
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Rationale 2: During pregnancy, there is a substantial increase in cardiac workload secondary to
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the increase in blood volume. Despite this, the systolic and diastolic blood pressures may
decrease during the first half of pregnancy. This is secondary to the peripheral vasodilatation.
During the second half of the pregnancy, the blood pressure will return to previous prepregnancy levels.
Rationale 3: The healthcare provider does not need to be consulted because this is a normal
finding.
Rationale 4: The client does not need to return to have her blood pressure checked on the
following day.
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Global Rationale: This small drop in blood pressure is expected and the nurse does not need to
assess the client for signs of hemorrhage. During pregnancy, there is a substantial increase in
cardiac workload secondary to the increase in blood volume. Despite this, the systolic and
diastolic blood pressures may decrease during the first half of pregnancy. This is secondary to
the peripheral vasodilatation. During the second half of the pregnancy, the blood pressure will
return to previous pre-pregnancy levels. The healthcare provider does not need to be consulted
because this is a normal finding. The client does not need to return to have her blood pressure
checked on the following day.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental
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variations in assessment techniques and findings.
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Question 27
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Type: MCSA
The student nurse is speaking with a nurse regarding the objectives of Healthy People 2020.
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Which of the following statements by the student nurse indicates that the student nurse requires
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further education regarding these objectives?
1. Parents of school-aged children really need to be educated about the importance of treating
strep throat.
2. African Americans really need to be educated about the symptoms associated with
hypertension.
3. People who smoke are twice as likely to die from a heart attack when compared to those who
dont smoke.
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4. African Americans can benefit greatly from education aimed at increasing their understanding
about the importance of exercise.
Correct Answer: 2
Rationale 1: It is appropriate to educate parents of school-aged children about the importance of
screening for and treating strep in their children. This can help prevent rheumatic fever and the
valvular problems that are associated with this infection.
Rationale 2: African Americans can benefit from blood pressure screening activities.
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Hypertension is often present without any symptoms so education about symptoms will not be
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particularly beneficial.
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Rationale 3: Smokers have double the mortality rate from myocardial infarction than
nonsmokers.
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Rationale 4: The impact of hypertension, diabetes, and obesity is particularly noted in African
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Americans. Exercise can reduce the risks for cardiovascular disease by promoting healthy
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weight, maintaining healthy blood pressure, and reducing the risk for development of diabetes.
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Global Rationale: It is appropriate to educate parents of school-aged children about the
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importance of screening for and treating strep in their children. This can help prevent rheumatic
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fever and the valvular problems that are associated with this infection. African Americans can
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benefit from blood pressure screening activities. Hypertension is often present without any
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symptoms so education about symptoms will not be particularly beneficial. Smokers have double
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the mortality rate from myocardial infarction than nonsmokers. The impact of hypertension,
diabetes, and obesity is particularly noted in African Americans. Exercise can reduce the risks
for cardiovascular disease by promoting healthy weight, maintaining healthy blood pressure, and
reducing the risk for development of diabetes.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.8: Discuss the objectives in Healthy People 2020 as they relate to the
cardiovascular system.
Question 28
Type: MCMA
The client is 3 months pregnant. The nurse recently reviewed the objectives of Healthy People
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adequate education has occurred according to the objectives?
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2020 regarding pregnant women. Which of the following statements by the client indicates
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Standard Text: Select all that apply.
1. I never got my rubella vaccination so Ive been staying away from my niece who has rubella.
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2. I stopped taking Accutane for my acne before we started trying to get pregnant.
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3. I have been so careful about taking my insulin now that Im pregnant.
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4. I have just one glass of wine each evening.
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Correct Answer: 1,2,3,5
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5. I had to change to a different medication to prevent my seizures before we got pregnant.
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Rationale 1: I never got my rubella vaccination so Ive been staying away from my niece
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who has rubella. Pregnant females who have not had or been immunized against rubella must
avoid contraction of the virus during the first trimester of pregnancy.
Rationale 2: I stopped taking Accutane for my acne before we started trying to get
pregnant. The use of Accutane during pregnancy can increase the risk of having a child with
congenital heart defects.
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Rationale 3: I have been so careful about taking my insulin now that Im pregnant. Females
with diabetes mellitus have an increased risk of having a child with a heart defect. Careful
regulation of the diabetes before and in early pregnancy can reduce the risk.
Rationale 4: I just have one glass of wine each evening. It is not appropriate to drink alcohol
during pregnancy because it increases the risk of having a child with birth defects.
Rationale 5: I had to change to a different medication to prevent my seizures before we got
pregnant. Some anti-seizure medications can increase the risk of having a child with a heart
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defect.
Global Rationale: Pregnant females who have not had or been immunized against rubella must
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avoid contraction of the virus during the first trimester of pregnancy. The use of Accutane during
pregnancy can increase the risk of having a child with congenital heart defects. Females with
diabetes mellitus have an increased risk of having a child with a heart defect. Careful regulation
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of the diabetes before and in early pregnancy can reduce the risk. It is not appropriate to drink
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alcohol during pregnancy because it increases the risk of having a child with birth defects. Some
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anti-seizure medications can increase the risk of having a child with a heart defect.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.8: Discuss the objectives in Healthy People 2020 as they relate to the
cardiovascular system.
Question 29
Type: MCMA
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The Emergency Department nurse determines that the client may be having a myocardial
infarction. Which of the following pieces of information indicate that the client is experiencing
an acute cardiovascular problem?
Standard Text: Select all that apply.
1. Blood pressure has dropped from normal and is 90/52.
2. Apical heart rate is 114 beats per minute.
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3. Skin is flushed and warm.
4. Respiratory rate is 28 per minute.
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5. The client is complaining of a headache.
Correct Answer: 1,2,4
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Rationale 1: Blood pressure has dropped from normal is 90/52. This client is hypotensive and
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this suggests that an acute cardiovascular problem may be occurring.
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Rationale 2: Apical heart rate is 114 beats per minute. The client is tachycardic and this is
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indicative of an acute cardiovascular problem.
Rationale 3: Skin is flushed and warm. Warm, flushed skin is not necessarily associated with
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an acute cardiovascular problem. Cyanosis, blue or gray-tinged skin, and pallor are associated
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with an acute cardiovascular problem.
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Rationale 4: Respiratory rate is 28 per minute. This client is tachypneic and this is associated
with an acute cardiovascular problem.
Rationale 5: The client is complaining of a headache. A headache is not necessarily a
symptom of an acute cardiovascular problem.
Global Rationale: This client is hypotensive and this suggests that an acute cardiovascular
problem may be occurring. The client is tachycardic and this is indicative of an acute
cardiovascular problem. Warm, flushed skin is not necessarily associated with an acute
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cardiovascular problem. Cyanosis, blue or gray-tinged skin, and pallor are associated with an
acute cardiovascular problem. This client is tachypneic and this is associated with an acute
cardiovascular problem. A headache is not necessarily a symptom of an acute cardiovascular
problem.
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Learning Outcome: 17.9: Apply critical thinking in selected simulations related to physical
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assessment of the cardiovascular system.
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Question 30
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Type: MCSA
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The client has been admitted to the Coronary Care Unit with a myocardial infarction. Which of
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the following statements by the client indicate that adequate learning has occurred?
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1. Im just sick to my stomach because I ate something that didnt agree with me.
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2. I think I must have given myself a little too much insulin this morning.
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3. Ive been breathing fast and my hearts been racing because my hearts not working right.
4. Just give me something for the nausea and I can go home.
Correct Answer: 3
Rationale 1: The client believes that the nausea is unrelated to an acute cardiovascular event
such as a myocardial infarction.
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Rationale 2: The client believes that his symptoms are related to hypoglycemia and will require
education about the seriousness of his heart condition.
Rationale 3: The client is correct when he states that his heart is not working well and his
respiratory rate and heart rate are up because of it.
Rationale 4: The client will be unable to go home until after he is stabilized and medically fit to
return home.
Global Rationale: The client does not understand the importance of the symptoms that he is
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experiencing. The client believes that the nausea is unrelated to an acute cardiovascular event
such as a myocardial infarction. The client believes that his symptoms are related to
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hypoglycemia and will require education about the seriousness of his heart condition. The client
is correct when he states that his heart is not working well and his respiratory rate and heart rate
are up because of it. The client will be unable to go home until after he is stabilized and
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medically fit to return home.
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Chapter 14. Assessing the Abdomen
Question 1
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Type: HOTSPOT
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The nurse is preparing to perform an abdominal assessment. The client states, Can you point to
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where my appendix is located? Draw an arrow to the location of the clients appendix.
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : The vermiform appendix is attached to the large intestines at the cecum.
Global Rationale:
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.
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Question 2
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Type: HOTSPOT
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The nurse is speaking with the client during the focused interview. The client states, My doctor
said that my spleen was enlarged. Where is my spleen? Draw an arrow to the location of the
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spleen.
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Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : The spleen, the largest of the lymphoid organs, is located in the left upper portion of
the abdomen directly inferior to the diaphragm.
Global Rationale:
Cognitive Level: Remembering
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.
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Question 3
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Type: MCMA
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A client asks the nurse, Whats the purpose of the liver? Which of the following statements would
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be beneficial for the nurse to share with the client?
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Standard Text: Select all that apply.
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1. It helps you digest fats.
2. It is an endocrine and exocrine gland.
3. It filters waste from the blood and makes urine.
4. It makes some blood clotting substances.
5. It can help you store certain vitamins.
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Correct Answer: 1,4,5
Rationale 1: It helps you digest fats. The liver helps the body digest fats by producing bile.
Rationale 2: It is an endocrine and exocrine gland. The pancreas is an example of an exocrine
and endocrine gland.
Rationale 3: It filters waste from the blood and makes urine. The kidneys filter nitrogen
waste from the blood and make urine.
Rationale 4: It makes some blood clotting substances. The liver makes blood clotting
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substances.
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Rationale 5: It can help you store certain vitamins. The liver can store certain types of
vitamins.
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Global Rationale: The liver produces and secretes bile for fat breakdown, but also aids in the
metabolism of proteins and carbohydrates. It stores some vitamins, helps with blood coagulation,
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produces antibodies, and detoxifies some harmful substances. The pancreas is an example of an
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Cognitive Level: Understanding
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exocrine and endocrine gland. The kidneys filter nitrogen waste from the blood and make urine.
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.
Question 4
Type: MCMA
The nurse is palpating the right upper quadrant of a clients abdomen. Which of the following
organs may be assessed during this portion of the assessment?
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Standard Text: Select all that apply.
1. Liver
2. Gallbladder
3. Appendix
4. Spleen
5. Stomach
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Correct Answer: 1,2
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Rationale 1: Liver. The liver is located in the right upper quadrant.
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Rationale 2: Gallbladder. The gallbladder is located in the right upper quadrant.
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Rationale 3: Appendix. The appendix is located in the right lower quadrant.
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Rationale 4: Spleen. The spleen is located in the left upper quadrant.
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Rationale 5: Stomach. The stomach is located in the left upper quadrant.
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Global Rationale: The liver is located in the right upper quadrant. The gallbladder is located in
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the right upper quadrant. The appendix is located in the right lower quadrant. The spleen is
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located in the left upper quadrant. The stomach is located in the left upper quadrant.
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Cognitive Level: Remembering
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.
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Question 5
Type: MCSA
A client asks the nurse, Whats the purpose of a gall bladder anyway? My mom lived for many
years without her gallbladder after she had to have it taken out. Which of the following
information would be beneficial for the nurse to share with this client?
1. You are right. We still dont know the function of the gallbladder.
3. It destroys old red blood cells.
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4. It helps you digest carbohydrates by producing enzymes.
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2. It stores bile until it is needed for digestion of fats.
Correct Answer: 2
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Rationale 1: The gallbladder does have an important function within the body.
Rationale 2: The gallbladder is used to store bile that is produced in the liver, until the bile is
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needed to help digest fats.
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Rationale 3: The spleen destroys red blood cells.
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Rationale 4: The pancreas helps the body digest carbohydrates.
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Global Rationale: The gallbladder is used to store bile. It is a thin-walled sac that is nestled in a
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shallow depression on the ventral surface of the liver. The gallbladder releases stored bile into
the duodenum when stimulated and thus promotes the emulsification of fats. The main functions
of the gallbladder are storing of bile and assisting in the digestion of fats. The spleen destroys red
blood cells. The pancreas helps the body digest carbohydrates.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen
Question 6
Type: MCMA
The nurse is palpating the left upper quadrant of a clients abdomen. Which of the following
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organs may be assessed during this portion of the assessment?
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Standard Text: Select all that apply.
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1. Liver
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2. Gallbladder
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3. Appendix
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4. Spleen
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5. Stomach
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Correct Answer: 4,5
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Rationale 1: Liver. The liver is located in the right upper quadrant.
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Rationale 2: Gallbladder. The gallbladder is located in the right upper quadrant.
Rationale 3: Appendix. The appendix is located in the right lower quadrant.
Rationale 4: Spleen. The spleen is located in the left upper quadrant.
Rationale 5: Stomach. The stomach is located in the left upper quadrant.
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Global Rationale: The spleen is located in the left upper quadrant. The stomach is located in the
left upper quadrant. The liver is located in the right upper quadrant. The gallbladder is located in
the right upper quadrant. The appendix is located in the right lower quadrant.
Cognitive Level: Remembering
Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.
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Question 7
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Type: MCMA
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The nurse is mapping the clients abdomen into four quadrants. Which of the following
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Standard Text: Select all that apply.
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landmarks would the nurse use to perform this assessment?
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3. Xiphoid process
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2. Midclavicular lines
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1. Umbilicus
4. Lower border of the right ribs
5. Iliac crests
Correct Answer: 1,3
Rationale 1: Umbilicus. To obtain four quadrants when mapping the abdomen, extend the
midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a
horizontal line perpendicular to the first line.
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Rationale 2: Midclavicular lines. The midclavicular lines are not used to map the clients
abdomen into four quadrants.
Rationale 3: Xiphoid process. To obtain four quadrants when mapping the abdomen, extend the
midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a
horizontal line perpendicular to the first line.
Rationale 4: Lower border of the right ribs. The lower border of the right ribs is not used to
map the clients abdomen into four quadrants.
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Rationale 5: Iliac crests. The iliac crests are not used to map the clients abdomen into four
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quadrants.
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Global Rationale: To obtain four quadrants when mapping the abdomen, extend the midsternal
line from the xiphoid process through the umbilicus to the pubic bone, then draw a horizontal
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line perpendicular to the first line. The midclavicular lines are not used to map the clients
abdomen into four quadrants. The lower border of the right ribs is not used to map the clients
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abdomen into four quadrants. The iliac crests are not used to map the clients abdomen into four
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Cognitive Level: Remembering
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quadrants.
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 19.2: Identify landmarks that guide assessment of the abdomen.
Question 8
Type: MCSA
The nurse is performing a focused interview with a 79-year-old client. Which of the following
statements by the client is unexpected?
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1. I have been having loose stools every day for the last 3 years.
2. I know I just dont drink as much water as I should.
3. My belly seems softer and flabbier as I get older.
4. My mouth is always dry.
Correct Answer: 1
Rationale 1: Older clients tend to experience constipation as a result of changes in their
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digestive tracts. Loose stools are an unexpected finding in the older client.
Rationale 2: Older clients do not tend to drink as much water as they should to avoid frequent
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urination.
Rationale 3: The older clients abdomen tends to be softer and more relaxed than in the younger
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adult.
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Rationale 4: The older clients saliva production is decreased resulting in a dry mouth.
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Global Rationale: Older clients tend to experience constipation as a result of changes in their
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digestive tracts. Loose stools are an unexpected finding in the older client. Older clients do not
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tend to drink as much water as they should to avoid frequent urination. The older clients
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abdomen tends to be softer and more relaxed than in the younger adult. The older clients saliva
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production is decreased resulting in a dry mouth.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.3: Develop questions to be used when completing the focused interview.
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Question 9
Type: MCMA
The student nurse is preparing to examine a client who is complaining of left lower quadrant
abdominal pain. The experienced nurse is observing the student nurses abdominal assessment.
Which of the following statements by the student nurse would indicate that the student nurse
requires further education?
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Standard Text: Select all that apply.
1. It is a little cool in our examination room; may I turn up the thermostat?
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2. Ive been told you are experiencing some pain in the lower left area of your abdomen. I will
examine that area first.
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3. I am going to stand on your left side so I can feel your liver better.
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4. Im going to place this drape over you so you dont feel too exposed during this examination.
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5. I am going to place this pillow behind your head and this pillow under your knees.
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Correct Answer: 2,3
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Rationale 1: It is a little cool in our examination room; may I turn up the thermostat? The
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nurse should provide an environment that is warm and comfortable.
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Rationale 2: Ive been told you are experiencing some pain in the lower left area of your
abdomen. I will examine that area first. When a client is experiencing abdominal pain, the
nurse should examine that area last.
Rationale 3: I am going to stand on your left side so I can feel your liver better. Stand on the
right side of the client, because the liver and the right kidney are in the right side of the abdomen.
Rationale 4: Im going to place this drape over you so you dont feel too exposed during this
examination. Maintain the dignity of the client through appropriate draping techniques.
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Rationale 5: I am going to place this pillow behind your head and this pillow under your
knees. The client should be in a supine position with a small pillow placed beneath the head and
knees.
Global Rationale: When a client is experiencing abdominal pain, the nurse should examine that
area last. Stand on the right side of the client, because the liver and the right kidney are in the
right side of the abdomen. The nurse should provide an environment that is warm and
comfortable. Maintain the dignity of the client through appropriate draping techniques. The
client should be in a supine position with a small pillow placed beneath the head and knees.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 19.4: Explain client preparation for assessment of the abdomen.
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Question 10
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Type: MCMA
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The nurse is performing an abdominal assessment on a client. During the focused interview, the
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client stated that he had been experiencing some abdominal pain. As the nurse assesses the
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client, which of the following behaviors indicates that the client may be experiencing pain or
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anxiety during the examination?
Standard Text: Select all that apply.
1. The clients respiratory rate is 26 per minute.
2. The client moves away from the nurses hands.
3. The client grimaces.
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4. The client pulls his knees toward his stomach.
5. The client coughs loudly.
Correct Answer: 1,2,3,4
Rationale 1: The clients respiratory rate is 26 per minute. If the clients respiratory rate
increases during the examination, it can indicate that the client is experiencing pain or anxiety.
Rationale 2: The client moves away from the nurses hands. The client may move away from
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the nurse during the examination if the client is experiencing pain.
Rationale 3: The client grimaces. Grimacing is a facial expression that can indicate that the
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client is experiencing pain during the assessment.
Rationale 4: The client pulls his knees toward his stomach. The client who exhibits guarding
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behavior is most likely experiencing pain.
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Rationale 5: The client coughs loudly. The client who coughs loudly is not necessarily
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experiencing pain. This is not a typical expression of pain or anxiety.
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Global Rationale: If the clients respiratory rate increases during the examination, it may
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indicate that the client is experiencing pain or anxiety. The client may move away from the nurse
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during the examination if the client is experiencing pain. Grimacing is a facial expression that
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can indicate that the client is experiencing pain during the assessment. The client who exhibits
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guarding behavior is most likely experiencing pain. The client who coughs loudly is not
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necessarily experiencing pain. This is not a typical expression of pain or anxiety.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19.4: Explain client preparation for assessment of the abdomen.
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Question 11
Type: MCSA
The client was recently admitted to the hospital with left lower quadrant pain. The client states, It
feels like my belly is cramping. Guarding is noted during the abdominal examination. During the
focused interview, the client admitted to experiencing a significant amount of occupational
stress. The nurse reviews the information included in the chart above and determines that the
client has developed a specific condition. Which of the following statements by the client is most
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consistent with this condition?
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1. I get home so late at night, but Ive got to stop lying down right after dinner.
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2. I drink a whole pot of coffee every day.
3. I drink 912 beers after I get home from work, every day.
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4. We have been growing green beans in our garden and I think I ate too many the other day.
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Correct Answer: 4
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Rationale 1: Lying down after meals is often associated with gastroesophageal reflux disorder.
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Rationale 2: Caffeine intake is associated with irritable bowel syndrome.
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Rationale 3: Drinking alcohol is associated with irritable bowel syndrome and pancreatitis.
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Rationale 4: This client is most likely experiencing diverticulitis. The clients white blood cell
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count, temperature, and blood pressure are elevated as a result of the infection. High-fiber food
intake can be a precipitating factor.
Global Rationale: This client most likely is experiencing diverticulitis. The clients white blood
cell count, temperature, and blood pressure are elevated as a result of the infection. High-fiber
food intake can be a precipitating factor. Lying down after meals is often associated with
gastroesophageal reflux disorder. Caffeine intake is associated with irritable bowel syndrome.
Drinking alcohol is associated with irritable bowel syndrome and pancreatitis.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
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Question 12
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Type: MCSA
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The nurse is performing an abdominal assessment on a client. While the nurse is palpating the
lower border of the liver, the nurse asks the client to take a deep breath and hold it. The client
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complains of a sharp pain located in the right upper quadrant. In which of the following ways
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would the nurse accurately document this finding?
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1. Positive Blumbergs sign
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4. Positive Psoas sign
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3. Positive Murphys sign
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2. Presence of pain at McBurneys point
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Correct Answer: 3
Rationale 1: Blumbergs sign can be elicited when the nurse presses on an area of the abdomen.
If the client complains of pain as the nurse pulls back and releases the compressed area, the client
has a positive Blumbergs sign.
Rationale 2: Pain at McBurneys point is associated with appendicitis. This area is located in the
right lower quadrant of the clients abdomen.
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Rationale 3: Murphys sign can be elicited when the client takes a deep breath and holds it while
the nurse presses into the right upper quadrant. The nurse is pressing against the gallbladder.
Normally, the client will not complain of pain.
Rationale 4: With the client in a supine position, the nurse places her left hand just above the
level of the clients right knee. The client is requested to raise the leg to meet the nurses hand.
Flexion of the hip causes contraction of the psoas muscle and indicates that the client is
experiencing peritoneal inflammation, or appendicitis.
Global Rationale: Pain with palpation of the liver is indicative of cholecystitis and is noted as a
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positive Murphys sign. The examination should be halted. Blumbergs sign is sharp pain
occurring with the release of a compressed area and is present when the client has peritoneal
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irritation. Pain at McBurneys point in the right lower quadrant is associated with appendicitis.
Pain that is elicited while flexing the hip is indicative of psoas muscle irritation and is associated
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with peritoneal inflammation or appendicitis.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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of the abdomen.
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Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
Question 13
Type: MCSA
The nurse is assessing the clients abdomen and notes dullness when percussing over the left
lower quadrant. Which of the following questions is most appropriate for the nurse to ask the
client at this time?
1. How much alcohol do you drink?
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2. Do you have pain after eating?
3. When was your last bowel movement?
4. Have you ever had splenomegaly?
Correct Answer: 3
Rationale 1: Alcohol can place the client at risk for hepatomegaly and inflammation of the liver.
Rationale 2: Pain after eating may indicate that some sort of upper gastrointestinal problem has
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developed.
Rationale 3: Stool in the distal portion of the clients colon can produce dullness upon percussion
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of the left lower quadrant.
Rationale 4: Splenomegaly would produce dullness while percussing the left upper quadrant.
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Global Rationale: Percussion over the abdomen produces tympany, and dullness is heard over
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the solid organs such as the liver and spleen. Dullness may also indicate an enlarged uterus,
distended urinary bladder or ascites. Dullness in the left lower quadrant may also indicate the
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presence of stool in the colon. Significant alcohol consumption may be associated with possible
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liver enlargement. The nurse would be able to percuss the liver in the right upper quadrant. Pain
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after eating is more likely to be associated with an upper gastrointestinal problem. Splenomegaly
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is associated with dullness while percussing the clients left upper quadrant.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
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Question 14
Type: MCMA
The nurse is completing discharge instructions for a client admitted with esophagitis. Which of
the following statements by the client indicate that the client requires further education?
Standard Text: Select all that apply.
1. Im going to talk to my doctor about a nicotine patch.
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2. I can do all of this stuff youre talking about as long as I dont have to give up my beer.
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3. I have been eating foods and drinks that were either too hot or too cold for my esophagus to
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handle.
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4. The root of this problem is that I just sleep too much.
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5. I told my wife to stop making serving me all of those vegetables.
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Correct Answer: 2,4,5
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Rationale 1: Im going to talk to my doctor about a nicotine patch. Smoking cigarettes is
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associated with an increased risk for developing esophagitis.
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Rationale 2: I can do all of this stuff youre talking about as long as I dont have to give up
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my beer. Alcohol can increase the clients risk for developing esophagitis.
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Rationale 3: I have been eating foods and drinks that were either too hot or too cold for my
esophagus to handle. Eating foods that are either too hot or too cold can be irritating to the
tissue and can result in esophagitis.
Rationale 4: The root of this problem is that I just sleep too much. Sleeping too much is not
associated with the development of esophagitis.
Rationale 5: I told my wife to stop making serving me all of those vegetables. Eating
vegetables is not associated with the development of esophagitis.
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Global Rationale: Alcohol can exacerbate and is an established risk factor for the development
of esophagitis. Sleeping too much is not associated with the development of esohagitis. Eating
vegetables is not associated with the development of esophagitis. Smoking cigarettes is
associated with an increased risk for developing esophagitis. Eating foods that are either too hot
or too cold can be irritating to the tissue and can result in esophagitis.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Client Need Sub:
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Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
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Question 15
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Type: MCSA
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The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the
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right upper portion of the back. The client states, This has been happening more often after I eat
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rich, high-fat foods. The nurse would suspect which of the following?
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2. Duodenal ulcer
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1. Cholecystitis
3. Gastritis
4. Pancreatitis
Correct Answer: 1
Rationale 1: Right upper quadrant pain that radiates to the right scapula is characteristic of
cholecystitis. The pain usually occurs after the client eats a fatty meal.
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Rationale 2: Duodenal ulcers cause aching, gnawing, epigastric pain. This is associated with
stress and NSAID use.
Rationale 3: Gastritis causes epigastric pain. It is associated with NSAID use, alcohol abuse,
stress, infection, H. pylori infection, and/ or autoimmune responses.
Rationale 4: Pancreatitis produces upper abdominal, knifelike, deep epigastric or umbilical area
pain. It is associated with alcohol abuse, use of acetaminophen, and infection.
Global Rationale: Right upper quadrant pain that radiates to the right scapula is characteristic of
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cholecystitis. The pain usually occurs after the client eats a fatty meal. Duodenal ulcers cause
aching, gnawing, epigastric pain. It is associated with stress and NSAID use. Gastritis causes
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epigastric pain. It is associated with NSAID use, alcohol abuse, stress, infection, H. pylori
infection, and autoimmune responses. Pancreatitis produces upper abdominal, knifelike, deep
epigastric or umbilical area pain. It is associated with alcohol abuse, use of acetaminophen, and
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infection.
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Client Need: Physiological Integrity
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Cognitive Level: Understanding
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
Question 16
Type: MCSA
The nurse is performing an abdominal assessment. After percussing the abdomen, the nurse
notes that the liver span is approximately 9 centimeters. Which of the following ways is an
appropriate way to document this finding?
1. Hepatomegaly
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2. A normal finding
3. Related to recent diagnosis of chronic bronchitis
4. Presence of ascites
Correct Answer: 2
Rationale 1: Hepatomegaly would be associated with a liver span greater than 10 centimeters.
Rationale 2: This is a normal finding.
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Rationale 3: The client with chronic bronchitis may have a liver that is displaced downward
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within the abdomen.
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Rationale 4: The client with ascites may have a liver that is displaced upward within the
abdomen.
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Global Rationale: The liver span is the distance between the lower and upper border of the
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liver. It should be approximately 5 to 10 centimeters (2 to 4 inches). The liver in this situation is
not enlarged, and it would be inappropriate for the nurse to determine that client has an enlarged
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liver (hepatomegaly). The client with chronic bronchitis may have a liver that is displaced
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downward within the abdomen. The client with ascites may have a liver that is displaced upward
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within the abdomen.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
Question 17
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Type: MCSA
The nurse is completing an abdominal assessment and is percussing over the left side of the
upper portion of the clients abdomen over the area of the stomach. The client states, I havent had
my breakfast, yet. The nurse would expect to find which of the following during this part of the
examination?
1. Dullness
2. Flatness
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3. Tympany
Correct Answer: 3
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4. Hyperesonance
Rationale 1: Dullness suggests a mass within the stomach. It is a short high-pitched sound heard
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over solid organs, masses, or fluid-filled structures.
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Rationale 2: Flat sounds are short and abrupt. They are heard over bone or muscle.
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Rationale 3: Tympany is the normal sound that can be heard when an air-filled structure is
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percussed.
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Rationale 4: Hyperesonance is a hollow sound that is louder than tympany. Hyperresonance is
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louder than tympany and is heard over air-filled or distended intestines.
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Global Rationale: Tympany is a loud, drum-like sound heard over structures filled with air,
such as the stomach or air in the intestines. Dullness is a soft to moderate thud-like sound heard
over solid organs such as the liver. If heard over the stomach, dullness suggests a stomach mass
and also may be heard after a large meal. Flatness is a soft, flat sound heard over muscle or bone.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
Question 18
Type: MCSA
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The nurse is documenting the findings of an abdominal assessment on a client and documents the
following information, pain noted during palpation at McBurneys point. In which of the
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following ways did the nurse elicit this response?
1. The nurse lightly palpated the around the clients umbilicus.
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3. The nurse palpated over the clients spleen.
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2. The nurse pressed into the clients abdomen and then pulled his hand back quickly.
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4. The nurse palpated the area between the clients ileum and umbilicus in the clients right lower
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quadrant.
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Correct Answer: 4
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Rationale 1: The nurse should be able to lightly palpate around the umbilicus without any
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complaints of pain by the client.
Rationale 2: This procedure is used to elicit the Blumbergs sign.
Rationale 3: Palpation over the clients spleen may be used to determine if the client has
splenomegaly.
Rationale 4: The nurse can palpate over McBurneys point to determine if the client has
developed appendicitis.
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Global Rationale: McBurneys point is located 2.5 to 5.1 centimeters above the anterosuperior
iliac spine, on a line between the ileum and the umbilicus. When the client experiences pain at
this site with palpation it is referred to as a positive Rovsings sign, which is suggestive of
peritoneal irritation that is most frequently associated with appendicitis. Pain with palpation over
the umbilicus may indicate an infectious process such as diverticulitis. A hernia may be palpated
or visualized during the nurses inspection of the clients abdomen. Pain as an area is compressed
and then is allowed to decompress is known as a positive Blumbergs sign. This sign occurs in
clients with peritoneal irritation. Normally, the client should feel pressure but no pain as the
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nurse palpates the clients spleen.
Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
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of the abdomen.
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Question 19
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Type: MCSA
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The client states, No one will let me eat or drink anything until after my test and its been 9 hours
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since I last ate anything! While auscultating the clients abdomen the nurse hears frequent bowel
sounds. In which of the following ways should the nurse accurately document this finding?
1. Borborygmi present
2. Hypoactive bowel sounds present
3. Bruit present
4. Friction rub present
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Correct Answer: 1
Rationale 1: Borborygmi are hyperactive bowel sounds.
Rationale 2: Hypoactive bowel sounds are not normally auscultated in clients who are merely
hungry. They are more often auscultated in clients who have developed a bowel obstruction or
who have had a major abdominal surgery.
Rationale 3: Bruits can be auscultated over blood vessels.
Rationale 4: Friction rubs are associated with the rubbing together of abdominal organs or
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organs that may be rubbing on the peritoneum.
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Global Rationale: Normal bowel sounds occur every 5 to 15 seconds. Borborygmi are
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hyperactive bowel sounds that are most often auscultated in clients who have not eaten recently.
Hypoactive bowel sounds are most often auscultated in clients who have had abdominal surgery
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or who have a bowel obstruction. A bruit is a pulsing, blowing sound that can be auscultated
over arteries. A friction rub is a rough, grating sound caused by the rubbing together of organs or
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an organ rubbing on the peritoneum.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
Question 20
Type: MCMA
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The nurse is assessing a client in the Emergency Department with complaints of right lower
quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign. The nurse
accurately suspects that which of the following conditions or problems may be occurring?
Standard Text: Select all that apply.
1. Constipation
2. Appendicitis
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3. Cholecystitis
4. Small bowel obstruction
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5. Peritonitis
Correct Answer: 2,5
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Rationale 1: Constipation. Constipation is not typically associated with a positive psoas sign.
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Rationale 2: Appendicitis. A positive psoas sign is indicative of irritation of the psoas muscle
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and is associated with appendicitis.
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Rationale 3: Cholecystitis. The client with cholecystitis may exhibit a positive Murphys sign.
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Rationale 4: Small bowel obstruction. The client with a small bowel obstruction may exhibit
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abnormal bowel sounds.
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Rationale 5: Peritonitis. A positive psoas sign is indicative of irritation of the psoas muscle and
is associated with peritoneal inflammation.
Global Rationale: A positive psoas sign is indicative of irritation of the psoas muscle and is
associated with peritoneal inflammation or appendicitis. Constipation is not typically associated
with a positive psoas sign. The client with cholecystitis may exhibit a positive Murphys sign.
The client with a small bowel obstruction may exhibit abnormal bowel sounds.
Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
Question 21
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Type: MCSA
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The nurse is auscultating the abdomen of a client for vascular sounds with the bell of the
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stethoscope. The nurse hears a soft, continuous humming sound. The nurse suspects that
dysfunction of which of the following organs ultimately may have resulted in the production of
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this sound?
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1. Stomach
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2. Spleen
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3. Pancreas
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Correct Answer: 4
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4. Liver
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Rationale 1: Dysfunction in the clients stomach did not result in this type of sound.
Rationale 2: Dysfunction in the clients spleen most likely did not result in this type of sound.
Rationale 3: Dysfunction in the clients pancreas did not result in this type of sound.
Rationale 4: The nurse is hearing an abnormal abdominal sound called a venous hum, which is
indicative of portal hypertension. Portal hypertension is the result of liver congestion.
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Global Rationale: The nurse is hearing an abnormal abdominal sound called a venous hum,
which is indicative of portal hypertension. Portal hypertension is the result of liver congestion.
Dysfunction in the clients stomach did not result in this type of sound. Dysfunction in the clients
spleen most likely did not result in this type of sound. Dysfunction in the clients pancreas did not
result in this type of sound.
Cognitive Level: Remembering
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Client Need: Physiological Integrity
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
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of the abdomen.
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Question 22
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Type: MCMA
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The nurse is performing an abdominal assessment on a client who had been previously diagnosed
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with cirrhosis. As the nurse inspected the clients abdomen, the nurse suspected that the client had
developed ascites. The nurse would perform which of the following nursing interventions as a
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result of this finding?
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Standard Text: Select all that apply.
1. Obtain stool specimen for occult blood.
2. Measure the clients abdominal girth.
3. Obtain stool specimen for culture and sensitivity.
4. Bilateral leg measurements.
5. Percuss the abdomen at midline.
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Correct Answer: 2,5
Rationale 1: Obtain stool specimen for occult blood. The nurse would not necessarily suspect
that the client had occult blood in the stool.
Rationale 2: Measure the clients abdominal girth. When ascites is suspected, the abdominal
girth should be measured to obtain a baseline for further evaluation.
Rationale 3: Obtain stool specimen for culture and sensitivity. The nurse does not need to
send a stool specimen for a culture and sensitivity. This would indicate that the nurse believed
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that the client had an infection within the gastrointestinal tract.
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Rationale 4: Bilateral leg measurements. The nurse does not necessarily need to measure the
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circumferences of the clients legs for edema.
Rationale 5: Percuss the abdomen at midline. The nurse would need to assess the clients
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abdomen for tympany during percussion. This is a sign of ascites.
Global Rationale: The nurse should measure the clients abdominal girth to obtain baseline
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information for further comparisons. The nurse should percuss the abdomen at midline for
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tympany because this is a sign of ascites. The nurse would not necessarily suspect that the client
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had occult blood in the stool. The nurse does not need to send a stool specimen for a culture and
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sensitivity. This would indicate that the nurse believed that the client had an infection within the
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gastrointestinal tract. The nurse does not necessarily need to measure the circumferences of the
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clients legs for edema.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
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Question 23
Type: FIB
The clients ideal body weight is 125 pounds. The nurse is calculating the clients weight in order
to determine if the client is obese. The client weighs 155.5 kilograms. Calculate the clients
weight in pounds. Round to the nearest whole number.
pounds
Standard Text:
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Correct Answer: 342 pounds
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Rationale: The client weighs more than 100 pounds over the ideal body weight. There are 2.2
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pounds in 1 kilogram. The clients weight in pounds is 342.1 pounds and when rounded to the
nearest whole number, the clients weight is 342 pounds.
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Global Rationale:
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Client Need: Physiological Integrity
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Cognitive Level: Applying
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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of the abdomen.
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Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
Question 24
Type: MCSA
The nurse is performing an abdominal assessment on an infant. The nurse notes that the
umbilicus is bulging and has been displaced slightly to the left of midline. The nurse would
suspect that the infant has developed which of the following conditions?
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1. Infection
2. Umbilical hernia
3. Ventral hernia
4. Hiatal hernia
Correct Answer: 2
Rationale 1: This is not a sign of an infection.
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Rationale 2: This is a normal finding in an infant. A protruding or displaced umbilicus is a
normal variation in pregnant females. An umbilical hernia occurs at the umbilicus and allows the
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intestines or other abdominal structures to protrude through the abdominus rectus muscle and
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come closer to the skin.
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Rationale 3: Ventral hernias occur in previous incisional sites.
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Rationale 4: A hiatal hernia is due to a weakening in the diaphragm that allows a portion of the
stomach and the esophagus to move into the thoracic cavity. This type of hernia is more
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commonly found in adults than in children.
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Global Rationale: An umbilical hernia occurs at the umbilicus and allows the intestines or other
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abdominal structures to protrude through the abdominus rectus muscle and come closer to the
skin. This is not a normal finding in an infant. A protruding or displaced umbilicus is a normal
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variation in pregnant females. Ventral hernias occur in previous incisional sites. A hiatal hernia
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is due to a weakening in the diaphragm that allows a portion of the stomach and the esophagus to
move into the thoracic cavity. This type of hernia is more commonly found in adults than in
children.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.6: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
Question 25
Type: SEQ
The nurse is performing an abdominal assessment on the client. Rank the following steps of
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assessment in the order that they should be performed.
Choice 1. Percuss the abdomen.
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Choice 2. Visualize the quadrants of the abdomen.
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Standard Text: Click and drag the options below to move them up or down.
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Choice 3. Palpate the abdomen.
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Choice 4. Auscultate the abdomen.
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Correct Answer: 5,2,4,1,3
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Choice 5. Encourage the client to void.
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assessment.
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Rationale 1: The first step is for the nurse to encourage the client to void prior to the abdominal
Rationale 2: The second step is for the nurse to visualize the quadrants of the clients abdomen.
Rationale 3: The third step is for the nurse to auscultate the abdomen.
Rationale 4: The fourth step is for the nurse to percuss the abdomen.
Rationale 5: The fifth step is for the nurse to palpate the abdomen.
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Global Rationale: The client should be encouraged to void prior to the abdominal assessment.
Physical assessment of the abdomen requires the use of inspection, auscultation, percussion, and
palpation. This order differs from that of physical assessment of other systems. The nurse should
remember to auscultate after inspection. Delaying percussion and palpation prevents disturbance
of the normal bowel sounds. During each of the procedures the nurse is gathering data related to
problems with underlying abdominal organs and structures.
Cognitive Level: Understanding
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need: Physiological Integrity
Learning Outcome: 19.7: Describe the variation in techniques required for assessment of the
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abdomen.
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Question 26
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Type: MCSA
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The nurse is caring for a client with hepatitis A virus. The client requests information about how
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the virus is transmitted. Which of the following statements by the nurse is the best response?
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this virus.
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1. This virus is transmitted by sexual contact with someone who already has been infected with
2. Most likely, you ate something that was contaminated with the virus.
3. It is spread by blood transfusions.
4. Have you ever injected an illegal drug?
Correct Answer: 2
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Rationale 1: Sexual contact with someone who is infected with a specific virus resulting in
hepatitis is most closely associated with developing hepatitis B or D.
Rationale 2: Eating food that is contaminated with hepatitis A virus may result in the client
developing clinical manifestations associated with hepatitis A virus.
Rationale 3: Blood product transfusions can result in the transmission of hepatitis B, C, or D
viruses.
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Rationale 4: Injecting illegal drugs can result in the transmission of hepatitis B, C, or D viruses.
Global Rationale: Educating clients about hepatitis A, B, and C viruses is included in the
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Healthy People 2020 objectives. Education about the viruses can help reduce transmission.
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Hepatitis A virus is transmitted through enteric routes and is usually the result of eating food that
was contaminated with the virus. Hepatitis B virus is transmitted parenterally, sexually, or
perinatally. Hepatitis C virus is transmitted via blood and blood products, parenterally, and
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through other unknown factors. Hepatitis B, C, and D viruses can be transmitted parentally and
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the client may be infected while injecting illegal drugs.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 19.8: Discuss the objectives in Healthy People 2020 as they relate to issues
of the abdomen and gastrointestinal system.
Question 27
Type: MCSA
The pediatric nurse is preparing an educational presentation for parents of school-aged children
regarding hepatitis. The nurse wishes to focus on the most common type that occurs in children.
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Which of the following types of hepatitis viruses would the nurse choose to focus on during this
presentation?
1. Hepatitis A virus
2. Hepatitis B virus
3. Hepatitis C virus
4. Hepatitis D virus
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Correct Answer: 1
Rationale 1: Hepatitis A virus is the most common type of virus resulting in hepatitis that
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develops in children.
Rationale 2: Hepatitis B virus is transmitted parenterally, sexually, or perinatally.
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Rationale 3: Hepatitis C virus is transmitted through blood and blood products, parenterally, and
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through unknown ways.
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Rationale 4: Hepatitis D virus is transmitted parenterally, sexually, and perinatally.
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Global Rationale: Hepatitis A occurs most frequently in children and young adults. Hepatitis B,
C, and D virus transmission seems unrelated to specific age groups and is most closely
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associated with specific risk factors or behaviors.
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Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19.8: Discuss the objectives in Healthy People 2020 as they relate to issues
of the abdomen and gastrointestinal system.
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Question 28
Type: MCMA
The student nurses are preparing educational presentations regarding the Healthy People 2020
objectives. The nursing instructor is reviewing the topics of their presentations. Which of the
following topics are appropriate and related to the objectives?
Standard Text: Select all that apply.
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1. Educate pregnant women regarding the importance of small, more frequent dry meals
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throughout the day to reduce nausea and vomiting.
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2. Educate Asian men about the importance of avoiding alcohol because this is a population that
is prone to alcohol abuse.
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3. Educate people who are anticipating traveling to India, Asia, Africa, or Central America about
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ways to reduce their risk of becoming infected with hepatitis E virus.
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4. Educate immunocompromised populations and those caring for them about the importance of
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safe food handling.
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5. Educate people about the relationship between regular, thorough oral hygiene practices and
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good nutrition.
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Correct Answer: 1,3,4,5
Rationale 1: Educate pregnant women regarding the importance of small, more frequent
dry meals throughout the day to reduce nausea and vomiting. Pregnant women who eat
smaller, dry meals throughout the day are less likely to experience nausea and vomiting than
women who eat fewer, larger meals during the day.
Rationale 2: Educate Asian men about the importance of avoiding alcohol because this is a
population that is prone to alcohol abuse. Caucasian and Hispanic populations are more prone
to alcohol abuse than Asians.
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Rationale 3: Educate people who are anticipating traveling to India, Asia, Africa, or
Central America about ways to reduce their risk of becoming infected with hepatitis E
virus. People who travel to Indian, Asia, Africa, or Central America are more likely to become
infected with hepatitis E virus.
Rationale 4: Educate immunocompromised populations and those caring for them about
the importance of safe food handling. Immunocompromised clients are more prone to
developing foodborne illnesses. Safe food handling when preparing food for these clients is very
important.
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Rationale 5: Educate people about the relationship between regular, thorough oral hygiene
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practices and good nutrition. Poor oral hygiene is associated with malnutrition.
Global Rationale: Pregnant women who eat smaller, dry meals throughout the day are less
likely to experience nausea and vomiting than women who eat fewer, larger meals during the
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day. People who travel to Indian, Asia, Africa, or Central America are more likely to become
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infected with hepatitis E virus. Immunocompromised clients are more prone to developing
foodborne illnesses. Safe food handling when preparing food for these clients is very important.
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prone to alcohol abuse than Asians.
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Poor oral hygiene is associated with malnutrition. Caucasian and Hispanic populations are more
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Type: HOTSPOT
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Chapter 15. Assessing the Peripheral Vascular System and Regional Lymphatic System
Question 1
The nurse is preparing to assess the clients dorsalis pedis pulse. Draw an arrow to where this
pulse can be palpated on the following figure.
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Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : The dorsalis pedis pulses may be felt on the medial side of the dorsum of the foot.
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Global Rationale:
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Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 18.1: Identify the anatomy and physiology of the peripheral vascular and
lymphatic systems.
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Question 2
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Type: MCSA
A client presents with an enlargement of several cervical lymph nodes and asks the nurse about
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the function of these structures. The nurse would respond with which of the following
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statements?
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1. Your lymph nodes filter blood for your body.
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2. They are responsible for the break down of old red blood cells.
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3. They make lymphocytes for you.
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Correct Answer: 4
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4. Your lymph nodes help to remove infectious organisms.
Rationale 1: Lymph nodes actually filter lymph fluid before returning it to the clients blood.
Rationale 2: The liver is responsible for breaking down old red blood cells.
Rationale 3: Lymphocytes are not made in lymph nodes. Lymph nodes filter lymph fluid before
returning it the blood.
Rationale 4: This statement is accurate. The lymph fluid is filtered in the lymph node to remove
pathogens before returning it the bloodstream.
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Global Rationale: The lymph fluid is filtered in the lymph node to remove pathogens before
returning it the bloodstream. The liver is responsible for breaking down old red blood cells.
Lymphocytes are not made in lymph nodes. Lymph nodes filter lymph fluid before returning it
the blood.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Implementation
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Client Need Sub:
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Learning Outcome: 18.1: Identify the anatomy and physiology of the peripheral vascular and
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lymphatic systems.
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Question 3
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Type: MCMA
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The nurse is performing a focused interview with a client who was recently diagnosed with
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varicose veins. Which of the following statements by the client are associated with risk factors
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for varicose veins?
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Standard Text: Select all that apply.
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1. My mother had big veins on her legs from the time I was little.
2. My father is of Japanese descent.
3. Im a hair stylist.
4. I was pregnant once and have a son.
5. I know I weigh a lot more than I should.
Correct Answer: 1,3,5
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Rationale 1: My mother had big veins on her legs from the time I was little. A client who has
a family history of varicose veins has an increased risk for developing them.
Rationale 2: My father is of Japanese descent. Risk factors for varicose veins include people
who are of Irish or German descent. People of Japanese descent do not necessarily have an
increased risk of developing varicose veins.
Rationale 3: Im a hair stylist. Hair stylists are more likely to be on their feet while they are
working and this does result in an increase in their risk of developing varicose veins.
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times have an increased risk for developing varicose veins.
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Rationale 4: I was pregnant once and have a son. People who have been pregnant multiple
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Rationale 5: I know I weigh a lot more than I should. People who are obese have an increased
risk for developing varicose veins.
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Global Rationale: A client who has a family history of varicose veins has an increased risk for
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developing them. Risk factors for varicose veins include people who are of Irish or German
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descent. People of Japanese descent do not necessarily have an increased risk of developing
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varicose veins. Hair stylists are more likely to be on their feet while they are working and this
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does result in an increase in their risk of developing varicose veins. People who have been
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pregnant multiple times have an increased risk for developing varicose veins. People who are
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obese have an increased risk for developing varicose veins.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 18.2: Develop questions that guide the focused interview.
Question 4
Type: MCMA
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While performing a focused interview with a healthy adult client, the nurse notes frequent
position changes, wringing of hands, lack of eye contact, incomplete sentences, and rapid speech.
The vital signs are BP 160/88, apical pulse 102 beats per minute, respiratory rate 26 per minute.
Which of the following are appropriate responses by the nurse?
Standard Text: Select all that apply.
1. Im going to take your temperature now.
2. Have you ever experienced chest pain?
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3. Are you feeling any anxiety right now?
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4. Are you experiencing any pain at this time?
5. Have you ever been diagnosed with hypothyroidism?
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Correct Answer: 2,3,4
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Rationale 1: Im going to take your temperature now. It will be appropriate to assess the
clients temperature, but the nurse should first determine whether the client is in pain or is
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experiencing anxiety.
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Rationale 2: Have you ever experienced chest pain? The clients actions may indicate that the
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client is experiencing pain. Pain can result in increased blood pressure, pulse, and respiratory
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rate. The nurse should determine if the client is experiencing pain and seek to treat the pain prior
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to continuing with the focused interview.
Rationale 3: Are you feeling any anxiety right now? The clients actions are consistent with
anxiety. Anxiety stimulates the sympathetic nervous system, which can result in
vasoconstriction, high blood pressure, increased heart rate, and respiratory rate.
Rationale 4: Are you experiencing any pain at this time? The client may be experiencing
chest pain. The nurse should determine whether the client is experiencing chest pain prior to
continuing the focused interview.
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Rationale 5: Have you ever been diagnosed with hypothyroidism? The clients vital signs and
actions are more likely associated with hyperthyroidism.
Global Rationale: It will be appropriate to assess the clients temperature, but the nurse should
first determine whether the client is in pain or is experiencing anxiety. The clients actions may
indicate that the client is experiencing pain. The client may be experiencing chest pain. The
nurse should determine whether the client is experiencing chest pain prior to continuing the
focused interview. Pain can result in increased blood pressure, pulse, and respiratory rate. The
nurse should determine if the client is experiencing pain and seek to treat the pain prior to
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continuing with the focused interview. The clients actions are also consistent with anxiety.
Anxiety stimulates the sympathetic nervous system, which can result in vasoconstriction, high
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blood pressure, increased heart rate, and respiratory rate. The clients vital signs and actions are
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more likely associated with hyperthyroidism.
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Cognitive Level: Applying
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Client Need: Psychosocial Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 18.2: Develop questions that guide the focused interview.
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Type: MCMA
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Question 5
The student nurse is performing an assessment of the clients peripheral vascular system with the
experienced nurses guidance. Which of the following actions by the student nurse indicate that
the student nurse requires further education?
Standard Text: Select all that apply.
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1. The student nurse continues to assess the client while the client is in a flat, supine position.
The clients respiratory rate increases to 26 breaths per minute and the client becomes dusky
around the mouth and lips.
2. The student nurse requests that the client remove all undergarments prior to putting the gown.
3. The client left her socks on and the student nurse assesses the clients pedal pulses over the
socks.
4. The client is wearing multiple rings and bracelets. The student nurse states that she may leave
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them on during the examination.
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5. The student nurse takes a blood pressure cuff, Doppler, and stethoscope into the clients room
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for this assessment.
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Correct Answer: 1,2,3,4
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Rationale 1: The student nurse continues to assess the client while the client is in a flat,
supine position. The clients respiratory rate increases to 26 breaths per minute and the
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client becomes dusky around the mouth and lips. The student nurse should pay careful
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attention to how well the client tolerates certain positions during the assessment. At this point,
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the student nurse should sit the client up to allow the client to breathe better.
Rationale 2: The student nurse requests that the client remove all undergarments prior to
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putting the gown . The client can leave on undergarments for this assessment.
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Rationale 3: The client left her socks on and the student nurse assesses the clients pedal
pulses over the socks. Socks should be removed prior to assessing the clients feet. Pulses, skin
temperature, skin color, quality of sensation, and capillary refill should be assessed and this
would be extremely difficult to assess while the clients socks are on her feet.
Rationale 4: The client is wearing multiple rings and bracelets. The student nurse states
that she may leave them on during the examination. The client should take off her jewelry.
Pulses may difficult to palpate around bracelets.
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Rationale 5: The student nurse takes a blood pressure cuff, Doppler, and stethoscope into
the clients room for this assessment. These pieces of equipment are required to perform this
assessment.
Global Rationale: The student nurse must pay attention to how well the client tolerates the
various positions during the assessment. The client needs to remove only socks and shoes prior
to putting on the gown. The socks must be removed to accurately assess the peripheral vascular
system. The client should take off her jewelry prior to the assessment. It is appropriate to bring
these pieces of equipment for the assessment.
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Cognitive Level: Applying
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Client Need: Psychosocial Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 18.3: Explain client preparation for assessment of the peripheral vascular
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system.
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Question 6
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Type: MCSA
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The nursing student is learning about the appropriate method to use when assessing a clients
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blood pressure. The student nurse asks the nursing instructor why it is necessary to palpate the
systolic pressure prior to the procedure. Which of the following is the nursing instructors best
response?
1. You can document this value if you cannot hear the blood pressure well.
2. This needs to be done only when the client is developing clinical manifestations associated
with shock.
3. You are more likely to get an accurate reading when you do it this way.
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4. It is the best way to determine an arterial obstruction.
Correct Answer: 3
Rationale 1: It is not appropriate to merely document the palpable systolic pressure. Efforts
should be made to document the clients blood pressure.
Rationale 2: When a client is developing clinical manifestations associated with shock, his blood
pressure is more likely to be lower than normal. The nurse should palpate the systolic pressure
for all clients regardless of their diagnoses.
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Rationale 3: Assessing the palpable systolic pressure helps to avoid inaccuracy in blood pressure
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assessment that can occur with an ausculatory gap, or space in which beats are not heard, during
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this assessment.
Rationale 4: This can be assessed by measuring the difference between the blood pressures in
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the arms. A difference of 10 mm Hg or more between the arms may indicate an obstruction of
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arterial flow to one arm.
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Global Rationale: Assessing the palpable systolic pressure helps to avoid inaccuracy in blood
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pressure assessment that can occur with an ausculatory gap, or space in which beats are not
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heard, during this assessment. It is not appropriate to merely document the palpable systolic
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pressure. Efforts should be made to document the clients blood pressure. When a client is
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developing clinical manifestations associated with shock, his blood pressure is more likely to be
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lower than normal. The nurse should palpate the systolic pressure for all clients regardless of
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their diagnoses. Arterial obstruction can be assessed by measuring the difference between the
blood pressures in the arms. A difference of 10 mm Hg or more between the arms may indicate
an obstruction of arterial flow to one arm.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 18.4: Describe techniques required for assessment of the peripheral
vascular system.
Question 7
Type: MCMA
The student nurse is preparing to perform an assessment of the clients peripheral vascular
system. The experienced nurse asks the student nurse questions to ensure the student nurse has
prepared adequately. Which of the following statements by the student nurse indicate that further
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education is required?
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Standard Text: Select all that apply.
1. I need to take a blood pressure only in the clients right arm.
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2. The best way to assess the carotid pulses is palpate one side and then the other.
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3. It will be easier to assess the clients carotid pulses if the client is obese.
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4. I should inspect the arms to ensure that they are close to the same size.
5. I should look at the extremities to ensure that hair distribution is normal and symmetrical. The
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Correct Answer: 1,3
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skin should be clean and free of any lesions.
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Rationale 1: I need to take a blood pressure only in the clients right arm. A thorough
peripheral vascular assessment includes blood pressure measurements taken in both arms and
both legs.
Rationale 2: The best way to assess the carotid pulses is palpate one side and then the other.
The carotid pulses should not be palpated at the same time because it may cause the client to
faint or pass out due to lack of blood flow to the brain.
Rationale 3: It will be easier to assess the clients carotid pulses if the client is obese. It is
much easier to assess the clients carotid pulses when the client has a long, thin neck.
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Rationale 4: I should inspect the arms to ensure that they are close to the same size. The
arms should be compared to each other to ensure that there is not a lymphatic problem that has
developed that would result in edema.
Rationale 5: I should look at the extremities to ensure that hair distribution is normal and
symmetrical. The skin should be clean and free of any lesions. The skin on the extremities
should be clean, dry, and intact. The clients pattern of hair distribution should be evaluated to
determine if there is adequate arterial circulation.
Global Rationale: The student nurse should take the clients blood pressure in both arms and
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both legs. It will be more difficult to assess the clients carotid pulses if the client is obese or has a
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short neck. The best way to palpate the clients carotid pulses is separately and not
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simultaneously. The student nurse should ensure that both arms are equal in size. The student
nurse should thoroughly assess the clients extremities.
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Cognitive Level: Applying
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 18.4: Describe techniques required for assessment of the peripheral
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Question 8
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vascular system.
Type: MCMA
The nurse is thoroughly assessing the client for any peripheral vascular problems. The client
requested the nurse to state exactly what the nurse was looking for during the assessment. Which
of the following statements by the nurse are unexpected?
Standard Text: Select all that apply.
1. I am feeling your feet to see how warm they are.
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2. I am looking for hair on your toes.
3. I am going to perform the Trendelenburgs test to see how well the radial and ulnar arteries are
supplying blood to your hand.
4. I am going to test your ability to feel sensations by giving you an injection.
5. I am going to perform the Allens test to see if you have any varicose veins.
Correct Answer: 3,4,5
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Rationale 1: I am feeling your feet to see how warm they are. Warmth felt at the distal
portions of the extremities indicate that the client is receiving an adequate amount of arterial
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blood flow to those areas.
Rationale 2: I am looking for hair on your toes. Hair growth on the clients toes indicates that
the client is receiving an adequate amount of arterial blood flow to the toes. This is especially
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helpful when the client routinely shaves the hair from the legs.
Rationale 3: I am going to perform the Trendelenburgs test to see how well the radial and
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ulnar arteries are supplying blood to your hand. The Trendelenburgs test is used to determine
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varicose veins.
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Rationale 4: I am going to test your ability to feel sensations by giving you an injection. The
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nurse should assess the clients ability to feel sensations by using the sharp and dull ends of a
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safety pin. An adequate ability to feel sensations indicates adequate arterial blood flow.
Rationale 5: I am going to perform the Allens test to see if you have any varicose veins. The
Allens test is used to determine if the client has problems with arterial blood flow from the radial
and ulnar arteries to the clients hand.
Global Rationale: It is important for the nurse to assess the clients peripheral extremities to
determine temperature. Hair growth on toes indicates adequate arterial blood flow. The Allens
test is used to determine patency of the radial and ulnar arteries. The nurse should use a safety
pin to assess the clients ability to feel dull and sharp sensations. The Trendelenburgs test can be
used to determine if the client has varicose veins in the legs.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 18.4: Describe techniques required for assessment of the peripheral
vascular system.
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Question 9
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Type: MCSA
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The nursing student is learning about blood pressure assessment and asks the instructor about
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blood pressure values. Which of the following responses is an accurate response?
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1. A normal blood pressure always depends on the clients previous values.
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2. A normal blood pressure is below 140/90.
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3. A client with prehypertension has a blood pressure that is greater than 140/90.
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4. A client with stage II hypertension has a blood pressure that is greater than 160/100.
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Correct Answer: 4
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Rationale 1: There are some specific guidelines set forth by the National Institutes of Health that
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can be used to classify a clients blood pressure as normal, prehypertension, stage I hypertension,
and stage II hypertension.
Rationale 2: A normal blood pressure is actually less than 120 (systolic) and less than 80
(diastolic).
Rationale 3: A client with prehypertension will have a blood pressure of 120139 (systolic) and
8089 (diastolic).
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Rationale 4: This is an accurate response. The client with stage II hypertension will have a blood
pressure greater than or equal to 160 (systolic) and greater than or equal to 100 (diastolic).
Global Rationale: There are some specific guidelines set forth by the National Institutes of
Health that can be used to classify a clients blood pressure as normal, prehypertension, stage I
hypertension, and stage II hypertension. The client with stage II hypertension will have a blood
pressure greater than or equal to 160 (systolic) and greater than or equal to 100 (diastolic). A
normal blood pressure is actually less than 120 (systolic) and less than 80 (diastolic). A client
with prehypertension will have a blood pressure of 120139 (systolic) and 8089 (diastolic).
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
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of the peripheral vascular system.
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Question 10
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Type: MCSA
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The nurse is taking the blood pressure of a client. The nurse obtains the blood pressure in both of
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the clients arms. The nurse determines that there is a difference of 15 mm Hg in the systolic
readings between the arms and repeats the assessment with the same results. The nurse suspects
which of the following may have occurred in this situation?
1. Inaccurate technique
2. Anxiety
3. Unilateral arterial obstruction
4. Shock
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Correct Answer: 3
Rationale 1: After repeating the procedure and determining the results were the same, the nurse
would not necessarily assume that the technique was faulty.
Rationale 2: Client anxiety may result in a higher blood pressure reading. It would not result in a
difference between blood pressures assessed in each arm.
Rationale 3: A difference of readings 10 mm Hg or more between arms may indicate an
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obstruction of arterial blood flow to one arm and is considered an abnormal finding.
Rationale 4: If the client is developing clinical manifestations associated with shock, the nurse
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would most likely determine that the clients blood pressure is lower than normal. Shock would
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not result in a difference between blood pressures assessed in each arm.
Global Rationale: A difference of readings 10 mm Hg or more between arms may indicate an
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obstruction of arterial blood flow to one arm and is considered an abnormal finding. After
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repeating the procedure and determining the results were the same, the nurse would not
necessarily assume that the technique was faulty. Client anxiety may result in a higher blood
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pressure reading. It would not result in a difference between blood pressures assessed in each
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arm. If the client is developing clinical manifestations associated with shock, the nurse would
most likely determine that the clients blood pressure is lower than normal. Shock would not
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result in a difference between blood pressures assessed in each arm.
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Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
of the peripheral vascular system.
Question 11
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Type: MCSA
The nurse examines the peripheral vascular system of a client diagnosed with chronic bronchitis
22 years ago. The nurse examines the clients hand. Which of the following statements by the
client is consistent with the clients diagnosis?
1. My fingers look so pointy and narrow at the ends.
2. My fingernails are as hard as a rock.
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3. My nails always look a little bluish.
4. My nails have a lot of strange ridges in them.
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Correct Answer: 3
Rationale 1: Many times, clients with a long-term history of chronic hypoxia such as chronic
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bronchitis, will exhibit clubbing of their fingers. The fingertips will look large at the ends.
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Rationale 2: Clients with lung problems resulting in chronic hypoxia will more likely to
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complain that their nails are soft and spongy.
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Rationale 3: This is a likely statement from someone who has a long history of disorder
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resulting in chronic hypoxia. The nails may look blue or gray due to oxygen deprivation.
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Rationale 4: his is more likely the result of another disorder such as a nutritional deficiency.
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Global Rationale: The statement regarding blueness is a likely statement from someone who
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has a long history of disorder resulting in chronic hypoxia. The nails may look blue or gray due
to oxygen deprivation. Many times, clients with a long-term history of chronic hypoxia such as
chronic bronchitis, will exhibit clubbing of their fingers. The fingertips will look large at the
ends, not pointy and narrow. Clients with lung problems resulting in chronic hypoxia will more
likely to complain that their nails are soft and spongy. Ridges in the nails are more likely the
result of another disorder such as a nutritional deficiency.
Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
of the peripheral vascular system.
Question 12
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Type: MCSA
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The nurse is documenting about an ulcer on the lateral aspect of the clients right great toe. The
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nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding. To
help determine information about the origin of the clients ulcer, which of the following pieces of
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the assessment will be most useful for the nurse?
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1. Skin turgor
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2. Calf measurements
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3. Homans sign
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Correct Answer: 4
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4. Peripheral pulses
fluid balance.
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Rationale 1: The nurse can use information about the clients skin turgor to help assess the clients
Rationale 2: Calf measurements can be compared to determine if the client is developing edema.
This information will be more helpful to use with a client who has venous insufficiency.
Rationale 3: Homans sign can be used to help determine if the client has developed a deep vein
thrombosis.
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Rationale 4: Peripheral pulses should be assessed to determine if the client has arterial
insufficiency. This is the most useful assessment at this time.
Global Rationale: Peripheral pulses should be assessed to determine if the client has arterial
insufficiency. This is the most useful assessment at this time. The nurse can use information
about the clients skin turgor to help assess the clients fluid balance. Calf measurements can be
compared to determine if the client is developing edema. This information will be more helpful
to use with a client who has venous insufficiency. Homans sign can be used to help determine if
the client has developed a deep vein thrombosis.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
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of the peripheral vascular system.
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Question 13
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Type: MCSA
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The nurse is assessing a client admitted to the hospital for congestive heart failure and notes 1+
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pitting edema of the left arm, as well as bilateral 1+ pitting edema in the clients ankles. The
clients history indicates that the client has had a myocardial infarction and a left mastectomy.
The nurse would suspect which of the following causes for the edema in the left arm?
1. Impaired lymphatic drainage
2. Noncompliance with medication regimen
3. Right-sided heart failure
4. Excessive intake of sodium
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Correct Answer: 1
Rationale 1: This client most likely has developed lymphedema due to the removal of lymph
nodes during the clients mastectomy. This type of surgery can inhibit the bodys ability to drain
lymph from the clients affected arm.
Rationale 2: Noncompliance with medication may result in edema that affects the clients
bilateral peripheral extremities. Unilateral edema indicates that there is a problem with the way
the lymph is able to drain from the clients extremity.
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Rationale 3: Right-sided heart failure often results in bilateral pitting edema. Unilateral pitting
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edema indicates that the lymph is not draining well from the clients arm.
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Rationale 4: Increased sodium intake can result in edema. However, this would most likely
result in bilateral peripheral edema.
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Global Rationale: This client most likely has developed lymphedema due to the removal of
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lymph nodes during the clients mastectomy. This type of surgery can inhibit the bodys ability to
drain lymph from the clients affected arm. Noncompliance with medication may result in edema
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that affects the clients bilateral peripheral extremities. Unilateral edema indicates that there is a
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problem with the way the lymph is able to drain from the clients extremity. Right-sided heart
failure often results in bilateral pitting edema. Unilateral pitting edema indicates that the lymph
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is not draining well from the clients arm. Increased sodium intake can result in edema. However,
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this would most likely result in bilateral peripheral edema.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
of the peripheral vascular system.
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Question 14
Type: MCSA
The nurse is completing an assessment on a client following a cardiac catheterization procedure.
During the initial assessment, the nurse easily palpates the clients right dorsalis pedis and
posterior tibial pulses. The pulses on the clients left leg are strong and easily palpable. During the
next assessment, the nurse is unable to palpate or find these pulses on the right side with a
Doppler. Which of the following would be the most appropriate action for the nurse at this time?
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1. Notify the healthcare provider immediately.
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2. Assess for the clients right popliteal pulse.
3. Take the clients blood pressure.
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4. Place the client in Trendelenburg position.
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Correct Answer: 2
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Rationale 1: The nurse should attempt to palpate the clients popliteal pulse. The healthcare
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provider should be notified, but the nurse should be prepared to provide information about the
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clients popliteal pulse during their conversation.
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Rationale 2: This is the appropriate action at this time. This will help the nurse determine how
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much of this extremity is still receiving oxygenated blood.
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Rationale 3: After the nurse assesses the clients popliteal pulses, it may be appropriate to check
the clients vital signs prior to notifying the healthcare provider.
Rationale 4: Trendelenberg can be used to treat a client in shock. The information about the
client does not indicate that the client has developed clinical manifestations associated with
shock.
Global Rationale: The nurse should attempt to palpate the clients popliteal pulse. This will help
the nurse determine how much of this extremity is still receiving oxygenated blood. After the
nurse assesses the clients popliteal pulses, it may be appropriate to check the clients vital signs
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prior to notifying the healthcare provider. The healthcare provider should be notified, but the
nurse should be prepared to provide information about the clients condition during their
conversation. Trendelenberg can be used to treat a client in shock. The information about the
client does not indicate that the client has developed clinical manifestations associated with
shock.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Client Need Sub:
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Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
of the peripheral vascular system.
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Question 15
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Type: MCMA
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While assessing a client with a laceration on the clients left third finger, the nurse notes the
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presence of inflammation and swelling of the finger. The nurse might expect to find which of the
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following?
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Standard Text: Select all that apply.
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1. 1cm, nontender, soft, left brachial node
2. cm, tender, firm, left superior superficial inguinal node
3. 2 cm, tender, firm, left epitrochlear node
4. cm, nontender, firm, left ulnar node
5. cm, tender, firm, left axillary lymph node
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Correct Answer: 3,5
Rationale 1: 1cm, nontender, soft, left brachial node. A 1 cm lymph node is not necessarily
enlarged. Tenderness usually indicates the presence of infection. Firmness can indicate infection.
Rationale 2: 2 cm, tender, firm, left superior superficial inguinal node. An infected wound
on the clients left third finger may result in a tender enlarged firm epitrochlear, brachial, and
axillary lymph nodes. The left superior superficial inguinal node drains lymph from the clients
left leg.
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Rationale 3: 2 cm, tender, firm, left superior superficial inguinal node. Normally, the
epitrochlear nodes are not palpable. A tender, firm and enlarged node such as this one may
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indicate the client has an infection. The epitrochlear node drains the forearm and third, fourth,
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and fifth fingers. A lymph node indicative of infection will be greater than 1 cm, tender, and
mobile.
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Rationale 4: 2 cm, nontender, firm, left ulnar node. The epitrochlear node drains lymph from
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the ulnar area. Lymph nodes in the arm are the following: subclavicular, central axillary,
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brachial, and epitrochlear.
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Rationale 5: 2 cm, tender, firm, left axillary lymph node. The client with an infected wound
on the left finger may have a tender enlarged lymph node in the axilla that can be found with
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light palpation.
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Global Rationale: Normally, the epitrochlear nodes are not palpable. A tender, firm and
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enlarged node such as this one may indicate the client has an infection. The epitrochlear node
drains the forearm and third, fourth, and fifth fingers. The client with an infected wound on the
left finger may have a tender enlarged lymph node in the axilla that can be found with light
palpation. A lymph node indicative of infection will be greater than 1 cm, tender, and mobile.
The left superior superficial inguinal node drains lymph from the clients left leg. The
epitrochlear node, not the ulnar node, drains lymph from the ulnar area. Lymph nodes in the arm
are the following: subclavicular, central axillary, brachial, and epitrochlear.
Cognitive Level: Analyzing
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
of the peripheral vascular system.
Question 16
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Type: MCMA
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The nurse is performing the assessment of an elderly client recently diagnosed with arterial
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insufficiency due to atherosclerosis. Which of the following findings are consistent with this
Standard Text: Select all that apply.
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1. Bilateral pitting edema 3+ in ankles and feet
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condition?
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3. Blood pressure 180/94
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2. Carotid bruit present
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4. Peripheral pulses 1+/4+ in dorsalis pedis bilaterally
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5. A pea-sized ulcer noted on the clients right great toe, no drainage, well-defined edges
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Correct Answer: 2,3,4,5
Rationale 1: Bilateral pitting edema 3+ in ankles and feet. Bilateral pitting edema is most
often attributed to right-sided heart failure.
Rationale 2: arotid bruit present. A narrowing of the carotid artery, as occurs with
atherosclerosis, will result in turbulent blood flow. This causes the swishing sound known as a
bruit.
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Rationale 3: Blood pressure 180/94. Clients with atherosclerosis and arterial insufficiency may
have hypertension.
Rationale 4: Peripheral pulses 1+/4+ in dorsalis pedis bilaterally. Atherosclerosis and arterial
insufficiency may result in decreased peripheral pulses.
Rationale 5: A pea-sized ulcer noted on the clients right great toe, no drainage, well-defined
edges. The client with arterial insufficiency may develop ulcers such as this one.
Global Rationale: A narrowing of the carotid artery, as occurs with atherosclerosis, will result
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in turbulent blood flow. This causes the swishing sound known as a bruit. Clients with
atherosclerosis and arterial insufficiency may have hypertension. Atherosclerosis and arterial
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insufficiency may result in decreased peripheral pulses. The client with arterial insufficiency
may develop ulcers such as this one. Bilateral pitting edema is most often attributed to right-
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sided heart failure.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
Question 17
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of the peripheral vascular system
Type: MCSA
The nurse is caring for a client who may have an arterial obstruction in her right ulnar artery.
Which of the following tests may be used to help determine the patency of this artery?
1. Trendelenburg test
2. Manual compression test
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3. Homans sign
4. Allens test
Correct Answer: 4
Rationale 1: This test can be used to evaluate valve competence in the presence of varicosities.
Rationale 2: If varicose veins are present, the nurse can determine the length of the varicose vein
and the competency of its valves with the manual compression test.
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Rationale 3: The test to elicit a Homans sign can be used to help determine if the client has a
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thrombosis.
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Rationale 4: The Allens test is used to evaluate the patency of both the radial and ulnar arteries.
Global Rationale: The Allens test is used to evaluate the patency of both the radial and ulnar
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arteries. The Trendelenberg test can be used to evaluate valve competence in the presence of
varicosities. If varicose veins are present, the nurse can determine the length of the varicose vein
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and the competency of its valves with the manual compression test. The test to elicit a Homans
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Cognitive Level: Understanding
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sign can be used to help determine if the client has a thrombosis.
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
of the peripheral vascular system.
Question 18
Type: MCMA
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The nurse is assessing a client who may have arterial insufficiency in the left lower leg. Which of
the following are consistent with this diagnosis?
Standard Text: Select all that apply.
1. Left dorsalis pedis pulse +1, right dorsalis pedis pulse +3
2. Skin is cool, tight, and shiny
3. When left leg is dependent, erythema is present
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5. Client complains of increased pain during rest periods
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4. When left leg is elevated, pallor is present
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Correct Answer: 1,2,3,4
Rationale 1: Left dorsalis pedis pulse +1, right dorsalis pedis pulse +3. The client with
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arterial insufficiency may have diminished pulses. The pulse in the left foot is difficult to
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palpate, while the pulse in the right foot is strong and easy to palpate.
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Rationale 2: Skin is cool, tight, and shiny. This finding is consistent with arterial insufficiency.
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The affected limb will feel cool. The skin may look tight and appear shiny. These findings
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indicate that the limb is not receiving an adequate arterial supply of oxygenated blood.
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Rationale 3: When left leg is dependent, erythema is present. This finding is consistent with
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arterial insufficiency. When in a dependent position, the affected limbs will become reddened.
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Rationale 4: When left leg is elevated, pallor is present. This finding is consistent with arterial
insufficiency. When elevated, affected limbs will become pale.
Rationale 5: Client complains of increased pain during rest periods. The client with arterial
insufficiency is more likely to complain of pain during exercise of the leg. The pain decreases or
is absent with rest.
Global Rationale: The client with arterial insufficiency may have diminished pulses. The pulse
in the left foot is difficult to palpate, but the pulse in the right foot is strong and easy to palpate.
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The affected limb will feel cool. The skin may look tight and appear shiny. These findings
indicate that the limb is not receiving an adequate arterial supply of oxygenated blood. When in a
dependent position, the affected limbs will become reddened. When elevated, affected limbs will
become pale. The client with arterial insufficiency is more likely to complain of pain during
exercise of the leg. The pain decreases or is absent with rest.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
of the peripheral vascular system.
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Question 19
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Type: MCMA
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The client was recently diagnosed with venous insufficiency. Which of the following statements
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by the client are consistent with this diagnosis?
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Standard Text: Select all that apply.
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1. My legs are so cold that they feel like ice.
2. My ankles and feet are always swollen.
3. The skin on my leg looks so pale.
4. When I walk around a lot, my legs just ache.
5. I have an ulcer on my inner leg above my ankle that just bleeds and bleeds.
Correct Answer: 2,5
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Rationale 1: My legs are so cold that they feel like ice. Clients with arterial insufficiency may
complain that their legs feel cool or cold. The nurse is more likely to determine that the legs of
clients with venous insufficiency have temperatures that are within normal limits.
Rationale 2: My ankles and feet are always swollen. Edema in the lower extremities is
associated with venous insufficiency.
Rationale 3: The skin on my leg looks so pale. Pale skin on the lower extremities is associated
with arterial insufficiency. Venous insufficiency results in darkened skin on the lower
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extremities.
Rationale 4: When I walk around a lot, my legs just ache. This statement is consistent with a
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client who has been diagnosed with arterial insufficiency. The type of discomfort associated with
venous insufficiency is aggravated by prolonged standing or sitting and is relieved by several
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hours of rest.
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Rationale 5: I have an ulcer on my inner leg above my ankle that just bleeds and bleeds.
This type of ulcer is consistent with a diagnosis of venous insufficiency. These ulcers are more
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likely to bleed and can be found in this area of the lower extremity. Arterial insufficiency ulcers
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are often described as dry, pale, with defined edges.
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Global Rationale: Edema in the lower extremities is associated with venous insufficiency. The
ulcers consistent with a diagnosis of venous insufficiency are likely to bleed and can be found in
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this area of the lower extremity. Arterial insufficiency ulcers are often described as dry, pale,
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with defined edges. Clients with arterial insufficiency may complain that their legs feel cool or
cold. The nurse is more likely to determine that the legs of clients with venous insufficiency have
temperatures that are within normal limits. Pale skin on the lower extremities is associated with
arterial insufficiency. Venous insufficiency results in darkened skin on the lower extremities.
Pain with walking is consistent with a client who has been diagnosed with arterial insufficiency.
The type of discomfort associated with venous insufficiency is aggravated by prolonged standing
or sitting and is relieved by several hours of rest.
Cognitive Level: Applying
Client Need: Physiological Integrity
www.mynursingtestprep.com
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
of the peripheral vascular system.
Question 20
Type: MCSA
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The client is visiting the healthcare providers office with complaints of discoloration of her
hands. The client states, My fingertips turn whitish and then later they get really red. The nurse is
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not surprised to learn from the healthcare provider that the client has which of the following
disorders?
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1. Lymphedema
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2. Raynauds disease
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3. Thrombosis
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4. Venous insufficiency
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Correct Answer: 2
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Rationale 1: Lymphedema is often described as edema that occurs in an affected extremity that
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is not draining lymph properly.
Rationale 2: The findings described are consistent with Raynauds disease, in which the
arterioles in the fingers develop spasms, causing intermittent skin pallor or cyanosis, then
redness. This condition is most commonly seen in young females.
Rationale 3: These findings are not consistent with a venous clot in the clients arm. Clients with
clots may have no symptoms at all or may experience pain.
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Rationale 4: Venous insufficiency results in discomfort that is aggravated by prolonged standing
or sitting and is relieved by rest. The clients complaints are not consistent with venous
insufficiency.
Global Rationale: The findings described are consistent with Raynauds disease, in which the
arterioles in the fingers develop spasms, causing intermittent skin pallor or cyanosis, then
redness. This condition is most commonly seen in young females. Lymphedema is often
described as edema that occurs in an affected extremity that is not draining lymph properly.
Clients with clots may have no symptoms at all or may experience pain. Venous insufficiency
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results in discomfort that is aggravated by prolonged standing or sitting and is relieved by rest.
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The clients complaints are not consistent with venous insufficiency.
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Cognitive Level: Remembering
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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of the peripheral vascular system.
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Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
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Type: MCSA
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Question 21
A female client being examined by the nurse exhibits 2+ pitting edema in the right arm, while the
left arm is normal in size. Which of the following responses by the nurses is most important at
this time?
1. How much salt do you have in your diet?
2. Does the other arm swell also?
3. Tell me about your past surgical procedures.
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4. Do you ever feel self-conscious about your arm?
Correct Answer: 3
Rationale 1: This client most likely has lymphedema. If salt intake was excessive, the nurse
would also determine swelling in other extremities. Unilateral swelling indicates that there may
be a problem with lymph drainage from the extremity.
Rationale 2: This is a good question but the nurse can see at this time that there is unilateral
swelling. This is not the most important question to ask at this time.
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Rationale 3: This is the most important thing for the nurse to determine. This information will
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help the nurse determine if the client has lymphedema due to a surgical procedure. Damage to or
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removal of lymph nodes can impact the ability of the lymph system to drain the arm adequately.
Rationale 4: This is important for the nurse to determine. However, this is not the most
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important question to ask at this time. The nurse should seek to determine how the lymphedema
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developed.
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Global Rationale: This client most likely has lymphedema. Damage to or removal of lymph
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nodes can impact the ability of the lymph system to drain the arm adequately, so information
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about previous surgical procedures is the priority question. This information will help the nurse
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determine if the client has lymphedema due to a surgical procedure. If salt intake was excessive,
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the nurse would also find swelling in other extremities. Unilateral swelling indicates that there
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may be a problem with lymph drainage from the extremity. The clients feelings of being self-
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conscious are important for the nurse to consider, but are not the most important at this time. The
nurse should seek to determine how the lymphedema developed.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
www.mynursingtestprep.com
Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
of the peripheral vascular system.
Question 22
Type: MCSA
While performing the assessment of the clients peripheral vascular system, the nurse notes that
there was a rapid filling of superficial veins during the Trendelenburg test. These findings would
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be most consistent with which of the following disorders?
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1. Valve incompetence
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2. Arterial insufficiency
3. Venous insufficiency
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4. Phlebitis
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Correct Answer: 1
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Rationale 1: This is consistent with valve incompetence that is associated with the development
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of varicose veins in the lower extremities.
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Rationale 2: The Trendelenberg test does not test for arterial insufficiency. The findings during
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the Trendelenberg test on this client demonstrate some issues with valve incompetence.
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Rationale 3: The findings during this clients Trendelenberg test are consistent with valve
incompetence, not venous insufficiency. The client with venous insufficiency will exhibit edema
and a brownish discoloration in the lower extremities.
Rationale 4: Phlebitis is an inflammation of the vein. The Trendelenberg test is not used to
determine if the client has phlebitis. The client with phlebitis will complain of tenderness along
the affected area of the vein.
Global Rationale: This finding is consistent with valve incompetence that is associated with the
development of varicose veins in the lower extremities. The Trendelenberg test does not test for
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arterial insufficiency. The findings are not consistent with venous insufficiency. The client with
venous insufficiency will exhibit edema and a brownish discoloration in the lower extremities.
Phlebitis is an inflammation of the vein. The Trendelenberg test is not used to determine if the
client has phlebitis. The client with phlebitis will complain of tenderness along the affected area
of the vein.
Cognitive Level: Understanding
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Client Need: Physiological Integrity
Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
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of the peripheral vascular system.
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Question 23
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Type: MCSA
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A clients blood pressure is 138/86 mm Hg. The nurse classifies this clients blood pressure as
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which of the following categories?
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1. Normal
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2. Prehypertension
3. Stage I hypertension
4. Stage II hypertension
Correct Answer: 2
Rationale 1: Normal blood pressures are less than 120 (systolic) and less than 80 (diastolic).
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Rationale 2: This blood pressure is classified as prehypertension because it is between 130 and
139 (systolic) and 80 and 89 (diastolic).
Rationale 3: Blood pressures falling into this category are those between 140 and 159 (systolic)
or those between 90 and 99 (diastolic).
Rationale 4: Blood pressures falling into this category are those greater than or equal to 160
(systolic) or greater than 100 (diastolic).
Global Rationale: This blood pressure is classified as prehypertension because it is between 130
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and 139 (systolic) and 80 and 89 (diastolic). Normal blood pressures are less than 120 (systolic)
and less than 80 (diastolic). Blood pressures falling into the Stage I hypertension category are
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those between 140159 (systolic) or those between 90 and 99 (diastolic). Blood pressures falling
into the stage II hypertension category are those greater than or equal to 160 (systolic) or greater
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than 100 (diastolic).
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Cognitive Level: Remembering
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment
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of the peripheral vascular system.
Question 24
Type: MCSA
The nurse is performing an assessment on a healthy 5 year old and palpates two enlarged lymph
nodes on the childs neck. The lymph nodes are soft, mobile, nontender, and each is less than 1
cm in diameter. The nurse would choose which of the following actions in this situation?
1. Assess for an infected wound.
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2. Document this as a normal finding.
3. Notify the healthcare provider.
4. Obtain an order for a throat culture.
Correct Answer: 2
Rationale 1: It is a normal finding to determine that a child has several enlarged lymph nodes
such as these. When lymph nodes are significantly enlarged, the nurse should assess the child for
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an infection.
Rationale 2: This is appropriate since these enlarged lymph nodes are small, nontender, and
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mobile.
Rationale 3: t is not necessary for the nurse to notify the healthcare provider at this time.
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Rationale 4: This would be an appropriate nursing action if the child had significantly enlarged
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lymph nodes and evidence that an infection was present in the childs pharynx.
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Global Rationale: It is a normal finding to determine that a child has several enlarged lymph
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nodes such as these. When lymph nodes are significantly enlarged, the nurse should assess the
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child for an infection. Documenting this as a normal finding is appropriate since these enlarged
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lymph nodes are small, nontender, and mobile. It is not necessary for the nurse to notify the
healthcare provider at this time. Obtaining an order for a throat culture would be an appropriate
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nursing action if the child had significantly enlarged lymph nodes and evidence that an infection
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was present in the childs pharynx.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 18.6: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings of the peripheral vascular system.
Question 25
Type: MCSA
The nurse is performing a peripheral vascular assessment of a female client who is 7 months
pregnant. The nurse notes mild peripheral edema, all other findings were normal. Which of the
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following actions by the nurse would be appropriate?
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1. Notify the healthcare provider immediately regarding this abnormal finding.
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2. Obtain an order from the healthcare provider for a diuretic to reduce the clients edema.
3. Document the findings as expected due to the clients pregnancy.
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4. Educate the client regarding ways to reduce the risk about peripheral vascular ulcer
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development.
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Correct Answer: 3
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Rationale 1: Mild peripheral edema is an expected finding when a pregnant client is in her third
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trimester. The clients healthcare provider does not need to be immediately notified.
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Rationale 2: The client does not need a diuretic to reduce the mild peripheral edema. This is a
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normal finding at this stage of the clients pregnancy.
Rationale 3: Pressure from the uterus on the lower extremities can obstruct venous return and
can cause edema, varicosities of the leg, and hemorrhoids. Edema is an expected finding because
the client is in her third trimester.
Rationale 4: Peripheral edema is a normal finding at this stage of the clients pregnancy. This
client is not necessarily at a greater risk for developing a peripheral vascular ulcer.
Global Rationale: Mild peripheral edema is an expected finding when a pregnant client is in her
third trimester. Pressure from the uterus on the lower extremities can obstruct venous return and
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can cause edema, varicosities of the leg, and hemorrhoids. The clients healthcare provider does not
need to be immediately notified. The client does not need a diuretic to reduce the mild peripheral
edema. This client is not necessarily at a greater risk for developing a peripheral
Chapter 16. Assessing the Musculoskeletal System
Question 1
Type: MCSA
The nurse is caring for a client with a right femur fracture. The nurse would correctly identify the
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femur as which of the following bone types?
1. Short
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2. Long
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3. Flat
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4. Irregular
Correct Answer: 2
Rationale 1: Bones are classified according to shape and composition. Short bones include the
carpals and tarsals.
Rationale 2: Bones are classified according to shape and composition. Long bones include the
femur and humerus.
Rationale 3: Bones are classified according to shape and composition. Flat bones include the
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parietal skull bone and sternum.
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Rationale 4: Bones are classified according to shape and composition. Irregular bonea include
the vertebrae and hips.
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Global Rationale: Bones are classified according to shape and composition. Long bones include
the femur and humerus; short bones include the carpals and tarsals; flat bones include the parietal
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skull bone and sternum; and irregular bones include the vertebrae and hips.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.1: Describe the anatomy and physiology of the bones, muscles, and
joints.
Question 2
Type: MCMA
The client is recovering from orthopedic surgery on a fractured arm. The nurse realizes that
skeletal muscles provide which of the following functions?
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Standard Text: Select all that apply.
1. Provide a body framework
2. Provide movement
3. Maintain posture
4. Generate heat
5. Calcium storage
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Correct Answer: 2,3,4
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Rationale 1: Provide a body framework. Skeletal muscles provide movement, maintain
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posture, and generate heat. Skeletal muscles do not provide a framework for the body. The bones
of the skeleton provide a framework and store minerals such as calcium and phosphorus.
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Rationale 2: Provide movement. Skeletal muscles provide movement, maintain posture, and
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generate heat.
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Rationale 3: Maintain posture. Skeletal muscles provide movement, maintain posture, and
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generate heat.
Rationale 4: Generate heat. Skeletal muscles provide movement, maintain posture, and
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generate heat.
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Rationale 5: Calcium storage. Skeletal muscles do not provide a framework for the body nor do
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they store minerals such as calcium. The bones of the skeleton provide a framework and store
minerals such as calcium and phosphorus.
Global Rationale: Skeletal muscles provide movement, maintain posture, and generate heat.
Skeletal muscles do not provide a framework for the body nor do they store minerals such as
calcium. The bones of the skeleton provide a framework and store minerals such as calcium and
phosphorus.
Cognitive Level: Understanding
www.mynursingtestprep.com
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.1: Describe the anatomy and physiology of the bones, muscles, and
joints.
Question 3
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Type: MCSA
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The clients chief complaint is pain in the foot. The nurse notes a deviation of the great toe from
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the midline and crowding of the remaining toes. There is enlargement and inflammation noted in
the area. The nurse would suspect which of the following conditions in this situation?
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1. Flat foot
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2. Gouty arthritis
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3. Hammertoe
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4. Bunion
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Correct Answer: 4
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Rationale 1: In pes planus, or flat foot, the arch of the foot is flattened, sometimes coming in
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contact with the floor.
Rationale 2: The toes are common sites for gouty arthritis. In this condition the
metarsolphlangeal joint of the toe is swollen, hot, red, and extremely painful. There is no
deviation of the toes.
Rationale 3: Hammertoe produces flexion of the proximal interphalangeal joint of a toe. The
distal metarsophalalgeal joint hyperextends.
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Rationale 4: A hallux valgus, or bunion, causes a deviation of the great toe from the midline,
and crowding of the remaining toes. This crowding results in deviation. The metatarsophalangeal
joint and bursa become enlarged and inflamed.
Global Rationale: A hallux valgus, or bunion, causes a deviation of the great toe from the
midline, and crowding of the remaining toes. The metatarsophalangeal joint and bursa become
enlarged and inflamed. In pes planus, or flat foot, the arch of the foot is flattened, sometimes
coming in contact with the floor. Hammertoe produces flexion of the proximal interphalangeal
joint of a toe, while the distal metatarsophalalgeal joint hyperextends. In gouty arthritis the
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metatarsophalangeal joint of the great toe is swollen, hot, red, and extremely painful.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub:
ng
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 23.2: Discuss the directional movements of the joints.
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Question 4
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Type: MCSA
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The nurse asks the client to pull the toes up towards the nose during an examination of the lower
1. Inversion
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extremities. The nurse is assessing which of the following movements?
2. Plantar flexion
3. Eversion
4. Dorsiflexion
Correct Answer: 4
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Rationale 1: Inversion is the movement of pointing the sole of the foot inward.
Rationale 2: Plantar flexion is the movement of pointing the toes toward the floor.
Rationale 3: Eversion is the movement of pointing the sold of the food outward.
Rationale 4: Dorsiflexion is the moement of pulling the toes upward toward the nose.
Global Rationale: Dorsiflexion is the movement of pulling the toes upward toward the nose.
Plantar flexion is the movement of pointing the toes toward the floor. Eversion is the movement
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of pointing the sole of the foot outward. Inversion is the movement of pointing the sole of the
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
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Client Need Sub:
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foot inward.
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 23.2: Discuss the directional movements of the joints.
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Question 5
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Type: MCMA
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The student nurse is assessing the clients lateral flexion. Which of the following instructions by
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the student to the client indicates the need for further instruction?
Standard Text: Select all that apply.
1. Tilt your head back and look at the ceiling.
2. Lean your head to the side and attempt to touch your ear to your shoulder.
3. Touch your chin to your chest.
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4. Attempt to raise your shoulders up toward your ears.
5. Attempt to rotate your head in a circular manner.
Correct Answer: 1,3,4,5
Rationale 1: Tile your head back and look at the ceiling. Tilting the head back and looking
toward the ceiling is an example of hyperflexion.
Rationale 2: Lean your head to the side and attempt to touch your ear to your shoulder.
Lateral flexion can be assessed by tilting the head to each shoulder with the ear from the same
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side.
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Touching the chin to the chest would be an example of flexion.
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Rationale 3: Touch your chin to your chest. Flexion refers to movements that reduce the angle.
Rationale 4: Attempt to raise your shoulders up toward your ears. Flexibility and mobility
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may be assessed by asking the client to raise and lower the shoulders but are not examples of
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methods to assess lateral flexion.
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Rationale 5: Attempt to rotate your head in a circular manner. Flexibility and mobility may
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be assessed by asking the client to rotate the head but it is not an example of methods of lateral
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flexion.
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Global Rationale: Lateral flexion of the head is attempted by touching each shoulder of the ear
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on the same side. Tilting the head back to look at the ceiling would be an example of
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hyperflexion. Touching the chin to the chest would assess flexion. Raising the shoulders toward
the ears and rotating the head are methods to assess mobility and flexibility of the client but do
not demonstrate lateral flexion.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
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Learning Outcome: 23.2: Discuss the directional movements of the joints.
Question 6
Type: MCSA
The nurse is caring for a client with a knee injury. The nurse would correctly identify the knee as
which of the following joint types?
1. Saddle
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2. Hinge
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3. Pivot
4. Plane
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Correct Answer: 2
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Rationale 1: Saddle joints consist of an articulating bone having both concave and convex areas
(resembling a saddle). The opposing surfaces fit together. The carpometacarpal joints of the
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thumbs are an example.
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Rationale 2: In hinge joints, a convex projection of one bone fits into a concave depression in
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another. Motion is similar to that of a mechanical hinge. These joints permit flexion and
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extension only. Examples include the elbow and knee joints.
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Rationale 3: In pivot joints, the rounded end of one bone protrudes into a ring of bone (and
possibly ligaments). The only movement allowed is rotation of the bone around its own long axis
or against the other bone. An example is the joint between the atlas and axis of the neck.
Rationale 4: In plane joints, the articular surfaces are flat, allowing only slipping or gliding
movements. Examples include the intercarpal and intertarsal joints, and the joints between the
articular processes of the ribs.
Global Rationale: The knee and elbows are hinge joints; the thumbs are saddle joints; the neck
is a pivot joint; the intercarpals and intertarsals are plane joints.
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Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.2: Discuss the directional movements of the joints.
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Question 7
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Type: MCHS
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The nurse is preparing to assess the posterior spine of a client. The nurse prepares to identify the
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iliac crest to determine symmetry. Identify the location of the iliac crest.
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Correct Answer:
Rationale : The iliac crests are used as landmarks on the posterior spine. They are used to assess
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for symmetry.
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Global Rationale:
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.4: Describe the techniques required for assessment of the
musculoskeletal system.
Question 8
Type: HOTSPOT
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The nurse is caring for a client with an injury to the arm. To check the client ability to move the
nurse directs the client to pronate the hand. Indicate the side of the table that arm should be
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rotated towards.
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : Pronation is a rotational movement of the radius around the ulna. It will result in the
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rotation of the hand and forearm so that the palm surface is facing downward to a posterior or
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Global Rationale:
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inferior position.
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Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 23.4: Describe the techniques required for assessment of the
musculoskeletal system.
Question 9
Type: HOTSPOT
The school nurse is providing an educational meeting with a group of teenaged girls. The nurse
is discussing the assessment for scoliosis. Use the diagram below to shade the area of the spine
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that will be assessed for the condition.
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Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : Scoliosis is a screening frequently completed on teenaged girls. Scoliosis is the
abnormal curvature of the thoracic spine.
Global Rationale:
Cognitive Level: Applying
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need: Health Promotion and Maintenance
Learning Outcome: 23.4: Describe the techniques required for assessment of the
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musculoskeletal system.
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Question 10
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Type: HOTSPOT
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The nurse is performing the bulge test on a clients left knee. Circle the area in which the nurse
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will need to assess for bulges when applying pressure.
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : The bulge sign can be assessed to check for the presence of fluid. If fluid is present
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there will be a bulging on the medial side. To perform the test, assist the client to a supine
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position. Use firm pressure to stroke the medial aspect of the knee upward several times
displacing any fluid. Next apply pressure to the lateral side of the knee while observing the
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medial side. In a normal test no fluid is present.
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Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.4: Describe the techniques required for assessment of the
musculoskeletal system.
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Question 11
Type: MCMA
A client comes to the emergency department complaining of a painful injury to the right knee
received while playing basketball. The nurse would include which of the following in the
examination of this client?
Standard Text: Select all that apply.
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1. Inspection
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2. Palpation
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3. Bulge sign testing
4. Ballottement
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5. Percussion
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Correct Answer: 1,2,3,4
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Rationale 1: Inspection. The nurse would visually inspect the knees general appearance
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including the presence or redness, swelling and dislocation. The knees appearance would be
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contrasted with the unaffected knee.
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Rationale 2: Palpation. The area would be palpated for tenderness and warmth.
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Rationale 3: Bulge sign testing. The bulge sign test is used to detect the presence of small
amounts of fluid (4 to 8 ml) in the suprapatellar bursa. The test involves placing the client in the
supine position and then using firm pressure to stroke the medial aspect of the knee upward
several times, displacing any fluid. As the pressure is applied to the lateral side of the knee the
medial side is observed for bulging.
Rationale 4: Ballottement. Ballottement is a technique used to detect fluid, or to examine or
detect floating body structures. The nurse displaces body fluid and then palpates the return
impact of the body structure.
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Rationale 5: Percussion. Percussion is the use of tapping actions by the examiner. This tapping
elicits sounds that can be evaluated for tone and depth to detect the presence of abnormalities.
Percussion is normally utilized to assess the lungs and abdominal cavity. It is not used to assess
for knee injuries.
Global Rationale: The assessment of a client presenting with an injury to the knee would
include inspection, palpation, bulge sign testing, and ballottement. The nurse would visually
inspect the knees general appearance, including the presence or redness, swelling and
dislocation. The knees appearance would be contrasted with the unaffected knee. The area would
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be palpated for tenderness and warmth. Ballottement is a technique used to detect fluid, or to
examine or detect floating body structures. The nurse displaces body fluid and then palpates the
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return impact of the body structure. The bulge sign test is used to detect the presence of small
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amounts of fluid (4 to 8 ml) in the suprapatellar bursa. The test involves placing the client in the
supine position and then using firm pressure to stroke the medial aspect of the knee upward
several times, displacing any fluid. As the pressure is applied to the lateral side of the knee the
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medial side is observed for bulging. Percussion is the use of tapping actions by the examiner.
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This tapping elicits sounds that can be evaluated for tone and depth to detect the presence of
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Cognitive Level: Applying
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used to assess for knee injuries.
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abnormalities. Percussion is normally utilized to assess the lungs and abdominal cavity. It is not
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 23.4: Describe the techniques required for assessment of the
musculoskeletal system.
Question 12
Type: MCSA
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The nurse is preparing to assess a clients spine for abnormalities. The nurse would ask the client
to do which of the following steps to gather the most information with this assessment?
1. Sit down, then stand as the nurse looks from the front of the client.
2. Stand, bend back slowly, then to the right and left while the nurse looks from the back.
3. Bend over, stand tall, and stretch arms over the head.
4. Sit down, then lean forward and dangle the arms at the sides of the body.
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Correct Answer: 2
Rationale 1: The client should be asked to stand during this assessment. This will allow the
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nurse to assess for symmetry.
Rationale 2: The spine should be visually inspected by viewing the back of the client. The client
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should be asked to stand during this assessment. This will allow the nurse to assess for
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symmetry. The spine should appear straight when viewed from the back.
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Rationale 3: Bending and stretching will not illicit the needed information about the spine.
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Range of motion and flexibility may be assessed by asking the client to bend over or stretch.
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Rationale 4: The spine is assessed by asking the client to stand. The nurse will then visually
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assess the client from the back.
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Global Rationale: The spine should be visually inspected by viewing the back of the client. The
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client should be asked to stand during this assessment. This will allow the nurse to assess for
symmetry. The spine should appear straight when viewed from the back. The cervical and
lumbar spine should appear concave, and the thoracic spine should appear convex. Range of
motion and flexibility may be assessed by asking the client to bend over or stretch.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.4: Describe the techniques required for assessment of the
musculoskeletal system.
Question 13
Type: MCSA
The clients chief complaint is numbness and tingling in the hands when interviewed by the nurse.
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The client complains of numbness and tingling in the arms when bending the wrist downward
and pressing the backs of the hands together. The nurse would suspect which of the following
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conditions in this situation?
1. Arthritis of the wrists
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2. Carpal tunnel syndrome
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3. Crepitus of the wrists
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4. Dupuytrens contracture
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Correct Answer: 2
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Rationale 1: Arthritis typically causes pain and limitations in movement but not numbness and
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tingling.
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Rationale 2: Carpal tunnel is a condition caused by compression of the median nerve. The test
described is called Phalens test, and when used on individuals with carpal tunnel syndrome, 80
percent experience pain, tingling, and numbness that radiates to the arm, shoulder, neck, or chest
within 60 seconds. Another assessment for carpal tunnel syndrome is called Tinels sign, and is
elicited by percussing lightly over the median nerve in each wrist. The test is positive if the client
feels numbness, tingling, and pain along the median nerve.
Rationale 3: Crepitus is a grating sound caused by bone fragments in joints and is suggestive of
degenerative disease, trauma, or inflammatory conditions.
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Rationale 4: Dupuytrens contracture involves inability to extend the fourth and fifth fingers but
is a painless, inherited disorder.
Global Rationale: Carpal tunnel is a condition caused by compression of the median nerve. The
test described is called Phalens test, and when used on individuals with carpal tunnel syndrome,
80 percent experience pain, tingling, and numbness that radiates to the arm, shoulder, neck, or
chest within 60 seconds. Another assessment for carpal tunnel syndrome is called Tinels sign,
and is elicited by percussing lightly over the median nerve in each wrist. The test is positive if
the client feels numbness, tingling, and pain along the median nerve. Arthritis typically causes
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pain and limitations in movement but not numbness and tingling. Crepitus is a grating sound
caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or
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inflammatory conditions. Dupuytrens contracture involves inability to extend the fourth and fifth
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fingers but is a painless, inherited disorder.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub: Physiological Adaptation
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Type: MCSA
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Question 14
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musculoskeletal system.
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Learning Outcome: 23.4: Describe the techniques required for assessment of the
The clients chief complaint is inability to move the fourth and fifth fingers during the nurses
interview. The nurse notes severe flexion in both of the affected fingers and upon palpation, but
there are no complaints of pain from the client. The nurse would suspect which of the following
conditions in this situation?
1. Dupuytrens contracture
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2. Carpal tunnel syndrome
3. Bursitis
4. Osteoarthritis
Correct Answer: 1
Rationale 1: Dupuytrens contracture involves inability to extend the fourth and fifth fingers, but
is a painless, inherited disorder.
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Rationale 2: Carpal tunnel is a condition caused by compression of the median nerve. In carpal
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tunnel syndrome the client feels numbness, tingling, and pain in the hands and wrists.
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Rationale 3: Bursitis involves inflammation of the bursae. The condition is manifested by
redness, warmth, swelling, and tenderness.
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Rationale 4: Osteoarthritis is the degeneration of the joints. The condition typically causes pain
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and limitations in movement, but not numbness and tingling.
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Global Rationale: Dupuytrens contracture involves inability to extend the fourth and fifth
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fingers, but is a painless, inherited disorder. Carpal tunnel is a condition caused by compression
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of the median nerve. In carpal tunnel syndrome the client feels numbness, tingling, and pain in
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the hands and wrists. Bursitis involves inflammation of the bursae. The condition is manifested
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by redness, warmth, swelling, and tenderness. Osteoarthritis is the degeneration of the joints. The
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condition typically causes pain and limitations in movement, but not numbness and tingling.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
system.
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Question 15
Type: MCSA
A young adult is seen in the clinic complaining of a lump the left wrist, but states it is not
painful. The nurse notes a round mass on the back of the wrist. The nurse would suspect which
of the following?
1. Rheumatoid arthritis
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2. Osteoarthritis
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3. Ganglion
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4. Carpal tunnel syndrome
Correct Answer: 3
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Rationale 1: Rheumatoid arthritis is an autoimmune disorder that presents with pain and
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tenderness in the joints. The condition may affect numerous joints. It is a systematic condition in
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which other body parts may be impacted in varying degrees.
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Rationale 2: Osteoarthritis is a condition in which the joints degenerate. The potential causes
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may include obesity, trauma, and occupational stressors. Joint pain with use/exercise is the chief
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symptom of osteoarthritis. It is commonly seen in the hips, knees, and hands.
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Rationale 3: A ganglion is a painless, round, fluid-filled mass. It arises from the tendon sheaths
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on the dorsum of the wrist and hand. It may be painful.
Rationale 4: Carpal tunnel syndrome results from compression of the median nerve. It may be
associated with occupations requiring repetitive tasks and pregnancy. It may begin with
numbness and tingling in the hands and fingers. Over time the condition may advance toward an
inability to grasp objects.
Global Rationale: The findings describe a ganglion, a painless, round, fluid-filled mass that
arises from the tendon sheaths on the dorsum of the wrist and hand. Rheumatoid arthritis is an
autoimmune disorder that presents with joint pain and tenderness. The joint regions may exhibit
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warmth and swelling. Osteoarthritis is a condition in which the joints degenerate. The condition
manifests with joint pain and stiffness. Carpal tunnel syndrome results from compression of the
median nerve. It manifests with discomfort in the wrist and potentially the reduction in the ability
to grasp objects.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
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system.
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Question 16
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Type: MCSA
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The nurse assesses a client and finds that a grating sound is present when a joint is bent and
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straightened. The nurse would correctly document this finding as which of the following?
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1. Subluxation
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3. Crepitation
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2. Grinding
4. Joint dislocation
Correct Answer: 3
Rationale 1: Subluxation refers to a partial joint location.
Rationale 2: Grinding sounds may be heard or felt with musculoskeletal disorders but it is not
appropriate medical terminology.
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Rationale 3: Crepitation is the medical term used to describe the grating sounds a joint makes
when the articulating surfaces have lost their cushioning cartilage.
Rationale 4: There is inadequate information to determine the joint is indeed dislocated.
Global Rationale: It is important to use proper terminology when reporting findings. Crepitation
is the proper term when a grating sound is present in a joint. Crepitation results when the joint
articulating surfaces have lost their cartilage. Subluxation refers to a partial joint dislocation.
There is inadequate information to determine if the joint is dislocated.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
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system.
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Question 17
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Type: MCSA
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The clients chief complaint is tenderness and stiffness in the wrist and elbow when interviewed
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by the nurse. The client reports the discomfort is worsened with activity. The nurse would
suspect which of the following conditions in this situation?
1. Carpal tunnel syndrome
2. Osteoarthritis
3. Crepitus of the wrists
4. Dupuytrens contracture
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Correct Answer: 2
Rationale 1: Carpal tunnel syndrome is caused by compression of the median nerve.
Rationale 2: Arthritis typically causes pain and limitations in movement, but not numbness and
tingling.
Rationale 3: Crepitus is a grating sound caused by bone fragments in joints and is suggestive of
degenerative joint disease, trauma, or inflammatory conditions.
Rationale 4: Dupuytrens contracture involves inability to extend the fourth and fifth fingers, but
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is a painless, inherited disorder.
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Global Rationale: Osteoarthritis is also known as degenerative joint disease. It is associated
with pain and stiffness of the joints. Carpal tunnel syndrome is caused by compression of the
median nerve. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of
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degenerative joint disease, trauma, or inflammatory conditions. Dupuytrens contracture involves
Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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inability to extend the fourth and fifth fingers, but is a painless, inherited disorder.
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
system.
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Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
Question 18
Type: MCSA
The nurse notes full range of motion against gravity with moderate resistance when assessing
muscle strength of the upper extremities in a client. The nurse would correctly document which
of the following choices?
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1. Poor
2. Normal
3. Fair
4. Good
Correct Answer: 4
Rationale 1: Full range of motion against gravity with full resistance is considered normal
muscle strength, also rated a 5. A rating of poor, or a 1, would be the presence of palpable
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muscle contraction with no movement.
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Rationale 2: Full range of motion against gravity with full resistance is considered normal
muscle strength, also rated a 5.
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Rationale 3: Full range of motion against gravity with full resistance is considered normal
muscle strength, also rated a 5. A rating of fair, or a 3, would be full range of motion with
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gravity.
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Rationale 4: Full range of motion against gravity with full resistance is considered normal
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muscle strength, also rated a 5. A rating of good, or a 4, would be full range of motion against
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gravity with moderate resistance.
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Global Rationale: Full range of motion against gravity with full resistance is considered normal
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muscle strength, also rated a 5. A rating of poor, or a 1, would be the presence of palpable
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muscle contraction with no movement. A rating of good, or a 4, would be full range of motion
against gravity with moderate resistance. A rating of fair, or a 3, would be full range of motion
with gravity. A rating of poor, or a 2, would be full range of motion without gravity, or passive
motion.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
system.
Question 19
Type: MCSA
The nurse notes swelling and tenderness of the olecranon process during palpation. The clients
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suspect which of the following conditions in this situation?
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chief complaint is pain upon movement of the forearm and wrist. The nurse would correctly
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1. Arthritis
2. Bursitis
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3. Epicondylitis
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4. Crepitus
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Correct Answer: 3
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Rationale 1: Rheumatoid arthritis may result in nodules in the olecranon bursa or along the
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extensor surface of the ulna. Nodules are firm, nontender, and not attached to the overlying skin.
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Rationale 2: Bursitis is characterized by a painful, inflamed warm area.
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Rationale 3: Lateral epicondylitis, also called tennis elbow, results from constant, repetitive
movements of the wrist and/or forearm. Pain occurs when the client attempts to extend the wrist
against resistance. Medial epicondylitis, also called pitchers or golfers elbow, results from
constant, repetitive flexion of wrist. Pain occurs when the client attempts to flex the wrist against
resistance.
Rationale 4: Crepitus is a grating sound caused by bone fragments in joints and is suggestive of
degenerative disease, trauma, or inflammatory conditions.
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Global Rationale: Lateral epicondylitis, also called tennis elbow, results from constant,
repetitive movements of the wrist and/or forearm. Pain occurs when the client attempts to extend
the wrist against resistance. Medial epicondylitis, also called pitchers or golfers elbow, results
from constant, repetitive flexion of wrist. Pain occurs when the client attempts to flex the wrist
against resistance. Rheumatoid arthritis will typically produce nontender nodules along the
extensor surface of the ulna. Bursitis is characterized by a painful area of inflammation. Crepitus
is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease,
trauma, or inflammatory conditions.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
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system.
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Question 20
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Type: MCSA
The nurse notes an exaggerated lumbar curve while inspecting the spine of a client. The nurse
1. Lordosis
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would correctly document which of the following choices?
2. Scoliosis
3. Kyphosis
4. Flattened curve
Correct Answer: 1
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Rationale 1: Lordosis is an exaggerated lumbar curve and is often present in pregnancy, obesity,
or other skeletal changes. The spine leans to the left or right in a list, and a line drawn from the
thoracic one vertebrae does not fall between the gluteal cleft.
Rationale 2: Scoliosis results when the spine curves to the right or left. It is noted in the thoracic
region.
Rationale 3: Kyphosis is an exaggerated thoracic dorsal curve resulting in asymmetry between
the sides of the posterior thorax.
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Rationale 4: A flattened lumbar curve is a concave curvature of the lumbar areas and occurs
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when lumbar muscles spasm.
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Global Rationale: Lordosis is an exaggerated lumbar curve and is often present in pregnancy,
obesity, or other skeletal changes. The spine leans to the left or right in a list, and a line drawn
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from the thoracic one vertebrae does not fall between the gluteal cleft. Scoliosis results when the
spine curves to the right or left. It is noted in the thoracic region. Kyphosis is an exaggerated
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thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. A
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flattened lumbar curve is a concave curvature of the lumbar areas and occurs when lumbar
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Cognitive Level: Analyzing
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muscles spasm.
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
system.
Question 21
Type: MCSA
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The nurse notes asymmetry of the iliac crests and gluteal folds while inspecting the spine of a
client. The clients spine has a slight curvature to the right, but denies complaints of pain. The
nurse would correctly document which of the following choices?
1. Kyphosis
2. Scoliosis
3. Spinal list
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4. Lordosis
Correct Answer: 2
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Rationale 1: Kyphosis results in an exaggerated thoracic dorsal curve that causes asymmetry
between the sides of the posterior thorax.
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Rationale 2: Scoliosis results when the spine curves to the right or left, causing an exaggerated
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thoracic convexity on that side.
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Rationale 3: A spinal list occurs when the spine leans to the left or right. The condition may be
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noted in conditions with paravertebral muscle spasms or herniated disks.
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Rationale 4: Lordosis is an exaggerated curve of the lumbar spine. It is noted most in condition
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such as pregnancy and obesity.
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Global Rationale: In scoliosis the spine curves to the right or left, causing an exaggerated
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thoracic convexity on that side. Kyphosis results in an exaggerated thoracic dorsal curve that
causes asymmetry between the sides of the posterior thorax. The spine leans to the left or right in
a spinal list. A plumb line drawn from T1 does not fall between the gluteal cleft. This condition
may occur with spasms in the paravertebral muscles or a herniated disk. Lordosis refers to an
exaggerated curve of the lumbar spine. It is seen most commonly in conditions such as
pregnancy and obesity.
Cognitive Level: Applying
Client Need: Physiological Integrity
www.mynursingtestprep.com
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
system.
Question 22
Type: MCSA
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The nurse is examining a client with a chief complaint of pain in the right great toe. The nurse
notes hardened nodules on the lateral aspect of the toe, as well as redness and swelling. The
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nurse would suspect which of the following?
1. Bunion
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2. Synovitis
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3. Hammertoe
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4. Gout
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Correct Answer: 4
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Rationale 1: The manifestations are consistent with a diagnosis of gout. Gout is a form of
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arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected
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joints. The findings describe tophi, which are the hardened nodules associated with the altered
the great toe.
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purine metabolism of gout. Bunions are thickening and inflammation of the bursa of the joint of
Rationale 2: The manifestations are consistent with a diagnosis of gout. Gout is a form of
arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected
joints. The findings describe tophi, which are the hardened nodules associated with the altered
purine metabolism of gout. Synovitis refers to an inflammation of the synovial membrane. It may
be present with pain and swelling but is typically seen more in the knee.
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Rationale 3: The manifestations are consistent with a diagnosis of gout. Gout is a form of
arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected
joints. The findings describe tophi, which are the hardened nodules associated with the altered
purine metabolism of gout. In hammertoe the metatarsophalangeal joint of the toe hyperextends
with flexion of the interphalangeal joint of the toe.
Rationale 4: The manifestations are consistent with a diagnosis of gout. Gout is a form of
arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected
joints. The findings describe tophi, which are the hardened nodules associated with the altered
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purine metabolism of gout.
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Global Rationale: The manifestations are consistent with a diagnosis of gout. Gout is a form of
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arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected
joints. The findings describe tophi, which are the hardened nodules associated with the altered
purine metabolism of gout. Bunions are thickening and inflammation of the bursa of the joint of
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the great toe. Synovitis occurs in the knee. In hammertoe the metatarsophalangeal joint of the toe
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hyperextends with flexion of the interphalangeal joint of the toe.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
system.
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Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
Question 23
Type: MCMA
The nurse is assessing a client with suspected rheumatoid arthritis. Which of the following
musculoskeletal changes would contribute to a positive diagnosis?
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Standard Text: Select all that apply.
1. Ulnar deviation
2. Bouchards nodes
3. Heberdens nodes
4. Swan-neck deformity
5. Symmetrical loss of function in extremities
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Correct Answer: 1,4,5
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Rationale 1: Ulnar deviation. In rheumatoid arthritis there is chronic inflammation of the
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metacarpophalangeal and interphalangeal joints leading to ulnar deviation.
Rationale 2: Bouchards nodes. The nodes that may appear on the fingers such as Bouchards
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and Heberdens nodes are associated with osteoarthritis. Bouchards nodes are located on the
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proximal interphalangeal joints.
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Rationale 3: Heberdens nodes. The nodes that may appear on the fingers such as Bouchards
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and Heberdens nodes are associated with osteoarthritis. Heberdens nodes are hard, typically
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painless, bony enlargements associated with osteoarthritis that may occur in the distal
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interphalangeal joints.
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Rationale 4: Swan-neck deformity. Another manifestation of rheumatoid arthritis involves
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what are known as swan-neck contractures. These result when the proximal interphalangeal
joints are hyperextended while the distal interphalangeal joints are fixed in flexion.
Rationale 5: Symmetrical loss of function in extremities. Rheumatoid arthritis impacts the
extremities symmetrically.
Global Rationale: Rheumatoid arthritis is an autoimmune condition. The disease may impact
multiple body systems. Symptoms of the condition include pain and inflammation. In rheumatoid
arthritis there is chronic inflammation of the metacarpophalangeal and interphalangeal joints
leading to ulnar deviation. Another manifestation of rheumatoid arthritis involves what are
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known as swan-neck contractures. These result when the proximal interphalangeal joints are
hyperextended while the distal interphalangeal joints are fixed in flexion. The impact on the
extremities is typically symmetrical in rheumatoid arthritis. The nodes that may appear on the
fingers such as Bouchards and Heberdens nodes are associated with osteoarthritis. Osteoarthritis
is a condition of joint degeneration.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
system.
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Question 24
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Type: MCSA
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The nurse is assessing a client with a suspected femur fracture. Which of the following findings
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would most support this diagnosis?
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1. External rotation of the lower leg and foot
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2. Internal rotation of the lower leg and foot
3. Limited hip internal rotation
4. Limited hip external rotation
Correct Answer: 1
Rationale 1: External rotation, not internal rotation, of the lower leg and foot is a classic sign of
a fractured femur.
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Rationale 2: External rotation, not internal rotation, of the lower leg and foot is a classic sign of
a fractured femur.
Rationale 3: Limitations of internal and external rotation in the hip signify inflammatory or
degenerative joint diseases.
Rationale 4: Limitations of internal and external rotation in the hip signify inflammatory or
degenerative joint diseases.
Global Rationale: External rotation, not internal rotation, of the lower leg and foot is a classic
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sign of a fractured femur. Limitations of internal and external rotation in the hip signify
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inflammatory or degenerative joint diseases.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal
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system.
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Type: MCSA
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Question 25
The nurse notes a child sitting in reverse tailor position during a well-child examination. The
nurse would correctly choose which of the following actions in this situation?
1. Notify the healthcare provider so that X-rays can be obtained.
2. Explain to the parent that this can cause joint stress.
3. Continue with the examination.
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4. Assess the child for back problems.
Correct Answer: 2
Rationale 1: The reverse tailor position should be discouraged as a result of the stresses it places
on the joints of a growing child. The preferred sitting position of the child does not, however,
indicate the presence of deformities that would require diagnostic testing.
Rationale 2: The reverse tailor position stresses the hip, knee, and ankle joints of the growing
child. Children should be encouraged to try other sitting positions to prevent these problems, and
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teaching the parent and the child regarding this is best done at the time the position is noted.
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Rationale 3: The reverse tailor position places stress on the joints of the growing child. The best
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time for the nurse to provide education is at the time of discovery. This education should be
performed prior to completing of the full assessment.
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Rationale 4: The reverse tailor position stresses the hip, knee, and ankle joints of the growing
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child. Back problems are not directly associated with the reverse tailor position.
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Global Rationale: The reverse tailor position stresses the hip, knee, and ankle joints of the
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growing child. The position has the individual sitting flat on the floor with the legs bent back
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similar to an upside down W. Children should be encouraged to try other sitting positions to
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prevent these problems, and teaching the parent and the child regarding this is best done at the
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time the position is noted. There is no need for the nurse to anticipate that X-rays will be needed
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as this position does not indicate deformities requiring diagnostic tests. The examination is a
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period of time in which the nurse can provide teaching to the patient. It would be remiss to
discuss this potential problem with the parents at the time noted. Thus, continuation of the
examination should not be done before the education has taken place. The reverse tailor position
does not promote back problems for the child.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental
related variations in assessment and findings.
Question 26
Type: MCSA
A 38-week pregnant client is complaining of lower back pain. The nurse notes a slight lordosis
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and waddling gait in the client. The nurse would correctly choose which of the following actions
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in this situation?
2. Notify the healthcare provider of the findings.
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Correct Answer: 3
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4. Ask the client if she has been lifting.
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3. Document the findings as normal.
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1. Suggest the client begin bed rest.
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Rationale 1: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the
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result of compensation for the enlarging fetus. The womans center of gravity shifts forward, and
her weight shifts farther back on the lower extremities, causing lower back pain. These are all
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normal findings during the later stages of pregnancy and do not require bed rest.
Rationale 2: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the
result of compensation for the enlarging fetus. The womans center of gravity shifts forward, and
her weight shifts farther back on the lower extremities, causing lower back pain. These are all
normal findings during the later stages of pregnancy and do not require notification of the
healthcare provider.
Rationale 3: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the
result of compensation for the enlarging fetus. The womans center of gravity shifts forward, and
her weight shifts farther back on the lower extremities, causing lower back pain. These are all
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normal findings during the later stages of pregnancy. The nurse should document these findings
as normal.
Rationale 4: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the
result of compensation for the enlarging fetus. The womans center of gravity shifts forward, and
her weight shifts farther back on the lower extremities, causing lower back pain. These are all
normal findings during the late stages of pregnancy and are not the result of lifting.
Global Rationale: During pregnancy estrogen and other hormones soften the cartilage in the
pelvis and increase the mobility of the joints. Lordosis, exaggeration of the lumbar spinal curve,
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and a waddling gait are the result of compensation for the enlarging fetus. The womans center of
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gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower
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back pain. These are all normal findings during the late stages of pregnancy and do not require
bed rest or notification of the healthcare provider. Lordosis and waddling gait in the later stages
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of pregnancy are not the result of lifting.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental
Question 27
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related variations in assessment and findings.
Type: MCSA
The nurse is caring for an elderly client. The nurse would expect which of the following in the
musculoskeletal system of an older adult?
1. Difficulty with dexterity
2. Increased bone production
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3. Risk for fractures
4. Pain when ambulating
Correct Answer: 3
Rationale 1: Difficulty with dexterity is a direct change associated with aging. Older clients may
have chronic conditions that may indirectly cause changes in this skill.
Rationale 2: The rate of bone production does not increase with aging.
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Rationale 3: Elderly clients are at risk for fracture as a result of decreased calcium absorption
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and loss of bone density.
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Rationale 4: Pain with ambulation is not a direct result of aging. Some chronic conditions seen
with greater frequency in the older adult may be associated with painful ambulation.
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Global Rationale: Elderly clients are at risk for fractures due to decreased calcium absorption
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and loss of bone density. Difficulty with dexterity is not a normal age related change. The rate of
bone production is not increased but decreased with aging. Pain with ambulation is not a direct
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levels and types of discomfort.
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result of aging; however, some chronic conditions of aging may be associated with varying
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental
related variations in assessment and findings.
Question 28
Type: MCSA
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The nurse is caring for an elderly client. The nurse would expect which of the following bone to
occur with aging?
1. No bone changes are associated with aging
2. Increased osteoblastic activity
3. Decreased calcium absorption
4. Increase in bone density
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Correct Answer: 3
Rationale 1: As individuals age, physiologic changes take place in the bones, muscles,
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connective tissue, and joints. These changes may affect the older clients mobility and endurance.
Bone changes include decreased calcium absorption and reduced osteoblast production.
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Rationale 2: Bone changes associated with aging include reduced osteoblast production.
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Osteoblasts are the cells responsible for bone production.
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Rationale 3: The rate of calcium absorption is reduced with aging.
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Rationale 4: Reductions in calcium absorption and reduced osteoblast production will result in a
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reduction of bone density. These changes are associated with aging.
Global Rationale: As individuals age, physiologic changes take place in the bones, muscles,
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connective tissue, and joints. These changes may affect the older clients mobility and endurance.
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Bone changes include decreased calcium absorption and reduced osteoblast production. Elderly
persons who are housebound and immobile or whose dietary intake of calcium and vitamin D is
low may also experience reduced bone mass and strength. During aging, bone resorption occurs
more rapidly than new bone growth, resulting in the loss of bone density typical of osteoporosis.
The entire skeleton is affected, but the vertebrae and long bones are especially impacted. The
elderly client will experience decreased calcium absorption. Osteoblasts are the cells responsible
for bone production. Osteoblast activity is reduced, not increased, with aging. Bone density
decreases, not increases, in the elderly.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental
related variations in assessment and findings.
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Question 29
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Type: MCSA
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The nurse is planning a program to promote Healthy People 2020 focus areas relating to
osteoporosis. Which of the following would appropriately serve as a primary prevention
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program?
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1. The development of a program to address available medication therapies for the individual
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with osteoporosis.
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2. Community screening programs to identify individuals who have early onset osteoporosis.
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3. Community education programs to discuss methods that can be implemented to reduce the
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chance of developing osteoporosis.
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4. The development of community support programs for individuals who have been diagnosed
with osteoporosis.
Correct Answer: 3
Rationale 1: Primary prevention seeks to provide education and reduce the incidence of disease.
Secondary prevention seeks to promote early diagnosis of conditions. Tertiary preventions goal
is to manage existing conditions while seeking to prevent related complications. Programs
seeking to discuss treatment options or to offer support for clients with the disorder are examples
of tertiary prevention.
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Rationale 2: Primary prevention seeks to provide education and reduce the incidence of disease.
Secondary prevention seeks to promote early diagnosis of conditions. Tertiary preventions goal
is to manage existing conditions while seeking to prevent related complications. Secondary
prevention seeks to promote early diagnosis of conditions.
Rationale 3: Primary prevention seeks to provide education and reduce the incidence of disease.
Secondary prevention seeks to promote early diagnosis of conditions. Tertiary preventions goal
is to manage existing conditions while seeking to prevent related complications. Programs to
reduce the incidence of osteoporosis are an example of primary prevention.
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Rationale 4: Primary prevention seeks to provide education and reduce the incidence of disease.
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Secondary prevention seeks to promote early diagnosis of conditions. Tertiary preventions goal
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is to manage existing conditions while seeking to prevent related complications. Programs
seeking to discuss treatment options or to offer support for clients with the disorder are examples
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of tertiary prevention.
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Global Rationale: Primary prevention seeks to provide education and reduce the incidence of
disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary
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preventions goal is to manage existing conditions while seeking to prevent related complications.
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Programs to reduce the incidence of osteoporosis are an example of primary prevention.
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Secondary prevention activities would include screening programs to identify individuals with
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early onset osteoporosis. Programs seeking to discuss treatment options or to offer support for
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clients with the disorder are examples of tertiary prevention.
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Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 23.7: Discuss objectives related to overall health of the musculoskeletal
system as presented in Healthy People 2020.
Question 30
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Type: MCSA
The nurse is admitting a client with a shoulder dislocation. The client tells the nurse that the
healthcare provider has told her she has a dislocated shoulder. The client asks the nurse what this
diagnosis means. The nurse would respond with which of the following statements?
1. I cannot tell you without your healthcare providers permission.
2. You have a muscle tear at the shoulder.
4. Your shoulder is fractured and separated from the joint.
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Correct Answer: 3
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3. Your shoulder bone has come apart from the shoulder joint.
Rationale 1: The client has voiced a concern and asked a question of the nurse. It is within the
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scope of practice and responsibility of the nurse to respond to this inquiry.
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Rationale 2: A dislocation is a displacement of the bone from its usual anatomical location in the
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joint. A muscle tear is not the same thing as a dislocation.
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Rationale 3: A dislocation is a displacement of the bone from its usual anatomical location in the
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joint.
Rationale 4: A dislocation is displacement of the bone from its usual anatomical location. This
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condition does not include a fracture.
Global Rationale: Dislocation is a displacement of the bone from its usual anatomical location
in the joint. A dislocation is not the same as a muscle tear, or a fracture of the shoulder. The
client has a concern and the nurse has the obligation to attempt to answer the questions presented
within the nurses scope of practice and responsibility.
Chapter 17. Assessing the Neurological System
Question 1
Type: MCMA
The student nurse is reviewing the cranial nerves. The student recognizes some of the nerves are
exclusively sensory nerves. Which of the following cranial nerves belong to this group?
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Standard Text: Select all that apply.
1. Olfactory nerve (cranial nerve I)
2. Optic nerve (cranial nerve II)
3. Trochlear nerve (cranial nerve IV)
4. Trigeminal nerve (cranial nerve V)
5. Facial nerve (cranial nerve VII)
Correct Answer: 1,2
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Rationale 1: Olfactory nerve (cranial cerve I). The cranial nerves may be classified by
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function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for
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receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves
are able to receive sensory information and perform physical activities. The olfactory nerve is a
sensory nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve
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responsible for vision.
Rationale 2: Optic nerve (cranial nerve II). The cranial nerves may be classified by function.
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The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving
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sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to
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receive sensory information and perform physical activities. The olfactory nerve is a sensory
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vision.
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nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve responsible for
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Rationale 3: Trochlear nerve (cranial nerve IV). The cranial nerves may be classified by
function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for
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receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves
are able to receive sensory information and perform physical activities. The trochlear nerve is a
motor nerve responsible for eye movement.
Rationale 4: Trigeminal nerve (cranial nerve V). The cranial nerves may be classified by
function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for
receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves
are able to receive sensory information and perform physical activities. The trigeminal nerve is a
mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity and palate.
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Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible.
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Rationale 5: Facial nerve (cranial nerve VI). The cranial nerves may be classified by function.
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The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving
sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to
receive sensory information and perform physical activities. The facial nerve is a mixed nerve
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responsible for taste, facial movements, and the production of tears and salivary stimulation.
Global Rationale: The cranial nerves may be classified by function. The nerves may be sensory,
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motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves
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allow the body to perform an action. Mixed nerves are able to receive sensory information and
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perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the
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sense of smell. The optic nerve is a sensory nerve responsible for vision. The trochlear nerve is a
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motor nerve responsible for eye movement. The trigeminal nerve is a mixed nerve is responsible
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for sensory impulses from the lower eyelid, nasal cavity, and palate. Motor actions of the
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trigeminal nerve involve teeth clenching and movement of the mandible. The facial nerve is a
mixed nerve responsible for taste, facial movements, and the production of tears and salivary
stimulation.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
Question 2
Type: HOTSPOT
The nurse is caring for a client having problems with emotional appropriateness as a result of a
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brain injury. Mark the area that has most likely been damaged.
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : The frontal lobe of the cerebrum is responsible for the control of emotions.
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Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
www.mynursingtestprep.com
Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
Question 3
Type: HOTSPOT
The nurse is caring for a client with a traumatic brain injury. The client has begun to experience
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bradycardia. What area of the brain is likely responsible for the changes in heart rate?
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : The brain stem is responsible for control of the vital signs.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
www.mynursingtestprep.com
Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
Question 4
Type: MCSA
The nurse is assessing a client to determine tremors associated with Parkinsons disease. The
nurse would correctly observe for which of the following movements?
1. Fasciculations
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2. Chorea
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3. Rhythmic shaking
4. Athetoid movements
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Rationale 1: Fasciculations are muscle twitches.
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Correct Answer: 3
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Rationale 2: Chores refer to controllable jerking movements as are associated with Huntingtons
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disease.
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Rationale 3: Rhythmic shaking of the hands is a manifestations associated with Parkinsons
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disease.
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Rationale 4: Athetoid moements are repetitive and slow and are seen with cerebral palsy.
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Global Rationale: The tremors noted with Parkinsons disease produce rhythmic shaking of the
hands. Fasciculations are muscle twitches; chorea is the uncontrollable jerking associated with
Huntingtons disease; athetoid movements are repetitive and slow and are seen with cerebral
palsy.
Cognitive Level: Applying
Client Need: Physiological Integrity
www.mynursingtestprep.com
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
Question 5
Type: MCSA
The nurse is performing a neurological assessment on a client experiencing anosmia. The nurse
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would suspect cranial nerve involvement in which of the following?
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1. Trochlear (cranial nerve IV)
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2. Trigeminal (cranial nerve V)
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3. Olfactory (cranial nerve I)
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4. Oculomotor (cranial nerve III)
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Correct Answer: 3
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Rationale 1: The trochlear nerve (cranial nerve IV) is related to vision. Dysfunction of the
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trochlear nerve nerve may include diplopia or strabismus.
Rationale 2: The trigeminal nerve (cranial nerve V) is responsible for sensory impulses from
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scalp, upper eyelid, nose, cornea, and lacrimal gland. Dysfunction of the trigeminal nerve may be
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associated with a loss of facial sensation.
Rationale 3: Anosmia is the absence of the sense of smell and can be indicative of problems
with the olfactory nerve (cranial nerve I).
Rationale 4: The oculomotor nerve (cranial nerve III) is associated with vision.
Global Rationale: Anosmia is the absence of the sense of smell and can be indicative of
problems with the olfactory nerve (cranial nerve I). The trochlear nerve (cranial nerve IV) is
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responsible for eye muscle movements. Dysfunction of the trochlear nerve nerve may include
diplopia or strabismus. The trigeminal nerve (cranial nerve V) has three branches. The
ophthalmic branch is responsible for sensory impulses from scalp, upper eyelid, nose, cornea,
and lacrimal gland. The maxillary branch is responsible for sensory impulses from lower eyelid,
nasal cavity, upper teeth, upper lip, and palate. The mandibular branch controls sensory impulses
from the tongue, lower teeth, skin of chin, and lower lip. Motor action function includes teeth
clenching, movements. Dysfunction of the trigeminal nerve may be associated with a loss of
facial sensation, sensation deficits in the tongue, lower teeth, skin of the chin and lower lip, and
papillary reflexes and extrinsic muscle movements of the eyes.
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Cognitive Level: Analyzing
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an inability to clench the teeth. The oculomotor nerve (cranial nerve III) is associated with
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
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Question 6
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Type: MCSA
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The nurse is assessing the patellar reflex on a client and obtains no reflexive activity. The client
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is alert and oriented. The nurse should do which of the following in this situation?
1. Document the findings as normal.
2. Notify the healthcare provider immediately.
3. Look at the medication records for central nervous system depressants.
4. Retest the reflex after having the client use distraction during the exam.
Correct Answer: 4
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Rationale 1: Reflexes are stimulus-response activities of the body. They are fast, predictable,
unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of
the reflex activity and not the activity itself. The reflex activity may be simple and take place at
the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded
using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not
normal. Before concluding that a reflex is absent or diminished the test should be repeated. The
client should be encouraged to relax. It may be necessary to distract the client to achieve
relaxation of the muscle before striking the tendon. Reflexes are stimulus-response activities of
the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The
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individual is aware of the results of the reflex activity and not the activity itself. The reflex
activity may be simple and take place at the level of the spinal cord, with interpretation at the
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cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a
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2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or
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diminished the test should be repeated.
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Rationale 2: There is no immediate need to notify the healthcare provider.
Rationale 3: Reflexes are stimulus-response activities of the body. They are fast, predictable,
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unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of
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the reflex activity and not the activity itself. The reflex activity may be simple and take place at
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the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded
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using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not
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normal. Before concluding that a reflex is absent or diminished the test should be repeated.
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Medications should eventually be reviewed to determine any impact on the nervous system but
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this action does not precede attempting to reassess the reflexes.
Rationale 4: Reflexes are stimulus-response activities of the body. They are fast, predictable,
unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of
the reflex activity and not the activity itself. The reflex activity may be simple and take place at
the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded
using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not
normal. Before concluding that a reflex is absent or diminished the test should be repeated. The
client should be encouraged to relax.
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Global Rationale: Reflexes are stimulus-response activities of the body. They are fast,
predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of
the results of the reflex activity and not the activity itself. The reflex activity may be simple and
take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity
is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar
reflex is not normal. Before concluding that a reflex is absent or diminished the test should be
repeated. The client should be encouraged to relax. It may be necessary to distract the client to
achieve relaxation of the muscle before striking the tendon. Documentation of the reflexes as
normal is not appropriate, as a score of 0 is not normal. There is no immediate need to notify the
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healthcare provider. Medications should eventually be reviewed to determine any impact on the
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nervous system but this action does not precede attempting to reassess the reflexes.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
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Question 7
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Type: MCSA
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The nurse is interviewing a client with suspected Lyme disease. Which of the following
questions would be a priority in this situation?
1. When was your last seizure?
2. Have you been hiking or camping lately?
3. What has your temperature been running?
4. Do you have an appetite?
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Correct Answer: 2
Rationale 1: Lyme disease is an infection caused by a spirochete transmitted by a bite from an
infected tick that lives on deer. This tick exposure may have come from hiking or camping.
Lyme disease if not treated may result in neurological disorders. There is not, however, any
indication that the client has long-term Lyme disease or neurological changes.
Rationale 2: Lyme disease is an infection caused by a spirochete transmitted by a bite from an
infected tick that lives on deer. This tick exposure may have come from hiking or camping.
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Rationale 3: Lyme disease is an infection caused by a spirochete transmitted by a bite from an
infected tick that lives on deer. This tick exposure may have come from hiking or camping.
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During the initial period after becoming infected the client may experience flu-like illnesses but
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there is no indication that this is the primary concern for the client.
Rationale 4: Lyme disease is an infection caused by a spirochete transmitted by a bite from an
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infected tick that lives on deer. This tick exposure may have come from hiking or camping. An
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priority area of concern for investigation.
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infectious process may result in changes in the clients appetite or dietary but this is not the
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Global Rationale: Lyme disease is an infection caused by a spirochete transmitted by a bite
from an infected tick that lives on deer. This tick exposure may have come from hiking or
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camping. Lyme disease if not treated may result in neurological disorders. There is not, however,
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any indication that the client has long-term Lyme disease or neurological changes. During the
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initial period after becoming infected the client may experience flu-like illnesses but there is no
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indication that this is the primary concern for the client. While appetite changes may result
during an infection this is not the priority for the nurses questions.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 24.2: Develop questions to be used when completing the focused interview.
Question 8
Type: MCSA
The nurse is performing the Romberg test and asks the client to stand with the feet together and
eyes closed. The nurse notes the findings are normal. Which of the following client responses
occurred in this situation? The client:
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1. Swayed from side to side.
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2. Had minimal swaying.
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3. Felt moderately dizzy.
4. Had complete loss of balance.
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Correct Answer: 2
Rationale 1: The Romberg test is used to test coordination and equilibrium. A minimal amount
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of swaying is normal. Swaying from side to side is not a normal finding.
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Rationale 2: The Romberg test is used to test coordination and equilibrium. A minimal amount
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of swaying is normal.
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Rationale 3: The Romberg test is used to test coordination and equilibrium. During the test, the
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client is asked to stand with feet together and arms at the sides. A minimal amount of swaying is
normal. The onset of dizziness is not a normal finding.
Rationale 4: The Romberg test is used to test coordination and equilibrium. A minimal amount
of swaying is normal. A complete loss of balance is not a normal finding.
Global Rationale: The Romberg test is used to test coordination and equilibrium. During the
test, the client is asked to stand with feet together and arms at the sides. The clients eyes are
initially open. Then, the examiner will ask the client to close his eyes. The examiner will need to
observe for swaying. A minimal amount of swaying is normal. Dizziness during the test is not a
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normal finding. Significant swaying from side to side and loss of balance are not normal findings
and may indicate a cerebellar dysfunction.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
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system.
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Question 9
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Type: MCMA
The nurse is assessing a client that experienced a head injury and assigns a Glascow Coma Scale
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Standard Text: Select all that apply.
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rating of 3. The nurse would correctly note which of the following for this client?
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2. No verbal response
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1. No response with eyes with commands
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3. Pupil response sluggish
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4. No motor movement
5. Pupils fixed and dilated
Correct Answer: 1,2,4
Rationale 1: No response with eyes with commands. The Glascow Coma Scale assesses level
of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and
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motor response. The client may score between 3 and 15 points with the tool. The lack of eye
response, verbal response, and motor response indicate a score of 3 points.
Rationale 2: No verbal response. The Glascow Coma Scale assesses level of consciousness on
a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response.
The client may score between 3 and 15 points with the tool. The lack of eye response, verbal
response, and motor response indicate a score of 3 points.
Rationale 3: Pupil response sluggish. The Glascow Coma Scale assesses level of consciousness
on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response.
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The client may score between 3 and 15 points with the tool. The lack of eye response, verbal
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response, and motor response indicate a score of 3 points. The lower the score, the more critical
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the clients condition. A score of 3 indicates the clients condition is grave. Pupil activity is not
evaluated using the Glascow Coma Scale.
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Rationale 4: No motor movement. The Glascow Coma Scale assesses level of consciousness on
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a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response.
The client may score between 3 and 15 points with the tool. The lack of eye response, verbal
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response, and motor response indicate a score of 3 points. The lower the score, the more critical
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the clients condition. A score of 3 indicates the clients condition is grave.
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Rationale 5: Pupils fixed and dilated. The Glascow Coma Scale assesses level of
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consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and
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motor response. The client may score between 3 and 15 points with the tool. The lack of eye
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response, verbal response, and motor response indicate a score of 3 points. The lower the score,
the more critical the clients condition. A score of 3 indicates the clients condition is grave. Pupil
activity is not evaluated using the Glascow Coma Scale.
Global Rationale: The Glascow Coma Scale assesses level of consciousness on a continuum
from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may
score between 3 and 15 points with the tool. The lack of eye response, verbal response and motor
response indicate a score of 3 points. Lower scores indicate more critical conditions. A score of 3
indicates the clients condition is grave. Pupil activity is not evaluated using the Glascow Coma
Scale.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
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Question 10
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Type: MCSA
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The nurse is performing a neurological assessment and needs to test cranial nerves. The nurse
asks the client to close both eyes and report when a touch with a wisp of cotton is felt. The nurse
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is assessing the function of which of the following cranial nerves?
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3. Facial nerve (cranial nerve VII)
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2. Abducens nerve (cranial nerve VI)
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1. Trigeminal nerve (cranial nerve V)
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Correct Answer: 1
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4. Optic nerve (cranial nerve II)
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Rationale 1: The cranial nerve V is responsible for facial sensations and may be assessed by a
wisp of cotton on the face.
Rationale 2: The cranial nerve VI is related to vision.
Rationale 3: The cranial nerve VII is related to facial movements and the sensation of taste.
Rationale 4: The cranial nerve II is related to vision.
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Global Rationale: The trigeminal nerve, cranial nerve V, is responsible for the facial sensations,
sensory impulses from the tongue, lower teeth, skin of chin, and lower lip. The nerve also has
motor functions including teeth clenching and movement of the mandible. The abducens nerve,
cranial nerve VI, is related to vision. The facial nerve, cranial nerve VII, has responsibilities
including facial expressions, the production of tears and salivary stimulation and is also
associated with taste. The optic nerve, cranial nerve II, has the sensory function of vision.
Cognitive Level: Applying
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Client Need: Physiological Integrity
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
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system.
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Question 11
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Type: MCSA
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The nurse in the photograph is performing an assessment on which of the following cranial
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nerves?
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1. Olfactory nerve (cranial nerve I)
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2. Optic nerve (cranial nerve II)
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3. Oculomotor nerve (cranial nerve III)
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4. Trochlear nerve (cranial nerve IV)
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Correct Answer: 1
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Rationale 1: The sense of smell assessment is being demonstrated in the photograph. The
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olfactory nerve (cranial nerve I) is being evaluated.
Rationale 2: Cranial nerve II is the optic nerve. Assessment of cranial nerve II (optic nerve)
would involve assessment of vision.
Rationale 3: Cranial nerve III (oculomotor nerve) involves the assessment of vision-related
parameters.
Rationale 4: Cranial nerve IV (trochlear nerve) involves the assessment of vision related
parameters.
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Global Rationale: The sense of smell assessment is being demonstrated in the photograph. The
olfactory nerve (cranial nerve I), which is responsible for the sense of smell, is being evaluated.
Cranial nerve II is the optic nerve. Assessment of cranial nerve II (optic nerve) would involve
assessment of vision. Cranial nerve III (oculomotor nerve) involves the assessment of papillary
reactivity and the extrinsic muscles of the eyes. Cranial nerve IV (trochlear nerve) assessment
would require assessing the movements of the eyes. This would include instructing the client to
follow an object such as the examiners finger with the eyes.
Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
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system.
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Question 12
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Type: MCSA
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Review the 2 photographs below. Which of the following cranial nerves is being evaluated by
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this activity being demonstrated?
1. Trigeminal nerve (cranial nerve V)
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2. Facial nerve (cranial nerve VII)
3. Vagus nerve (cranial nerve X)
4. Hypoglossal nerve (cranial nerve XII)
Correct Answer: 4
Rationale 1: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the
tongue for swallowing, movement of food during eating, chewing and speech. The trigeminal
nerve (cranial nerve V) is responsible for sensory impulses from the tongue, lower teeth, skin of
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the teeth and lower lip.
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Rationale 2: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the
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tongue for swallowing, movement of food during eating, chewing and speech. The facial nerve
(cranial nerve VII) is responsible for the sense of taste.
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Rationale 3: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the
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tongue for swallowing, movement of food during eating, chewing and speech. The vagus nerve
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(cranial nerve X) innervates the muscles of the throat and mouth for swallowing and talking.
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Rationale 4: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the
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tongue for swallowing, movement of food during eating, chewing, and speech.
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Global Rationale: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of
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the tongue for swallowing, movement of food during eating, chewing and speech. The trigeminal
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nerve (cranial nerve V) is responsible for facial sensation and temporal and massetter strength.
The facial nerve (cranial nerve VII) is responsible for the sense of taste and facial expressions.
The vagus nerve (cranial nerve X) innervates the muscles of the throat and mouth for swallowing
and talking.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
www.mynursingtestprep.com
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
Question 13
Type: MCSA
The nurse is examining a client experiencing vertigo and wants to perform the Romberg test. The
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nurse would correctly provide which set of instructions to the client?
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1. Touch your finger to your nose, alternating hands.
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2. Walk across the room by placing one foot in front of the other, heel to toes.
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3. Walk on your toes, then on your heels, then on your toes again.
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4. Stand with your feet together, arms at sides, and eyes open.
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Correct Answer: 4
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Rationale 1: The Romberg test is used to assess coordination and equilibrium. During the test
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the client is asked to stand with feet together, arms at sides, and eyes open. As the test progresses
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the client is asked to close her eyes. The amount of swaying done by the client once the eyes are
closed is observed. Touching the finger to the nose with alternating hands is referred to as the
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Romberg test.
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finger-to-nose test and is used to assess coordination and equilibrium but is not the same as the
Rationale 2: Walking across the room in this manner describes tandem walking. This technique
is used to observe gait.
Rationale 3: Walking in this manner enables the examiner to assess posture. The examiner
should note the clients stance and the degree of stiffness or relaxation.
Rationale 4: The Romberg test is used to assess coordination and equilibrium. During the test
the client is asked to close her eyes. The degree of swaying demonstrated is evaluated.
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Global Rationale: The Romberg test is used to assess coordination and equilibrium. During the
test the client is asked to stand with feet together, arms at sides, and eyes open. As the test
progresses the client is asked to close her eyes. The amount of swaying done by the client once
the eyes are closed is observed. Walking across the room by placing one foot in front of the
other, heel to toes, describes tandem walking, which is used to observe gait. Posture is assessed
by asking the client to walk on the toes, then on the heels. Touching the finger to the nose with
alternating hands is referred to as the finger-to-nose test and is used to assess coordination and
equilibrium but is not the same as the Romberg test.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
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system.
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Question 14
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Type: MCSA
The nurse is performing a neurological assessment on a client and needs to use stereognosis[0]
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Which of the following instructions would the nurse provide for the client?
1. Tell me if you feel one or two objects touching you with your eyes closed.
2. Identify the object in your hand with your eyes closed.
3. Identify the number being traced in your hand with your eyes closed.
4. Open and close your hand each time I tell you to.
Correct Answer: 2
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Rationale 1: Stereognosis is the ability to identify an object without seeing it. It is illustrated by
asking the client to identify objects placed in the hands with the eyes closed. Asking the client to
identify the presence of objects touching them is not an example of the technique.
Rationale 2: Stereognosis is the ability to identify an object without seeing it. It is illustrated by
asking the client to identify objects placed in the hands with the eyes closed.
Rationale 3: Stereognosis is the ability to identify an object without seeing it. It is illustrated by
asking the client to identify objects placed in the hands with the eyes closed. Asking the client to
identify the presence of objects touching them is not an example of the technique. Graphesthesia
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is the ability to perceive writing on the skin.
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Rationale 4: Sterognosis is the ability to identify an object without seeing it. It is illustrated by
asking the client to identify objects placed in the hands with the eyes closed. Asking the client to
open and close the hand may be used to assess the ability to follow commands to assess hand
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strength.
Global Rationale: Stereognosis [0]is the ability to identify an object without seeing it. It is
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illustrated by asking the client to identify objects placed in the hands with the eyes closed.
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Asking the client to identify the presence of objects touching them is not an example of the
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technique. Graphesthesia is the ability to perceive writing on the skin. Asking the client to open
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and close the hand may be used to assess the ability to follow commands to assess hand strength.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
Question 15
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Type: MCSA
The nurse performing reflex testing on a client uses the reflex hammer to gently strike the
forearm about two inches above the wrist. The nurse is assessing which of the following
reflexes?
1. Brachioradialis
2. Biceps
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3. Triceps
4. Achilles
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Correct Answer: 1
Rationale 1: The brachioradialis reflex is initiated by striking the forearm just above the wrist.
The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by
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striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the
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foot and striking the Achilles tendon.
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Rationale 2: The brachioradialis reflex is initiated by striking the forearm just above the wrist.
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The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by
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striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the
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foot and striking the Achilles tendon.
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Rationale 3: The brachioradialis reflex is initiated by striking the forearm just above the wrist.
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The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by
striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the
foot and striking the Achilles tendon.
Rationale 4: The brachioradialis reflex is initiated by striking the forearm just above the wrist.
The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by
striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the
foot and striking the Achilles tendon.
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Global Rationale: The brachioradialis reflex is initiated by striking the forearm just above the
wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is
initiated by striking just above the olecranon process. The Achilles reflex is initiated by
dorsiflexion of the foot and striking the Achilles tendon.
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
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system.
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Question 16
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Type: MCSA
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The nurse is admitting a client with suspected meningitis and notes a positive Brudzinskis sign
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1. Seizure activity
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note which of the following?
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has been noted in the history and physical. To validate this assessment finding, the nurse would
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2. Neck pain and stiffness
3. Flexion of the legs and thighs
4. Neck extension
Correct Answer: 3
Rationale 1: Brudzinskis sign is assessed in clients suspected of having meningitis. To assess for
this sign the client is placed in a supine position and assisted to flex the neck. In a positive test
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the legs and thighs will also flex. Seizure activity may be seen in meningitis but seizure activity
does not constitute a positive Brudzinskis sign.
Rationale 2: Brudzinskis sign is assessed in clients suspected of having meningitis. To assess for
this sign the client is placed in a supine position and assisted to flex the neck. In a positive test
the legs and thighs will also flex. Neck pain and stiffness may be noted with meningitis but this
is referred to as nuchal rigidity.
Rationale 3: Brudzinskis sign is assessed in clients suspected of having meningitis. To assess for
this sign the client is placed in a supine position and assisted to flex the neck. In a positive test
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the legs and thighs will also flex.
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Rationale 4: Neck extension is not associated with Brudzinskis sign.
Global Rationale: Brudzinskis sign is assessed in clients suspected of having meningitis. To
assess for this sign the client is placed in a supine position and assisted to flex the neck. In a
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positive test the legs and thighs will also flex. Seizure activity may be seen in meningitis but
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seizure activity does not constitute a positive Brudzinskis sign. Neck pain and stiffness may be
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noted with meningitis but this is referred to as nuchal rigidity. It does not constitute a positive
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Cognitive Level: Applying
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Brudzinskis sign. Neck extension is not associated with a positive Brudzinskis sign.
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
Question 17
Type: MCSA
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The nurse is assessing cranial nerve XI (spinal accessory). Which of the following statements
would the nurse say to the client?
1. Shrug your shoulders and turn your head against my hand.
2. Stick out your tongue and move it from side to side.
3. Taste these foods and decide which is sweet and which is sour.
4. Smell these items and identify what they are.
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Correct Answer: 1
Rationale 1: The spinal accessory nerve (cranial nerve XI) controls shoulder and neck
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movements. The examiner planning to test this nerve should ask the client to shrug the shoulders
and turn the head.
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Rationale 2: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the
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tongue.
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Rationale 3: The facial nerve (cranial nerve VII) is responsible for the sense of taste.
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Rationale 4: Smell is controlled by the olfactory nerve (cranial nerve I).
Global Rationale: The spinal accessory nerve (cranial nerve XI) controls shoulder and neck
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movements. The examiner planning to test this nerve should ask the client to shrug the shoulders
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and turn the head. The hypoglossal nerve (cranial nerve XII) is responsible for the movement of
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the tongue. The facial nerve (cranial nerve VII) is responsible for the sense of taste and
symmetrical facial movements. Smell is controlled by the olfactory nerve (cranial nerve I).
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
www.mynursingtestprep.com
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
Question 18
Type: MCMA
The nurse is performing a neurological assessment and needs to assess for vibration, as well as
sharp and dull sensation. The nurse would use which of the following objects to obtain this
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information?
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Standard Text: Select all that apply.
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1. Tuning fork
2. Paper clip
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3. Safety pin
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4. Cotton ball
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5. Tongue blade
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Correct Answer: 1,3
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Rationale 1: Tuning fork. To test for sharp and dull sensation, areas of the clients skin are
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touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation
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clients body.
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is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the
Rationale 2: Paper clip. To test for sharp and dull sensation, areas of the clients skin are
touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation
is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the
clients body.
Rationale 3: Safety pin. To test for sharp and dull sensation, areas of the clients skin are
touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation
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is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the
clients body.
Rationale 4: Cotton ball. The trigeminal nerve (cranial nerve V) may be evaluated by using a
wisp of cotton to touch the face.
Rationale 5: Tongue blade. The gag reflex may be evaluated by using a tongue blade.
Global Rationale: To test for sharp and dull sensation, areas of the clients skin are touched with
the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or
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sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the clients
body. The paper clip may be used to assess for the ability to determine the identity of an object
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unseen. A cotton ball may be used to assess sensation when evaluating the facial nerve. A tongue
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blade would be used to assess the gag reflex and the movements of the tongue.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
Type: MCSA
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Question 19
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system.
The nurse has assessed a client and notes diminished reflexes. The nurse would correctly
document which of the following?
1. 4+/0-4+
2. 3+/0-4+
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3. 2+/0-4+
4. 1+/0-4+
Correct Answer: 1
Rationale 1: 4+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ =
diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
Rationale 2: 3+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ =
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diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
Rationale 3: 2+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ =
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diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
Rationale 4: 1+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ =
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diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
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Global Rationale: Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+
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= diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
of the neurologic system.
Question 20
Type: MCSA
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The nurse is interviewing a client and notes that the left eyelid is drooping. The nurse would
correctly chart which of the following conditions?
1. Ptosis
2. Nystagmus
3. Strabismus
4. Myopia
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Correct Answer: 1
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Rationale 1: Ptosis, or a dropped lid, is usually related to weakness of the muscles.
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Rationale 2: Nystagmus is an involuntary movement of the eyeball.
Rationale 3: Strabismus causes deviation of one or both eyes and is due to lack of muscular
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coordination.
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Rationale 4: Myopia is a visual disturbance in which the individual is unable to see objects that
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are at a distance.
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Global Rationale: Ptosis, or a dropped lid, is usually related to weakness of the muscles.
Nystagmus is an involuntary movement of the eyeball. Strabismus causes deviation of one or
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both eyes and is due to lack of muscular coordination. Myopia is a visual disturbance in which
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the individual is unable to see objects that are at a distance.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
www.mynursingtestprep.com
Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
of the neurologic system.
Question 21
Type: MCSA
The nurse observes drainage from a clients ears after a head injury, and suspects a cerebral spinal
fluid (CSF) leak. Which of the following descriptions would best support this finding?
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1. Yellow without sediment
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2. Blood-tinged without sediment
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3. Clear, colorless
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4. Pink without sediment
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Correct Answer: 3
Rationale 1: It is important to recognize CSF as clear and colorless. Due to its appearance, it can
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be mistaken for normal drainage such as rhinorrhea. Yellow drainage is not consistent with
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cerebral spinal fluid.
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Rationale 2: It is important to recognize CSF as clear and colorless. Due to its appearance, it can
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cerebral spinal fluid.
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be mistaken for normal drainage such as rhinorrhea. Blood-tinged fluid is not consistent with
Rationale 3: It is important to recognize CSF as clear and colorless. Due to its appearance, it can
be mistaken for normal drainage such as rhinorrhea.
Rationale 4: It is important to recognize CSF as clear and colorless. Pink drainage without
sediment is not consistent with cerebral spinal fluid.
Global Rationale: It is important to recognize CSF as clear and colorless. Due to its appearance,
it can be mistaken for normal drainage such as rhinorrhea. Yellow drainage is not consistent with
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normal cerebral spinal fluid. Blood-tinged fluid is not consistent with normal cerebral spinal
fluid. Pink drainage without sediment is not consistent with cerebral spinal fluid.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
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of the neurologic system.
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Question 22
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Type: MCSA
The nurse notes that a client has difficulty with ambulation due to an unsteady gait. The nurse
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would correctly document this finding as which of the following?
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1. Flaccidity
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2. Paralysis
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4. Ataxia
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3. Hemiparesis
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Correct Answer: 4
Rationale 1: Flaccidity refers to muscle tone. The flaccid body part is not toned but is limp.
Rationale 2: Paralysis refers to the inability to move parts of the body.
Rationale 3: Hemiparesis refers to a weakness on one side of the body.
Rationale 4: Ataxia refers to the loss of balance or coordination.
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Global Rationale: Ataxia refers to loss of balance and/or coordination. Flaccidity refers to
muscle tone. Paralysis refers to the inability to move parts of the body. Hemiparesis refers to a
weakness on one side of the body.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
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of the neurologic system.
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Question 23
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Type: MCSA
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The nurse is interviewing a client that states he does not have any feeling on right side of the
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body. After confirmation of this subjective data, the nurse would correctly document which of
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the following?
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1. Anesthesia
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3. Hypalgesia
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2. Analgesia
4. Hypoesthesia
Correct Answer: 1
Rationale 1: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence
of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased,
but not absent, sensation.
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Rationale 2: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence
of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased,
but not absent, sensation.
Rationale 3: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence
of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased,
but not absent, sensation.
Rationale 4: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence
of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased,
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but not absent, sensation.
tp
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Global Rationale: Anesthesia is the inability to perceive the sense of touch. Analgesia is the
absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a
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decreased, but not absent, sensation.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
Question 24
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of the neurologic system.
Type: MCSA
The nurse is admitting a client with suspected meningitis. During the assessment, the nurse asks
the client to flex the chin down toward the chest. The client verbalizes pain and stiffness during
this action. The nurse would document this as which of the following?
1. Muscle spasms
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2. Neck strain
3. Nuchal rigidity
4. Brudzinskis sign
Correct Answer: 3
Rationale 1: Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck
stiffness. The presence of muscle spasms are not associated with meningitis and are not elicited
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in this manner.
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not involve having the client flex the chin toward the chest.
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Rationale 2: Neck strain is not associated with meningitis. The assessment of neck strain would
Rationale 3: Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck
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stiffness.
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Rationale 4: Brudzinskis sign is assessed in clients suspected of having meningitis. The sign is
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present when neck flexion causes flexion of the legs and thighs
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Global Rationale: Nuchal rigidity occurs with meningeal irritation, which will cause pain and
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neck stiffness. The presence of muscle spasms are not associated with meningitis and are not
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elicited in this manner. Neck strain is not associated with meningitis. The assessment of neck
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strain would not involve having the client flex the chin toward the chest. Brudzinskis sign is
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assessed in clients suspected of having meningitis. The sign is present when neck flexion causes
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flexion of the legs and thighs.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
www.mynursingtestprep.com
Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
of the neurologic system.
Question 25
Type: MCSA
While interviewing a client the nurse notes the clients eyes moving involuntarily. The nurse
would correctly document which of the following findings?
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1. Nystagmus
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2. Presbyopia
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3. Anosmia
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4. Polyneuritis
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Correct Answer: 1
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Rationale 1: Nystagmus is an abnormal, involuntary eye movement.
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Rationale 2: Presbyopia is an eye disorder in which the individual loses the ability to see objects
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that are near.
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Rationale 3: Anosmia refers to the absence of the sense of smell.
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Rationale 4: Polyneuritis refers to nerve inflammation.
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Global Rationale: Nystagmus is an involuntary eye movement. Presbyopia is visual
disturbances. Polyneuritis refers to nerve inflammation. Anosmia refers to the absence of smell.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
www.mynursingtestprep.com
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
of the neurologic system.
Question 26
Type: MCSA
The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of
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the plantar reflex. The nurse would correctly chart which of the following?
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1. Hyperreflexia
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2. Babinski response
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3. Brudzinski sign
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4. Nuchal rigidity
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Correct Answer: 2
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Rationale 1: Hyperreflexia refers to a reflex that is abnormally strong.
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Rationale 2: The Babinski response is fanning of the toes with the great toe pointing downward
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when the sole of the foot is stimulated. This response is considered abnormal in adults.
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Rationale 3: Brudzinski sign refers to flexion of the legs and thighs when the neck is flexed and
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is an assessment used to confirm meningitis.
Rationale 4: Nuchal rigidity refers to stiffness of the neck and is most often seen in meningitis.
Global Rationale: The Babinski response is fanning of the toes with the great toe pointing
downward when the sole of the foot is stimulated. This response is considered abnormal in
adults. The findings described do not support hyperreflexia. Hyperreflexia refers to a reflex that
is abnormally strong. Brudzinski sign refers to flexion of the legs and thighs when the neck is
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flexed and is an assessment used to confirm meningitis. Nuchal rigidity refers to stiffness of the
neck and is most often seen in meningitis.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 24.5: Describe developmental, cultural, psychosocial, and environmental
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variations in assessment techniques and findings of the neurologic system.
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Question 27
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Type: MCSA
The nurse is preparing a neurological health seminar for the staff on the unit. Which of the
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following statements would the nurse include in the teaching plan?
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1. Older adults experience fewer accidents and injuries.
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2. Alcohol or drug use increases the risk for accidents and injury.
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3. Head injuries are more common in adults than children.
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4. Epilepsy occurs only in children under age 15.
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Correct Answer: 2
Rationale 1: Older adults experience more accidents and injuries.
Rationale 2: Alcohol or drug use does increase the risk for accidents and injury and neurologic
disorders.
Rationale 3: Head injuries are more common in children than adults.
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Rationale 4: Epilepsy occurs across the age span.
Global Rationale: Alcohol or drug use does increase the risk for accidents and injury and
neurologic disorders. Older adults experience more accidents and injury. Head injuries are more
common in children than adults. Epilepsy occurs across the age span.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Planning
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Client Need Sub:
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Learning Outcome: 24.5: Describe developmental, cultural, psychosocial, and environmental
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variations in assessment techniques and findings of the neurologic system.
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Question 28
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Type: MCSA
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The nurse is reviewing the history and physical on a client and notes a history of syncope. The
1. Soft diet
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2. Seizure precautions
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nurse would implement which of the following for this client?
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3. Fall precautions
4. Intake and output
Correct Answer: 3
Rationale 1: Syncope is a sudden, brief loss of consciousness, and the nurse would need to
provide safety for a client experiencing this condition. Dietary changes may be indicated for
problems with chewing or swallowing but not for syncope.
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Rationale 2: Syncope is a sudden, brief loss of consciousness, and the nurse would need to
provide safety for a client experiencing this condition. Seizure precautions may be indicated for
an individual with a seizure-related disorder but not for the presence of syncope.
Rationale 3: Syncope is a sudden, brief loss of consciousness, and the nurse would need to
provide safety for a client experiencing this condition.
Rationale 4: Intake and output may be assessed for a variety of conditions but are not directly
needed by the client experiencing episodes of syncope.
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Global Rationale: Syncope is a sudden, brief loss of consciousness, and the nurse would need to
provide safety for a client experiencing this condition. Dietary changes may be indicated for
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problems with chewing or swallowing but not for syncope. Seizure precautions may be indicated
for an individual with a seizure-related disorder but not for the presence of syncope. Intake and
output may be indicated for a variety of medical conditions but are not indicated for the presence
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of syncope.
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Client Need: Physiological Integrity
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Cognitive Level: Analyzing
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 24.7: Apply critical thinking in selected simulations related to physical
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assessment of the neurologic system.
Question 29
Type: MCSA
The nurse is observing a clients ambulation abilities and notes a scissors gait. The nurse would
suspect which of the following disorders in this client?
1. Parkinsons disease
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2. Multiple sclerosis
3. Myasthenia gravis
4. Muscular dystrophy
Correct Answer: 2
Rationale 1: The client with Parkinsons disease displays stooped posture a shuffling gait. This is
known as a festination gait.
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Rationale 2: A scissors gait is characterized by spastic lower limb movement with stiffness and
jerkiness. The knees come together, the legs come in front of each other, and the legs are
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abducted as short, slow steps are taken. This gait is associated with multiple sclerosis.
Rationale 3: The client with myasthenia gravis has muscle weakness, and facial abnormalities
such as ptosis are consistent with the condition. The client with muscular dystrophy has muscle
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weakness and may present with a waddling gait or walk on the toes to promote balance.
Rationale 4: The client with muscular dystrophy has muscle weakness and may present with a
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waddling gait or walk on the toes to promote balance.
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Global Rationale: A scissors gait is characterized by spastic lower limb movement with
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stiffness and jerkiness. The knees come together, the legs come in front of each other, and the
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legs are abducted as short, slow steps are taken. This gait is associated with multiple sclerosis.
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The client with Parkinsons disease displays stooped posture a shuffling gait. This is known as a
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festination gait. The client with myasthenia gravis has muscle weakness, and facial abnormalities
such as ptosis are consistent with the condition. The client with muscular dystrophy has muscle
weakness and may present with a waddling gait or walk on the toes to promote balance.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
www.mynursingtestprep.com
Learning Outcome: 24.7: Apply critical thinking in selected simulations related to physical
assessment of the neurologic system.
Question 30
Type: MCSA
The nurse is assessing cognitive function in a client who experienced a cerebral vascular
accident. The nurse should focus on which of the following?
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1. Ability to smell items while eyes are closed
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2. Orientation to time, place, and person
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3. Ability to walk with a smooth, steady gait
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4. Ability to speak clearly
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Correct Answer: 2
Rationale 1: Cognitive function refers to mental abilities. The assessment of mental abilities
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may be performed by determining the clients orientation to time, place, and person. The ability to
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smell objectives while the eyes are closed is a means of assessing cranial nerve function.
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Rationale 2: Cognitive function refers to mental abilities. The assessment of mental abilities
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may be performed by determining the clients orientation to time, place, and person.
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Rationale 3: Cognitive function refers to mental abilities. The assessment of mental abilities
may be performed by determining the clients orientation to time, place, and person. The ability to
walk smoothly with a steady gait and to speak clearly are items that may be included in the
assessment of a client who has had a cerebral vascular accident but these reflect motor function
and do not reflect cognitive abilities.
Rationale 4: Cognitive function refers to mental abilities. The assessment of mental abilities
may be performed by determining the clients orientation to time, place, and person. The ability to
walk smoothly with a steady gait and to speak clearly are items that may be included in the
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assessment of a client who has had a cerebral vascular accident but these reflect motor function
and do not reflect cognitive abilities.
Global Rationale: Cognitive function refers to mental abilities. The assessment of mental
abilities may be performed by determining the clients orientation to time, place, and person. The
ability to smell objectives while the eyes are closed is a means of assessing cranial nerve
function. The ability to walk smoothly with a steady gait and to speak clearly are items that may
be included in the assessment of a client who has had a cerebral vascular accident but these
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reflect motor function and do not reflect cognitive abilities.
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Chapter 18. Assessing the Female Breasts, Axillae, and Reproductive System
Question 1
Type: HOTSPOT
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A teenaged client has been brought to the clinic with complaints of pain. After an examination it
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was determined that the client has an inflamed Bartholins cyst. After the examination the client
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location of the Bartholins gland.
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and her mother ask the nurse to show them the location of the gland involved. Mark an X on the
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : The Bartholins glands, or greater vestibular glands, are located posteriorly at the
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base of the vestibule and produce mucus, which is released into the vestibule.
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Global Rationale:
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Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive
system.
Question 2
Type: HOTSPOT
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The nurse is caring for a pregnant client. The nurse notes the healthcare provider has documented
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Correct Answer:
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Standard Text: Select the correct area on the image.
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the client has a positive Goodells sign. Mark an X on the area to which this refers.
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Rationale : Goodells sign refers to the softening of the cervix during pregnancy.
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Cognitive Level: Understanding
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Global Rationale:
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive
system.
Question 3
Type: MCMA
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The nurse is preparing to assess a female clients external genitalia. The structures included in this
assessment would be:
Standard Text: Select all that apply.
1. Vagina
2. Cervix
3. Clitoris
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4. Labia majora
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5. Labia minora
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Correct Answer: 3,4,5
Rationale 1: Vagina. The internal female reproductive organs are the vagina, uterus, cervix,
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fallopian tubes, and ovaries.
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Rationale 2: Cervix. The internal female reproductive organs are the vagina, uterus, cervix,
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fallopian tubes, and ovaries.
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Rationale 3: Clitoris. Female external genitalia include the mons pubis, labia, glands, clitoris,
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and perianal area.
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Rationale 4: Labia minora. Female external genitalia include the mons pubis, labia, glands,
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clitoris, and perianal area.
Rationale 5: Labia majora. Female external genitalia include the mons pubis, labia, glands,
clitoris, and perianal area.
Global Rationale: The female external genitalia include the clitoris, labia majora, and the labia
minora. The vagina and cervix are considered to be internal genitalia.
Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive
system.
Question 4
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Type: MCSA
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The nurse notes a forward-tilted uterus with a downward-tilted cervix when examining a female
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client. The nurse would correctly document which of the following findings in this situation?
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1. Anteflexion
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2. Retroflexion
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3. Anteversion
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4. Midposition
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Correct Answer: 3
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tilted downward.
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Rationale 1: The uterus in anteflexion is folded forward at a 90-degree angle with the cervix is
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Rationale 2: The retroverted uterus is tilted backward with the cervix tilted upward.
Rationale 3: Normal variations of uterine position include anteversion in which the uterus is
tilted forward, the cervix is tilted downward.
Rationale 4: The uterus in midposition lies parallel to the tailbone with the cervix pointed
straight.
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Global Rationale: Normal variations of uterine position include anteversion (the uterus is tilted
forward, the cervix is tilted downward), midposition (the uterus lies parallel to the tailbone, the
cervix is pointed straight), and retroversion (the uterus is tilted backward, the cervix is tilted
upward). Abnormal variations of uterine position include anteflexion (the uterus is folded
forward at a 90-degree angle, the cervix is tilted downward), and retroflexion (the uterus is
folded backward at a 90-degree angle, the cervix is tilted upward).
Cognitive Level: Applying
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Client Need: Physiological Integrity
Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive
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system.
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Question 5
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Type: MCSA
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The nurse notes that the uterus is folded backward with the cervix tilted upward when examining
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a female client. The nurse would correctly document which of the following findings in this
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1. Retroversion
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situation.
2. Retroflexion
3. Midposition
4. Anteflexion
Correct Answer: 2
Rationale 1: The retroversion positioned uterus is tilted backward with the cervix tilted upward.
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Rationale 2: The retroflexion uterus is folded backward at a 90-degree angle with the cervix
tilted upward.
Rationale 3: The midposition uterus lies parallel to the tailbone, the cervix is pointed straight.
Rationale 4: The anteversion uterus is tilted forward with the cervix tilted downward.
Global Rationale: Normal variations of uterine position include anteversion (the uterus is tilted
forward, the cervix is tilted downward), midposition (the uterus lies parallel to the tailbone, the
cervix is pointed straight), and retroversion (the uterus is tilted backward, the cervix is tilted
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upward). Abnormal variations of uterine position include anteflexion (the uterus is folded
forward at a 90-degree angle, the cervix is tilted downward), and retroflexion (the uterus is
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folded backward at a 90-degree angle, the cervix is tilted upward). Fibroids are benign tumors
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located within the uterine walls.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive
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system.
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Question 6
Type: HOTSPOT
The nurse is reviewing the technique utilized to obtain an endocervical specimen on a client.
Mark with an X the location from which the specimen will be obtained.
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Correct Answer:
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Standard Text: Select the correct area on the image.
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Rationale : The comprehensive pap smear will include swabbed specimens from the
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endocervical region.
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Cognitive Level: Applying
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Global Rationale:
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 21.2: Explain client preparation for the assessment of the reproductive
system.
Question 7
Type: MCMA
The nurse is preparing to examine the female reproductive system of a client. The nurse would
anticipate using which of the following assessment techniques?
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Standard Text: Select all that apply.
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
5. Aspiration
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Correct Answer: 1,2
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Rationale 1: Inspection. When completing the assessment of the female reproductive system the
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examiner will inspect the external genitalia.
Rationale 2: Palpation. Palpation will be used in the examination of the female reproductive
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system. The abdomen will be palpated to assess for the size and shape of the internal organs.
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Rationale 3: Percussion. Percussion will not be employed in the assessment of the female
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reproductive system. Percussion will be used to assess the gastrointestinal and pulmonary
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systems.
Rationale 4: Auscultation. Auscultation will not be used to assess the female reproductive
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systems.
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system. Auscultation will be used to assess the cardiovascular, pulmonary, and gastrointestinal
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Rationale 5: Aspiration. Aspiration will not be used to assess the female reproductive system.
Aspiration may be performed to obtain a sample.
Global Rationale: The physical assessment techniques of inspection and palpation are used in
the examination of the female reproductive system. When completing the assessment of the
female reproductive system the examiner will inspect the external genitalia. Palpation will be
used in the examination of the female reproductive system. The abdomen will be palpated to
assess for the size and shape of the internal organs. Percussion will not be employed in the
assessment of the female reproductive system. Percussion will be used to assess the
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gastrointestinal and pulmonary systems. Auscultation will not be used to assess the female
reproductive system. Auscultation will be used to assess the cardiovascular, pulmonary, and
gastrointestinal systems. Aspiration will not be used to assess the female reproductive system.
Aspiration may be performed to obtain a sample.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Planning
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Client Need Sub:
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Learning Outcome: 21.2: Explain client preparation for the assessment of the reproductive
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system.
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Question 8
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Type: MCSA
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The nurse is examining a 65 year old and palpates a mobile, smooth, round-shaped mass in the
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left lower abdominal quadrant. The nurse would correctly choose which of the following actions
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next?
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1. Ask the client if she is menstruating.
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2. Report the findings to the healthcare provider.
3. Re-examine the area using a vaginal speculum.
4. Ask the client if she could be pregnant.
Correct Answer: 2
Rationale 1: The client in this scenario is elderly. Menstruation is not a viable option.
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Rationale 2: In women who have been postmenopausal for more than 2.5 years, palpable ovaries
are considered abnormal as the ovaries would normally atrophy with the decrease in estrogen.
Rationale 3: The ovary cannot be viewed with a vaginal speculum.
Rationale 4: The age of the client would not support a likely pregnancy for the client in the
scenario. In addition, the pregnant uterus would not be palpated in the area described.
Global Rationale: In women who have been postmenopausal for more than 2.5 years, palpable
ovaries are considered abnormal as the ovaries would normally atrophy with the decrease in
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estrogen. The ovary cannot be viewed with a vaginal speculum, and a pregnant uterus would not
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be palpated in this area. Menstruation is not relevant to this situation.
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Cognitive Level: Analyzing
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 22.3: Develop questions to be used when conducting the focused interview.
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Question 9
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Type: MCSA
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The nurse is performing a gynecological examination and is ready to insert the speculum. The
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nurse would correctly insert the speculum at which of the following angles with the client in the
lithotomy position?
1. 90 degrees
2. 45 degrees
3. Straight down
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4. Straight up
Correct Answer: 2
Rationale 1: The speculum should be inserted at a 45-degree downward angle. This angle
matches the downward slope of the vagina when the client is in the lithotomy position.
Rationale 2: The speculum should be inserted at a 45-degree downward angle. This angle
matches the downward slope of the vagina when the client is in the lithotomy position.
Rationale 3: The speculum should be inserted at a 45-degree downward angle. This angle
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matches the downward slope of the vagina when the client is in the lithotomy position.
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Rationale 4: The speculum should be inserted at a 45-degree downward angle. This angle
matches the downward slope of the vagina when the client is in the lithotomy position.
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Global Rationale: The speculum should be inserted at a 45-degree downward angle. This angle
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matches the downward slope of the vagina when the client is in the lithotomy position.
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Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 22.4: Describe techniques required for assessment of the female
reproductive system.
Question 10
Type: MCMA
The nurse is preparing to perform an endocervical swab and needs to choose the most effective
equipment to collect this specimen. The nurse would have which of the following ready for this
procedure?
www.mynursingtestprep.com
Standard Text: Select all that apply.
1. Microscopic slides
2. Saline
3. Cytobrush
4. Cotton applicator
5. Fixative
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Correct Answer: 1,3,5
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Rationale 1: Microscopic slides. The slides will be used to place the specimen on.
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Rationale 2: Saline. Saline is used to moisten a cotton tipped applicator but is not needed with
the cytobrush.
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Rationale 3: Cytobrush. The cytobrush is preferred to obtain the endocervical cells.
Rationale 4: Cotton applicator. The use of the cotton application is not as highly recommended
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as the cytobrush. The endocervical cells will not adhere as well to the cotton-tipped applicator.
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Rationale 5: Fixative. A fixative is a solution used to secure the specimen.
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Global Rationale: When preparing to obtain an endocervical swam specimen the nurse will
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need to have microscopic slides, cytobrush, and a fixative. The slides will be used to place the
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specimen on. The cell specimens are obtained using a cytobrush. The cotton applicator will not
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be used in place of the cytobrush as it is not as effective in obtaining cells. Saline is used to
moisten a cotton-tipped applicator but not used with the cytobrush.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
www.mynursingtestprep.com
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 22.4: Describe techniques required for assessment of the female
reproductive system.
Question 11
Type: MCSA
The nurse is performing a vaginal examination on a client who has had a hysterectomy. Which of
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the following would the nurse choose to do in this situation?
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1. Defer the cervical scrape.
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2. Use the vaginal wall for the cervical scrape.
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3. Tell the client an examination is not needed.
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4. Use the surgical stump for the cervical scrape.
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Correct Answer: 4
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Rationale 1: Clients who have had hysterectomies should have the surgical stump scraped as
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part of the examination. Deferring the cervical assessment could result in the omission of
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important information for the comprehensive care of the client.
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Rationale 2: Specimens from the vaginal walls are indicated but do not replace the need to have
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cells obtained from the cervical stump.
Rationale 3: Clients that have had hysterectomies should have the surgical stump scraped as part
of the examination.
Rationale 4: Clients that have had hysterectomies should have the surgical stump scraped as part
of the examination.
Global Rationale: Clients who have had hysterectomies should have the surgical stump scraped
as part of the examination. Deferring the scrape, using the walls of the vagina, or telling the
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client the examination is not needed would reduce the clients ability to have a comprehensive
pelvic examination. Important cellular specimens must be obtained from the cervical stump.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 22.4: Describe techniques required for assessment of the female
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reproductive system.
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Question 12
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Type: MCSA
The nurse assisting the healthcare provider who is performing a bimanual examination on an
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extremely obese client. The healthcare provider is unable to palpate the uterus. Which of the
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following actions would most likely be selected in this situation?
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2. Schedule an X-ray.
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1. Defer the examination.
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3. Schedule an ultrasound.
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4. Ask the client if she has had recent problems.
Correct Answer: 3
Rationale 1: Forgoing an examination as a result of difficulties encountered is not a responsible
action. The nurse has a responsibility to utilize other methods available as indicated.
Rationale 2: The use of an X-ray is not the best diagnostic test to review the condition of soft
tissue organs and surrounding tissue.
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Rationale 3: In an obese female palpation of the uterus may be difficult. An ultrasound would
allow for examination of the female reproductive organs.
Rationale 4: The size of the client is the most likely cause of the inability to palpate the uterus.
A discussion of recent problems is a part of the assessment but it does not reduce the need to
discuss obtaining the ultrasound.
Global Rationale: In the obese female, it may be difficult to clearly differentiate the uterine
structures and an ultrasound may be needed. Obtaining an ultrasound can only be done after
consulting with the healthcare provider about the findings. The remaining choices are incorrect
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for this situation. An X-ray is not the best diagnostic test to review the condition of soft tissue
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organs and surrounding tissue. Deferring the examination does not meet the needs of the client.
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Determining the clients recent health history does not meet the needs of the client in having the
uterus evaluated.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 22.4: Describe techniques required for assessment of the female
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Question 13
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reproductive system.
Type: MCSA
The nurse is examining a pregnant client and notes the cervix is soft in texture and nontender.
The nurse would correctly document which of the following conditions in this situation?
1. Nabothian cyst
2. Chadwicks sign
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3. Hegars sign
4. Goodells sign
Correct Answer: 4
Rationale 1: Nabothian cysts are yellow and nodular and are benign areas that may appear after
childbirth.
Rationale 2: Chadwicks sign, also occurring during pregnancy, is the appearance of a bluish-
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purple coloration of the cervix due to vascular congestion.
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Rationale 3: Hegars sign refers to the softening of the lower uterine segemt during pregnancy.
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Rationale 4: During pregnancy, the vascularity of the cervix increases and contributes to the
softening of the cervix. This is a normal finding called Goodells sign.
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Global Rationale: During pregnancy, the vascularity of the cervix increases and contributes to
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the softening of the cervix. This is a normal finding called Goodells sign. Chadwicks sign, also
occurring during pregnancy, is the appearance of a bluish-purple coloration of the cervix due to
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vascular congestion. Hegars sign refers to a softening of the lower uterine segment during
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pregnancy. Nabothian cysts are yellow and nodular and are benign areas that may appear after
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childbirth.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
of the female reproductive system.
Question 14
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Type: MCSA
The nurse is examining a pregnant client and notes the cervix has a bluish-purple change in
coloration. The nurse would correctly document which of the following conditions in this
situation?
1. Nabothian cyst
2. Goodells sign
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3. Chadwicks sign
4. Bloody show
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Correct Answer: 3
Rationale 1: Nabothian cysts are yellow and nodular and are benign areas that may appear after
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childbirth.
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Rationale 2: Vascularity of the cervix also contributes to the softening of the cervix, and is
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called Goodells sign.
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Rationale 3: Chadwicks sign appears during pregnancy and is the appearance of a bluish-purple
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coloration of the cervix due to vascular congestion.
Rationale 4: Expulsion of the mucous plug at the endocervical canal produces a bloody show at
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the initiation of labor.
Global Rationale: Chadwicks sign appears during pregnancy and is the appearance of a bluishpurple coloration of the cervix due to vascular congestion. Nabothian cysts are yellow and
nodular and are benign areas that may appear after childbirth. Vascularity of the cervix also
contributes to the softening of the cervix, and is called Goodells sign. Nabothian cysts are yellow
and nodular and are benign areas that may appear after childbirth. Expulsion of the mucous plug
at the endocervical canal produces a bloody show at the initiation of labor.
Cognitive Level: Applying
www.mynursingtestprep.com
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
of the female reproductive system.
Question 15
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Type: MCSA
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The nurse notes reddened areas on the labia and a discharge that is white and curd-like in the
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vaginal canal when examining a female client. The nurse would suspect which of the following
conditions in this situation.
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1. Contact dermatitis
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2. Yeast infection
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3. Herpes infection
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4. Venereal warts
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Correct Answer: 2
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Rationale 1: Contact dermatitis is characterized by reddened lesions that weep and form crusts.
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Rationale 2: Yeast infections are the most common female genital infection and can produce
redness, pruritis, and cheese-like discharge.
Rationale 3: Herpes infection causes small, red, painful ulcerations.
Rationale 4: Venereal warts appear as cauliflower-shaped, raised, moist papules.
Global Rationale: Yeast infections are the most common female genital infection and can
produce redness, pruritis, and cheese-like discharge. Contact dermatitis is characterized by
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reddened lesions that weep and form crusts. Herpes infection causes small, red, painful
ulcerations. Venereal warts appear as cauliflower-shaped, raised, moist papules.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
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of the female reproductive system.
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Question 16
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Type: MCSA
The nurse is examining a female client and notes a greenish discharge with a foul odor. The
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client also exhibits guarding of the abdomen. The nurse would suspect which of the following
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conditions in this situation?
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1. Trichomoniasis
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3. Gonorrhea
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2. Herpes infection
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4. Bacterial vaginosis
Correct Answer: 3
Rationale 1: Frothy yellow-green discharge is seen in trichomoniasis.
Rationale 2: Herpes infection produces red, painful vesicles with localized swelling.
Rationale 3: Green discharge that has a foul smell is associated with gonorrhea, which may
spread to the abdominal cavity to cause pelvic inflammatory disease.
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Rationale 4: Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy
odor.
Global Rationale: Green discharge that has a foul smell is associated with gonorrhea, which
may spread to the abdominal cavity to cause pelvic inflammatory disease. Frothy yellow-green
discharge is seen in trichomoniasis. Herpes infection produces red, painful vesicles with
localized swelling. Bacterial vaginosis presents with a creamy-gray to white discharge that has a
fishy odor.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
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Question 17
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of the female reproductive system.
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Type: MCSA
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The nurse is examining the external genitalia of a female client and notes raised, cauliflower-
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1. Genital warts
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shaped papules. The nurse would suspect which of the following conditions in this situation?
2. Herpes infection
3. Bartholins abscess
4. Contact dermatitis
Correct Answer: 1
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Rationale 1: Genital warts present as raised, cauliflower-shaped papules.
Rationale 2: Herpes infection produces red, painful vesicles with localized swelling.
Rationale 3: Bartholins abscess produces inflammatory signs such as redness and warm skin.
Bartholins abscess produces inflammatory signs such as redness and warm skin.
Rationale 4: Contact dermatitis produces red, weepy rashes.
Global Rationale: Genital warts present as raised, cauliflower-shaped papules as described.
Herpes infection produces red, painful vesicles with localized swelling. Bartholins abscess
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produces inflammatory signs such as redness and warm skin. Contact dermatitis produces red,
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weepy rashes.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
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of the female reproductive system.
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Type: MCSA
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Question 18
The nurse notes documentation in the clients history and physical of a nontender protrusion into
the anterior vaginal wall. The nurse would suspect which of the following conditions in this
situation?
1. Inflammation of the Skenes gland
2. Prolapsed uterus
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3. Rectocele
4. Cystocele
Correct Answer: 4
Rationale 1: The Skenes glands are examined by palpation on both sides of the urethra.
Rationale 2: A prolapsed uterus may protrude from the vaginal wall, and may occur with or
without straining.
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Rationale 3: A rectocele is a hernia that is formed when the rectum pushes into the posterior
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vaginal wall.
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Rationale 4: A cystocele is a hernia that is formed when the urinary bladder is pushed into the
vaginal wall.
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Global Rationale: A cystocele is a hernia that is formed when the urinary bladder is pushed into
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the vaginal wall. The Skenes glands are examined by palpation on both sides of the urethra. A
prolapsed uterus may protrude from the vaginal wall, and may occur with or without straining. A
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Cognitive Level: Analyzing
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rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall.
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
of the female reproductive system.
Question 19
Type: MCSA
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The nurse is reading the history and physical and notes documentation of a protrusion into the
posterior vaginal wall. The nurse would suspect which of the following conditions in this
situation?
1. Ovarian cyst
2. Bartholins gland infection
3. Cystocele
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4. Rectocele
Correct Answer: 4
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Rationale 1: Ovarian cysts cause inflammation and tenderness upon examination.
Rationale 2: The Bartholins glands are palpated by gently squeezing the posterior region of the
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labia majora.
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Rationale 3: A cystocele is a hernia that is formed when the urinary bladder is pushed into the
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vaginal wall.
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Rationale 4: A rectocele is a hernia that is formed when the rectum pushes into the posterior
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vaginal wall.
Global Rationale: A rectocele is a hernia that is formed when the rectum pushes into the
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posterior vaginal wall. Ovarian cysts cause inflammation and tenderness upon examination. The
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Bartholins glands are palpated by gently squeezing the posterior region of the labia majora. A
cystocele is a hernia that is formed when the urinary bladder is pushed into the vaginal wall.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
www.mynursingtestprep.com
Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
of the female reproductive system.
Question 20
Type: MCSA
The nurse is interviewing a female client that reports a grayish discharge with a fishy odor. The
nurse would suspect which of the following conditions in this situation?
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1. Bacterial vaginosis
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2. Chlamydia
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3. Genital warts
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4. Gonorrhea
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Correct Answer: 1
Rationale 1: Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy
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odor.
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Rationale 2: A yellow discharge can be noted in a chlamydia infection.
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Rationale 3: Genital warts are raised, moist, cauliflower-shaped papules.
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Rationale 4: Gonorrhea is associated with a foul-smelling discharge.
Global Rationale: Bacterial vaginosis presents with a creamy-gray to white discharge that has a
fishy odor. A yellow discharge can be seen in chlamydial infection. Genital warts are raised,
moist, cauliflower-shaped papules. Green discharge that has a foul smell is associated with
gonorrhea.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
www.mynursingtestprep.com
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
of the female reproductive system.
Question 21
Type: MCSA
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The nurse is interviewing a female client who reports a frothy, yellow-green discharge. The
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nurse would suspect which of the following conditions in this situation?
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1. Vaginitis
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2. Trichomoniasis
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3. Gonorrhea
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4. Chlamydia
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Correct Answer: 2
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Rationale 1: Vaginitis indicates a nonspecific inflammation of the vagina.
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Rationale 2: Frothy yellow-green discharge is seen in trichomoniasis.
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Rationale 3: Green discharge that has a foul smell is associated with gonorrhea.
Rationale 4: A yellow discharge can be seen in chlamydial infection.
Global Rationale: Frothy yellow-green discharge is seen in trichomoniasis. Vaginitis indicates a
nonspecific inflammation of the vagina. Green discharge that has a foul smell is associated with
gonorrhea. Green discharge that has a foul smell is associated with gonorrhea. A yellow
discharge can be seen in chlamydial infection.
Cognitive Level: Analyzing
www.mynursingtestprep.com
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
of the female reproductive system.
Question 22
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Type: MCSA
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The nurse is examining the external genitalia of a female client and notes small vesicular lesions
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that are painful. The nurse would suspect which of the following conditions in this situation?
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1. Genital warts
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2. Herpes infection
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3. Bartholins abscess
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4. Contact dermatitis
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Correct Answer: 2
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Rationale 1: Genital warts produce cauliflower-like lesions.
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Rationale 2: Herpes infection produces red, painful vesicles with localized swelling.
Rationale 3: Bartholins abscess produces inflammatory signs, such as redness and warm skin.
Rationale 4: Contact dermatitis produces red, weepy rashes.
Global Rationale: Herpes infection produces red, painful vesicles with localized swelling.
Genital warts produce cauliflower-like lesions. Bartholins abscess produces inflammatory signs,
such as redness and warm skin. Contact dermatitis produces red, weepy rashes.
www.mynursingtestprep.com
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
of the female reproductive system.
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Question 23
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Type: MCSA
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The nurse is examining the external genitalia of a female client and notes draining papules. The
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nurse would suspect which of the following conditions in this situation?
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1. Genital warts
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2. Herpes infection
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3. Syphilitic lesion
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4. Contact dermatitis
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Correct Answer: 3
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Rationale 1: Genital warts produce cauliflower-like lesions.
Rationale 2: Herpes infection produces red, painful vesicles with localized swelling.
Rationale 3: Syphilitic lesions are painless papules that may begin to produce drainage.
Rationale 4: Contact dermatitis produces red, weepy rashes.
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Global Rationale: Syphilitic lesions are painless papules that may begin to produce drainage.
Genital warts produce cauliflower-like lesions. Herpes infection produces red, painful vesicles
with localized swelling. Contact dermatitis produces red, weepy rashes.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
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of the female reproductive system.
Question 24
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Type: MCSA
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The nurse is providing education on menopause to a group of female clients. Which of the
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following statements made by one of the clients would indicate the need for further instruction
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by the nurse?
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1. My periods may be irregular and less frequent.
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2. Night sweats and hot flashes are commonly experienced.
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3. My mood changes are a normal part of menopause.
4. Vaginal dryness may occur during menopause.
Correct Answer: 1
Rationale 1: Menopause is said to have occurred when the female has not experienced a period
in over one year.
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Rationale 2: As estrogen levels decline, symptoms include night sweats, hot flashes, mood
changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete.
Rationale 3: As estrogen levels decline, symptoms include night sweats, hot flashes, mood
changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete.
Rationale 4: As estrogen levels decline, symptoms include night sweats, hot flashes, mood
changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete.
Global Rationale: Menopause is said to have occurred when the female has not experienced a
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period in over one year. As estrogen levels decline, symptoms include night sweats, hot flashes,
mood changes, and vaginal dryness, but if menstruation is still occurring, menopause is not
Cognitive Level: Analyzing
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Client Need: Health Promotion and Maintenance
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complete.
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Evaluation
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Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental
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Type: MCSA
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Question 25
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variations in assessment and findings.
The nurse is interviewing an elderly female client. Which of the following statements made by
the client would cause intervention by the nurse?
1. I use a lubricant for sex to help with dryness.
2. I take hormone pills to help with my hot flashes.
3. My periods stopped for 5 years, but recently restarted.
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4. I dont have a desire for sex very often, but neither does my husband.
Correct Answer: 3
Rationale 1: The use of lubrication for sexual intimacy is normal due to vaginal dryness,
although libido may be diminished in both the male and female.
Rationale 2: The use of estrogen replacement therapy can alleviate symptoms related to night
sweats, hot flashes, and mood changes.
Rationale 3: Women may assume that postmenopausal bleeding is normal and ignore it, but this
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may be suggestive of inadequate estrogen therapy or endometrial cancer, and follow-up is
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required.
Rationale 4: The use of lubrication for sexual intimacy is normal due to vaginal dryness,
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although libido may be diminished in both the male and female.
Global Rationale: Women may assume that postmenopausal bleeding is normal and ignore it,
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but this may be suggestive of inadequate estrogen therapy or endometrial cancer, and follow-up
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is required. The use of lubrication for sexual intimacy is normal due to vaginal dryness, although
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libido may be diminished in both the male and female. The use of estrogen replacement therapy
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can alleviate symptoms related to night sweats, hot flashes, and mood changes.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental
variations in assessment and findings.
Question 26
Type: MCMA
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The nurse is examining an adolescent female and notes no pubic hair on the pubis area. The
nurse would correctly choose which of the following actions?
Standard Text: Select all that apply.
1. Ask the client if she is menstruating.
2. Examine the client for breast buds.
3. Report the findings to the healthcare provider.
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4. Document the findings as normal.
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5. Assess the clients dietary intake.
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Correct Answer: 1,2,3
Rationale 1: Ask the client if she is menstruating. The presence or absence of menstrual
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history will aid in the determination of hormonal function.
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Rationale 2: Examine the client for breast buds. The presence or absence of breast buds will
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aid in the confirmation of the maturity of secondary sexual characteristics.
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Rationale 3: Report the findings to the healthcare provider. Abnormalities may be indicative
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of endocrine pathology and need to be reported to the healthcare provider for follow-up.
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Rationale 4: Document the findings as normal. According to Tanners Maturation Stages in the
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female, the findings in this situation are not normal for the adolescent female client. The
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adolescent female should have fine, sparse hair beginning at the labia and rising up the pubis.
Rationale 5: Assess the clients dietary intake. Dietary intake information in the client who
presents with physical immaturities in the event they also exhibit signs of nutritional
deficiencies. There is no supportive information indicating that there are nutritional needs unmet.
Global Rationale: According to Tanners Maturation Stages in the female, the findings in this
situation are not normal for the adolescent female client. The adolescent female should have fine,
sparse hair beginning at the labia and rising up the pubis. Abnormalities may be indicative of
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endocrine pathology and need to be reported to the healthcare provider for follow-up. Potentially
related factors will need to be investigated. Subjective data related to menstruation are relevant
to the situation. The presence or absence of menstrual history will aid in the determination of
hormonal function. The presence or absence of breast buds will aid in the confirmation of the
maturity of secondary sexual characteristics. Dietary intake information in the client who
presents with physical immaturities may be reviewed in the event they also exhibit signs of
nutritional deficiencies. There is no supportive information indicating that there are nutritional
needs unmet.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental
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Question 27
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variations in assessment and findings.
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Type: MCSA
The nurse is examining an adult female and notes thick, coarse pubic hair covering the pubis and
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extending to the thighs. The nurse would correctly choose which of the following actions?
1. Ask the client if she has started menstruation.
2. Report the findings to the healthcare provider.
3. Document the findings as normal.
4. Ask the client if she is sexually active.
Correct Answer: 3
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Rationale 1: The clients physical appearance indicates the correct level of maturation.
Information concerning menstruation is not needed.
Rationale 2: In the presence of normal findings the healthcare provider does not need
notification.
Rationale 3: According to Tanners Maturation Stages in the female, the findings in this situation
are appropriate for the adult female client. No further subjective information is required by the
nurse. The nurse should document the findings.
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Rationale 4: Information concerning the clients level of sexual activity is not relevant to the
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client in this scenario.
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Global Rationale: According to Tanners Maturation Stages in the female, the findings in this
situation are appropriate for the adult female client. No further subjective information is required
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by the nurse. The nurse should document the findings. The clients physical appearance indicates
the correct level of maturation. Information concerning menstruation is not needed. In the
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presence of normal findings the healthcare provider does not need notification. Information
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Cognitive Level: Analyzing
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concerning the clients level of sexual activity is not relevant to the client in this scenario.
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental
variations in assessment and findings.
Question 28
Type: MCSA
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The community health nurse is preparing a presentation concerning the sexual health of teenaged
girls. The objectives of Healthy People 2020 are being used as guidelines. When planning the
offering which of the following should be included?
1. Increase the number of teens who are using oral contraceptives.
2. Increase the number of teens who utilize relationship counseling services.
3. Increase the number of teens who are tested for HIV.
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4. Increase the number of teens who understand their reproductive functions.
Correct Answer: 3
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Rationale 1: The goals of Healthy People 2020 seek to increase the proportion of adolescents
who abstain from sexual intercourse or use condoms if sexually active and to increase the
percentage of adolescents who have been tested for HIV. There are no provisions to dictate the
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use of oral contraceptives.
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Rationale 2: Relationship counseling services are not included in the Healthy People 2020
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objectives.
Rationale 3: The goals of Healthy People 2020 seek to increase the proportion of adolescents
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who abstain from sexual intercourse or use condoms if sexually active and to increase the
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percentage of adolescents who have been tested for HIV.
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People 2020.
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Rationale 4: The understanding of reproductive functions is not direct objectives of Healthy
Global Rationale: The goals of Healthy People 2020 seek to increase the proportion of
adolescents who abstain from sexual intercourse or use condoms if sexually active and to
increase the percentage of adolescents who have been tested for HIV. There are no provisions to
dictate the use of oral contraceptives. Relationship counseling services are not included in the
Healthy People 2020 objectives. The understanding of reproductive functions is not a direct
objective of Healthy People 2020.
Question 29
Type: MCMA
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The nurse is conducting a breast health workshop for a group of women. Which of the following
would the nurse include in this workshop when outlining risk factors for breast cancer?
Standard Text: Select all that apply.
1. Caucasian race
2. Positive family history
3. Low socioeconomic status
4. Hormone replacement therapy
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5. Female age 35 to 40
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Correct Answer: 1,2,3,4
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Rationale 1: Caucasian race. Caucasian females, especially over the age of 40 have a higher
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risk of developing breast cancer than any other race or ethnic group.
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Rationale 2: Positive family history. A positive family history of breast cancer places an
individual at a higher risk of developing breast cancer. The individual is at an even greater risk if
the family member developed breast cancer prior to menopause.
Rationale 3: Low socioeconomic status. Lower socioeconomic status places an individual at
risk for breast cancer for a number of reasons, including lack of education on preventative
measures and diagnostic recommendations; fear that breast cancer is not treatable and has a high
mortality rate, thus they avoid diagnosis; and the mother of the family in lower socioeconomic
groups often places her familys health care needs above hers.
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Rationale 4: Hormone replacement therapy. Hormone replacement therapy is linked to higher
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incidence of breast cancer.
Rationale 5: Female age 35 to 40. Females between the ages of 35 to 40 have not been found to
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have a high incidence of breast cancer.
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Global Rationale: Caucasian females over the age of 40, positive family history, low
socioeconomic status, and taking hormone replacement therapy are risk factors for breast cancer.
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Cognitive Level: Understanding
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Females from 35 to 40 years of age are not at a high risk for developing breast cancer.
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of
female breasts.
Question 30
Type: MCSA
The nurse is performing an assessment on a newborn and notes a thin, milky discharge from the
infants nipple. The nurse knows this is a:
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1. congenital anomaly.
2. highly irregular finding.
3. reason to call in a specialist.
4. common finding in newborns.
Correct Answer: 4
Rationale 1: The breast tissue of newborns is sometimes swollen because of hyperestrogenism
of pregnancy, and some infants may produce a thin discharge called witchs milk, which subsides
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as the infants body eliminates maternal hormones. This is not considered a congenital anomaly.
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Rationale 2: The breast tissue of newborns is sometimes swollen because of hyperestrogenism
of pregnancy, and some infants may produce a thin discharge called witchs milk, which subsides
as the infants body eliminates maternal hormones; therefore, this is not considered an irregular
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finding.
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Rationale 3: The breast tissue of newborns is sometimes swollen because of hyperestrogenism
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of pregnancy, and some infants may produce a thin discharge called witchs milk, which subsides
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as the infants body eliminates maternal hormones; therefore, there would be no reason to contact
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a specialist.
Rationale 4: The breast tissue of newborns is sometimes swollen because of hyperestrogenism
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of pregnancy, and some infants may produce a thin discharge called witchs milk, which subsides
in newborns.
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as the infants body eliminates maternal hormones; therefore, this assessment finding is common
Global Rationale: The breast tissue of newborns is sometimes swollen because of
hyperestrogenism of pregnancy. Some infants may produce a thin discharge called witchs milk,
which subsides as the infants body eliminates maternal hormones. This is neither irregular nor
hereditary, and there is no reason to call on a specialist.
Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment
of the breasts and axillae.
Question 31
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Type: MCSA
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A female client is hospitalized with injury and tissue destruction of the left pectoralis major and
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serratus anterior muscles due to a motor vehicle accident. The nurse would include which of the
following information during the discharge teaching?
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1. Prosthestic devices
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2. Support bras
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3. Plastic surgery
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4. Physical therapy
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Correct Answer: 2
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Rationale 1: A prosthetic device is not indicated as treatment in this scenario, so discharge
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teaching for such devices is not necessary.
Rationale 2: Discharge teaching regarding the need for the client to wear a support bra would be
indicated in this scenario since injury has occurred to the left pectoralis major and serratus
anterior muscles, as these comprise the suspensory ligaments of the breasts.
Rationale 3: Plastic surgery is not indicated as treatment in this scenario, so discharge teaching
for such devices is not necessary.
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Rationale 4: Physical therapy is not indicated as treatment in this scenario, so discharge teaching
for such devices is not necessary.
Global Rationale: The overall contour of the breasts is determined by the suspensory ligaments,
which provide support, and the major muscles of support are the pectoralis major and serratus
anterior muscles. The major function of the muscles of the chest wall is to support breast and
lymphatic tissue. Undergarments, which provide needed support after discharge, are an important
part of the clients recoveryfor emotional as well as physical health. Although prostheses, plastic
surgery, and physical therapy may all be part of the comprehensive care plan, supporting the
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breast and lymph tissue until such time as muscle strength is restored or reconstructed would be
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an important nursing intervention.
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Cognitive Level: Analyzing
Client Need Sub: Basic Care and Comfort
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae.
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Question 32
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Type: MCSA
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The nurse is using inspection to assess the breasts of a female client. Which of the following
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findings might the nurse obtain using this assessment technique?
1. Symmetry
2. Hard nodules
3. Tenderness
4. Skin consistency
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Correct Answer: 1
Rationale 1: Symmetry of the breasts indicates that both breasts are nearly the same size and
shape. This assessment is performed by the technique of inspection.
Rationale 2: Hard nodules in the breast tissue cannot be assessed by inspection. Palpation would
be necessary for this type of assessment.
Rationale 3: Tenderness cannot be assessed by inspection. Palpation would be necessary for this
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type of assessment.
Rationale 4: Skin thickening cannot be assessed by inspection. Palpation would be necessary for
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this type of assessment.
Global Rationale: Symmetry is the only finding that the nurse would assess using the technique
of inspection when examining the breasts. The remaining findings would all be obtained using
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the technique of palpation.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Question33
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Learning Outcome: 16.4: Describe techniques for assessment of the breasts and axillae.
Type: MCMA
The nurse is teaching an older adult client about breast self-examination (BSE). Which of the
following should the nurse provide during this instruction?
Standard Text: Select all that apply.
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1. Additional lighting
2. Increased time
3. Opportunity for questions
4. Large-print handouts
5. A quiz at the end of the instruction
Correct Answer: 1,2,3,4
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Rationale 1: Additional lighting. Additional lighting may be necessary when teaching the older
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adult client about BSE due to failing eyesight in some of these clients.
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Rationale 2: Increased time. More time may be required for the focused interview of the older
client who may have a more difficult time talking about something as private as the breasts.
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Rationale 3: Opportunity for questions. Allowing an ample amount of opportunity for
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questions is necessary for some older adults who may take longer to process new information.
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Rationale 4: Large-print handouts. Large-print handouts may be necessary when teaching the
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older adult client about BSE due to failing eyesight in some of these clients.
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Rationale 5: A quiz at the end of the instruction. A quiz at the end of the instruction is not
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indicated as this may cause the client to feel undue stress.
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Global Rationale: More time may be required for the focused interview of the older client who
may have a more difficult time talking about something as private as the breasts. Limited range
of motion and failing eyesight are some of the physical changes that accompany the aging
process. Providing additional lighting, moving at a slower pace, and using handouts or pamphlets
with large print may be helpful. A quiz would not be indicated as this may cause the client to
experience undue stress.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 16.7: Identify anatomical, physiologic, developmental, psychosocial, and
cultural variation that guide assessment.
Question 34
Type: MCSA
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The nurse is asking a client questions regarding lifestyle patterns. Which of the following
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statements by the client would alert the nurse to possible risk for breast cancer?
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1. I work in a chemical factory.
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2. I drink two glasses of wine each night.
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3. I have smoked two packs of cigarettes daily for four years.
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4. I occasionally have unprotected sexual contact with unknown partners.
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Correct Answer: 2
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Rationale 1: Exposure to chemicals by working in a chemical factory would place the client at
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risk for developing lung-related cancers or other body system cancers or disease.
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Rationale 2: Research indicates that alcohol intake in excess of nine drinks per week may
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increase a womans risk of developing breast cancer. Two glasses of wine each night totals 14
drinks per week.
Rationale 3: Smoking two packs of cigarettes daily for four years would place the client at risk
for developing lung-related cancers or disease.
Rationale 4: Occasional unprotected sexual contact with unknown partners increases risk for
STDs, HIV, as well as cervical cancer.
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Global Rationale: Research indicates that a high-fat diet may increase a womans risk of
developing breast cancer as well as alcohol intake in excess of nine drinks per week. Exposure to
chemicals and cigarette smoke would place the client at risk for developing lung-related cancers
or disease, and unprotected sexual contact increases risk for STDs, HIV, as well as cervical
cancer.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 16.2: Develop questions to be used when completing the focused interview.
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Question 35
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Type: MSA
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The nurse is teaching selfbreast examination to a client and demonstrates inspecting the breasts
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with arms over the head. The client asks the nurse why this is necessary. The nurse would
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respond with which of the following?
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1. It allows any masses to bulge forward to be seen.
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2. This is the only position to detect Pagets disease.
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3. This is the best position to look for skin dimpling.
4. It is the only way to look for nipple retraction.
Correct Answer: 3
Rationale 1: Masses are rarely visible with inspection so stating that this position would allow
for any masses to bulge forward to be seen is an inaccurate statement.
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Rationale 2: Pagets disease is a rare type of breast cancer typified by a red, scaly, eczema-like
area over the nipple and, like nipple retraction, does not have to be visualized with the arms over
the head.
Rationale 3: This statement is accurate since recent dimpling of the skin over a mass is often a
visible sign of breast cancer, and it is accentuated with the clients arms over the head.
Rationale 4: Nipple retraction is a possible sign of breast cancer, but it does not require the arms
over the head for visualization.
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Global Rationale: Dimpling of the skin over a mass is usually a visible sign of breast cancer.
Dimpling is accentuated with the clients arms over the head. Pagets disease is a rare type of
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breast cancer typified by a red, scaly, eczema-like area over the nipple and, like nipple retraction,
does not have to be visualized with the arms over the head. Masses are rarely visible with
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inspection.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Type: MCSA
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Question 36
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Learning Outcome: 16.4: Describe techniques for assessment of the breasts and axillae
The nurse is assessing a client and confirms the presence of galactorrhea. The nurse understands
that this finding is:
1. suggestive of endocrine disorders.
2. may indicate a malignancy.
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3. probably an infection.
4. usually indicative of lactation.
Correct Answer: 1
Rationale 1: Galactorrhea is lactation not associated with childbearing and occurs most
commonly with endocrine disorders or medications, including some antidepressant and
antihypertensive medications.
intraductal papilloma, or it may indicate a malignancy.
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Rationale 2: Unilateral discharge from the nipple is suggestive of benign breast disease, an
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Rationale 3: Infections of the breast often cause enlargement and tenderness of the axillary
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lymph nodes.
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Rationale 4: Normal lactation is associated with childbearing and is not called galactorrhea.
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Global Rationale: Galactorrhea is lactation not associated with childbearing and occurs most
commonly with endocrine disorders or medications, including some antidepressants and
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antihypertensives. Unilateral discharge from the nipple is suggestive of benign breast disease, an
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intraductal papilloma, or cancer. Infections of the breast cause enlargement and tenderness of the
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axillary lymph nodes.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment
of the breasts and axillae
Question 37
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Type: MCMA
The nurse is examining a client with a history of benign breast disease (sometimes referred to as
fibrocystic breast disease). The nurse would expect which of the following findings during this
assessment?
Standard Text: Select all that apply.
1. Straw-colored discharge from the nipples
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2. Freely movable masses
3. Hard, fixed nodules
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4. Thickened breast tissue
5. Masses with well defined boundaries
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Correct Answer: 1,2,4,5
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Rationale 1: Straw-colored discharge from the nipples. Straw-colored discharge from the
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nipples is common with benign breast disease. Discharge from the nipples may be clear, straw-
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colored, milky, or green.
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Rationale 2: Freely movable masses. Masses with benign breast disease are generally freely
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movable.
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Rationale 3: Hard, fixed nodules. Hard, fixed nodules are more commonly associated with
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cancer of the breast.
Rationale 4: Thickened breast tissue. The symptoms of benign breast disease are a result of
fibrosis, which is a thickening of the normal breast tissue and may be accompanied by cyst
formation.
Rationale 5: Masses with well defined boundaries. The masses of benign breast disease are
typically well demarcated (having defined boundaries).
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Global Rationale: Upon palpation of fibrocystic breasts, the masses feel soft, well demarcated
and freely movable. Discharge from the nipples may be clear, straw-colored, milky, or green.
These symptoms are a result of fibrosis, which is a thickening of the normal breast tissue and
may be accompanied by cyst formation. Hard, fixed nodules are suggestive of cancer of
lymphoma.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment
of the breasts and axillae.
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Question 38
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Type: MCSA
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The nurse is teaching a client with benign breast disease about symptom relief. Which of the
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1. Avoiding all fat in the diet
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following topics would the nurse include in this session?
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2. Wearing a firm bra
3. Limiting salt intake
4. Drinking tea instead of coffee
Correct Answer: 3
Rationale 1: Avoiding all fat in the diet is not advisable for any client; limiting the amount of
saturated fats may help alleviate pain associated with benign breast disease.
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Rationale 2: Wearing a firm bra has not been identified as treatment method for pain associated
with benign breast disease.
Rationale 3: Limiting salt intake has been found to help alleviate pain associated with benign
breast disease.
Rationale 4: Limiting caffeine is advisable to help alleviate the pain associated with benign
breast disease; however, drinking tea instead of coffee would not help since both contain
caffeine.
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Global Rationale: Symptom management includes such things as pharmacological hormones,
diuretics, limiting caffeine, wearing a supportive bra, and decreasing salt intake may help relieve
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symptoms of breast pain and tenderness, especially in the premenstrual period.
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Chapter 19. Assessing the Male Breasts and Reproductive System
Question 1
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Type: MCSA
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During the examination of an elderly male the nurse notes thin, gray pubic hairs and a scrotal sac
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that hangs significantly lower than the penis. The nurse would correctly choose which of the
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following actions?
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1. Document the findings as normal.
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2. Inform the client that he is no longer fertile.
3. Notify the healthcare provider of the findings.
4. Ask the client about his sexual practices.
Correct Answer: 1
Rationale 1: The older adult male begins to demonstrate thinning and graying of the pubic hair.
The penis and testicles begin to diminish in size and the scrotum hangs lower.
Rationale 2: Sperm production in the middle aged and older man is reduced but there is still
adequate sperm production to father children.
Rationale 3: The findings are normal and do now warrant notification of the healthcare provider.
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Rationale 4: The sexual practices of the client are not impacted by the findings. Inquiry into
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them is not indicated at this time.
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Global Rationale: According to Tanners Maturation Stages in the male, the findings in this
situation are appropriate for the elderly male client. Although sperm production does decline
during middle age, the presence of viable sperm in the elderly male contradicts infertility. No
further subjective information is required by the nurse, and the healthcare provider does not need
notification.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
system.
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Question 2
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Type: MCSA
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During the examination of a male client who has not been circumcised, the nurse is attempts to
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retract the foreskin of the penis, but skin is very tight and cannot be pulled back. The nurse
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2. Paraphimosis
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1. Urethral stricture
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would correctly anticipate which of the following conditions?
3. Urethritis
4. Phimosis
Correct Answer: 4
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Rationale 1: Urethral strictures would be suspected in the event of voiding problems or a
pinpoint size meatus opening was noted not an inability to retract the foreskin over the glans
penis.
Rationale 2: Paraphimosis is a condition in which the foreskin cannot be moved back over the
glans penis once it has been retracted
Rationale 3: Urethritis manifests with symptoms including redness and edema around the glans
and foreskin, eversion of the urethral mucosa, and drainage.
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Rationale 4: Phimosis refers to a condition in which the foreskin cannot be moved back over the
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glans penis.
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Global Rationale: Phimosis is a condition in which the foreskin is too tight to retract over the
glans penis. Paraphimosis is a condition in which the foreskin cannot be moved back over the
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glans penis once retracted. Urethritis is a condition in which the urethra is infected or inflamed.
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Signs of urethritis include redness and edema around the glans and foreskin, eversion of urethral
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mucosa, and drainage. A urethral stricture is suspected if the urinary meatus is pinpoint size.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
system.
Question 3
Type: MCSA
The nurse is interviewing a male client who states I feel like I have a bag of worms in my
scrotum. The nurse would correctly suspect which of the following conditions?
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1. Orchitis
2. Varicocele
3. Epididymitis
4. Hernia
Correct Answer: 2
Rationale 1: Orchitis refers to a swelling and inflammation of the testicles.
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Rationale 2: A varicocele is a distention of the spermatic cord and may be described as a bag of
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worms.
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Rationale 3: Epididymitis is an inflammatory condition of the epididymis.
Rationale 4: An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal,
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which indicates a protrusion of the intestine into the groin region.
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Global Rationale: Swelling or inflammation of the testicles is referred to as orchitis. A
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varicocele is a distention of the spermatic cord and often is described as a bag of worms.
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Epididymitis is an inflammatory condition of the epididymis. An inguinal hernia feels like a
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bulge or mass upon palpation of the inguinal canal, which indicates a protrusion of the intestine
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into the groin region.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
system.
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Question 4
Type: MCMA
When caring for a male client scheduled for a prostatectomy due to cancer, the nurse would
expect which of the following assessment findings to be present?
Standard Text: Select all that apply.
1. Enlargement of the scrotal sac
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2. Pyuria
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3. Increase in prostatic specific antigen (PSA)
4. Dribbling of urine
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5. Difficulty in initiating urine stream
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Correct Answer: 3,4,5
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Rationale 1: Enlargement of the scrotal sac. The scrotal sac will not be enlarged with a
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diagnosis for prostate cancer. Scrotal sac enlargement may be noted in the presence of
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inflammation of the testicles or the epididymis.
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Rationale 2: Pyruia. Pyruia refers to pus in the urine. Pus in the urine is not consistent with the
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presence of prostate cancer.
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Rationale 3: Increase in prostatic specific antigen (PSA). Low levels of prostatic specific
antigen are present in normal, healthy men. Laboratory values for the PSA will be elevated in the
presence of prostate cancer.
Rationale 4: Dribbling of urine. The dribbling of urine may be seen with prostate cancer.
Dribbling will occur in the presence of prostate enlargement.
Rationale 5: Difficulty in initiating urine stream. Prostate enlargement as seen in malignant
conditions may result in the client experiencing difficulty in initiating the urine stream.
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Global Rationale: The scrotal sac of the client diagnosed with prostate cancer would not be
enlarged. The prostate is located on each side of the male urethra just below the bladder. It is not
anatomically near the scrotal sac. Pyruia refers to pus in the urine. Pus in the urine is not
consistent with a diagnosis of prostate cancer. Low levels of prostatic specific antigen (PAS) are
present in normal, healthy men. PSA levels are used to assess for the presence of prostate cancer.
Laboratory values for the PSA will be elevated in the presence of prostate cancer. Conditions of
the prostate gland may result in urinary changes. The dribbling of urine may be seen with
prostate cancer. Dribbling or difficulty starting the urine stream may be seen in the presence of
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prostate enlargement.
Cognitive Level: Analyzing
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
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system.
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Question 5
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Type: MCSA
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While performing prostate palpation, the nurse notes that the client expresses severe tenderness
in the client?
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and discomfort during the procedure. The nurse should suspect which of the following conditions
1. Prostate cancer
2. Prostatitis
3. Enlargement of the prostate
4. Urinary tract infection
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Correct Answer: 2
Rationale 1: The presence of extreme hardness or nodules is characteristic of prostate cancer.
Rationale 2: The prostate should feel smooth, firm, or rubbery, and extend no larger than 1
centimeter into the rectal area. This exam should not cause tenderness, which is an indication of
inflammation.
Rationale 3: Enlargement of the prostate will cause urinary tract symptoms such as difficulty in
starting a stream, or dribbling of urine.
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Rationale 4: Urinary tract infections will cause painful and frequent urination.
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Global Rationale: Upon examination, the prostate should feel smooth, firm, or rubbery, and
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extend no larger than 1 centimeter into the rectal area. This exam should not cause tenderness,
which is an indication of inflammation. The presence of extreme hardness or nodules is
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characteristic of prostate cancer. Enlargement of the prostate will cause urinary tract symptoms
such as difficulty in starting a stream, or dribbling of urine. Urinary tract infections will cause
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painful and frequent urination.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
system.
Question 6
Type: HOTSPOT
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The nurse is providing education to a client who has been experiencing symptoms consistent
with BPH. The nurse presents a diagram the client to illustrate the location of the prostate. Mark
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with an X the correct location of the prostate gland.
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Standard Text: Select the correct area on the image.
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Correct Answer:
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Rationale : The lobes of the prostate gland are located on each side of the male urethra.
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Global Rationale:
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
system.
Question 7
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Type: HOTSPOT
The nurse is caring for a client who has hypospadias . Mark the figure provided to illustrate the
location of the phenomena.
Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : Hypospadias is a condition in which the urinary meatus opens on the underside of
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the penis.
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Global Rationale:
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
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system.
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Type: MCSA
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Question 8
A couple seeking infertility treatments has just received the results of a semen analysis, which
shows a diminished sperm count. The nurse would ask which of the following questions to the
male in this scenario?
1. How often do you masturbate?
2. Do you smoke?
3. How old is your present house?
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4. Do you still want to have children?
Correct Answer: 3
Rationale 1: Masturbation does not influence sperm count and the ability to father children.
Rationale 2: Tobacco use does not impact sperm count and the ability to father children.
Rationale 3: The age of the home may be influencing the sperm count. Lead paint may be
present in older homes built before 1979. Lead exposure may result in reduced libido, diminished
sperm count and abnormal sperm motility.
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Rationale 4: The responsibility of the nurse is to assess for related causes, not to assess the
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desire to father children.
Global Rationale: Males exposed to lead may experience decreased libido, diminished sperm
count, and abnormal sperm motility. Lead may be present is homes built before 1979.
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Masturbation and tobacco use do not influence sperm count and motility. The responsibility of
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the nurse is to assess for related causes, not to assess the desire to father children.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 21.2: Develop questions to be used when completing the focused interview.
Question 9
Type: MCSA
During the focused interview, a male client describes his erection and ejaculate in terms that are
less than professional. The nurse would correctly do which of the following?
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1. Ask the client to refrain from using the terms.
2. Ask the client to define the terms.
3. Document the clients responses in the terms used.
4. Find another nurse to complete the assessment.
Correct Answer: 3
Rationale 1: Men may be embarrassed to discuss health problems or concerns involving their
reproductive organs. During the interview use words that the man can understand, and do not be
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embarrassed or offended by the words he uses.
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Rationale 2: Asking the client to define terms may promote a sense of inferiority. Men may be
embarrassed to discuss health problems or concerns involving their reproductive organs; it is
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important for the nurse to ask questions in a non-threatening, matter-of-fact manner.
Rationale 3: The words and responses of the client will need to be documented. They provide
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the framework of the subjective data from the assessment.
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Rationale 4: Asking another nurse to complete the interview reduces the quality and continuity
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of care and is inappropriate.
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Global Rationale: During the interview use words that the man can understand, and do not be
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embarrassed or offended by the words he uses. Asking the client to define terms may promote a
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sense of inferiority. Men may be embarrassed to discuss health problems or concerns involving
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their reproductive organs; it is important for the nurse to ask questions in a nonthreatening,
matter-of-fact manner. Consider the psychologic, social, and cultural factors that affect sexuality
and sexual activity. The words and responses of the client will need to be documented. Asking
another nurse to complete the interview reduces the quality and continuity of care and is
inappropriate.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 21.2: Develop questions to be used when completing the focused interview.
Question 10
Type: MCSA
The nurse has completed testicular self-exam teaching for a male client. Which of the following
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statements if made by the client would indicate the need for further instruction?
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1. I will feel hardened areas where the testicles and epididymis are located.
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2. I should perform this exam monthly.
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3. I should be in a warm room or the shower to perform this exam.
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4. I should apply gentle pressure to each testicle to feel the area.
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Correct Answer: 1
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Rationale 1: The contour of the testicles should be firm and smooth.
Rationale 2: The testicular self-examination should be performed monthly beginning in
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adolescence.
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Rationale 3: The most opportune time to perform the testicular self-examination is in the shower
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or bath. Heat and steam will warm the hands and will help their movement over the skin surface.
Rationale 4: The correct technique utilizes a gentle pressure over the surface of the skin.
Global Rationale: Testicular self-exam should be performed monthly beginning in adolescence.
The scrotum will descend in a warm environment such as the bath or shower, allowing adequate
palpation. Gentle pressure should be applied to locate the testicle and epididymis, but these areas
are normally soft, without lumps or hardness.
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Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 21.3: Describe techniques required for assessment of the male reproductive
system.
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Question 11
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Type: MCMA
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The student nurse is preparing to examine the male reproductive system of a client. Prior To
starting the examination the student nurse explains to the supervising nurse the techniques that
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will be used. Plans to use which of the following indicates the need for further instruction?
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1. Inspection
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2. Palpation
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4. Auscultation
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3. Percussion
5. Aspiration
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Standard Text: Select all that apply.
Correct Answer: 3,4,5
Rationale 1: Inspection. The physical assessment techniques of inspection and palpation are
used in the examination of the male reproductive system.
Rationale 2: Palpation. The physical assessment techniques of inspection and palpation are
used in the examination of the male reproductive system.
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Rationale 3: Percussion. The physical assessment techniques of inspection and palpation are
used in the examination of the male reproductive system. Percussion is used to assess the chest
and abdomen.
Rationale 4: Auscultation. The physical assessment techniques of inspection and palpation are
used in the examination of the male reproductive system. Auscultation is used to assess the
gastrointestinal, cardiovascular, and respiratory systems.
Rationale 5: Aspiration. The physical assessment techniques of inspection and palpation are
used in the examination of the male reproductive system. Aspiration may be used to obtain a
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specimen.
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Global Rationale: Examination of the male reproductive system will utilize the techniques of
inspection and palpation. The external genitalia will be inspected as the onset of the examination.
Palpation will be used to assess the organs. Percussion is utilized in the assessment of the
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gastrointestinal system. Auscultation is used to assess the gastrointestinal, cardiac, and
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respiratory systems. Aspiration is a technique used to obtain a specimen.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Planning
system.
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Learning Outcome: 21.3: Describe techniques required for assessment of the male reproductive
Question 12
Type: MCMA
The nurse is preparing to examine a male clients reproductive organs. Which of the following
steps should the nurse do in preparation for this examination?
Standard Text: Select all that apply.
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1. Secure a private examination room.
2. Use clean hands for the examination.
3. Ask the client to lie down on the exam table.
4. Ask the client to empty his bladder.
5. Make sure the rooms temperature is cool and comfortable.
Correct Answer: 1,2,4,5
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Rationale 1: Secure a private examination room. A private room is indicated to perform a
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physical examination.
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Rationale 2: Use clean hands for the examination. The examiner must have clean hands to
perform the exam. This will reduce the transmission of infections.
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Rationale 3: Ask the client to lie down flat on the exam table. The examination may be
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performed with the client sitting or standing. The client does not need to lie flat.
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Rationale 4: Ask the client to empty his bladder. Emptying the bladder will reduce discomfort
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during palpation portions of the exam. In addition, a full bladder may impede the examination.
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Rationale 5: Make sure the rooms temperature is cool and comfortable. The examination
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room must be comfortable for the client.
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Global Rationale: Ensure that the examining room is warm and private. The examiner will need
to wash hands and put on gloves before beginning the examination. The gloves will need to be
worn during the examination. Ask the client to empty his bladder, remove his clothing, and put
on a gown or drape. The assessment may be done with the client sitting or standing. There is no
need for the client to lie flat. Expose only those body parts being examined to preserve modesty.
It is necessary for the client to be comfortable. The temperature should be regulated accordingly.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 21.3: Describe techniques required for assessment of the male reproductive
system.
Question 13
Type: MCSA
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During the examination of a male clients scrotum the nurse detects a hardened area in the right
side of the scrotal sac. The nurse would correctly choose which of the following actions to
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complete first?
2. Notify the healthcare provider of this finding.
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4. Ask the client about sexual practices.
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3. Use a light to perform transillumination.
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1. Ask the client about voiding patterns.
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Correct Answer: 3
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Rationale 1: Voiding patterns are not related to the findings of the examination.
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Rationale 2: Abnormalities noted on the assessment will need to be reported to the healthcare
report.
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provider but first, the nurse must obtain additional supporting information to include in the
Rationale 3: Transillumination is indicated to obtain further information.
Rationale 4: The clients sexual practices do not have direct bearing on the findings.
Global Rationale: The scrotum contains the testes and the epididymis, which should not feel
hard upon palpation. Areas suggesting abnormalities may be detected using transillumination, or
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the use of light to examine the scrotum. Upon transillumination, light should shine through the
scrotum with a red glow, with the testes showing up as oval structures. Abnormal areas, such as
masses, will not show penetration of the light. The clients voiding patterns or sexual practices are
not relevant to this situation, and the nurse requires additional information prior to notification of
the healthcare provider.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Client Need Sub:
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Learning Outcome: 21.3: Describe techniques required for assessment of the male reproductive
system.
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Question 14
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Type: HOTSPOT
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assess the right inguinal region.
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A client has presented for a physical examination. During the examination the nurse palpates to
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Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : The X should be placed on the right side at the diagram just below the hair line
where the thigh and the scrotum meet.
Global Rationale:
Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 21.3: Describe techniques required for assessment of the male reproductive
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system.
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Question 15
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Type: MCSA
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The nurse is examining a male client and notes small clusters of vesicular lesions on the glans
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penis. The client states the areas are painful and that often are reddened. The nurse would suspect
1. Carcinoma
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which of the following?
2. Genital warts
3. Syphilis
4. Genital herpes
Correct Answer: 4
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Rationale 1: Carcinoma lesions are nodular or ulcerative.
Rationale 2: Genital warts present as soft fleshy growths.
Rationale 3: Syphilis presents as nonpainful ulcers called chancres.
Rationale 4: Genital herpes presents as painful ulcerations.
Global Rationale: Genital herpes lesions present as painful ulcerations. Carcinoma lesions are
nodular or ulcerative. Genital warts are soft, painless, fleshy growths. Syphilis produces
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nonpainful ulcers called chancres.
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Cognitive Level: Analyzing
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 21.4: Differentiate normal from abnormal findings in physical assessment.
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Question 16
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Type: MCSA
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The nurse is assessing a male infant and notes only one testis. The mother asks what effect this
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will have on the child. Which of the following would be a correct response by the nurse?
1. There will be a need for your child to have hormone replacement therapy.
2. He will be unable to father children.
3. He will do fine and have no problems.
4. There will be a normal level of sperm production.
Correct Answer: 1
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Rationale 1: The testes produce sperm and testosterone. With one testis, there will be a
reduction in produced testosterone requiring hormone replacement therapy.
Rationale 2: The exiting testis will produce sperm, which will allow for him to reproduce.
Rationale 3: There are implications of the condition. This is a broad and potentially misleading
statement.
Rationale 4: The testes produce sperm and testosterone. With one testis, there will be a
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reduction in produced testosterone
Global Rationale: The testes produce sperm and testosterone. With one testis, there will be a
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reduction in produced testosterone and sperm. The client will need to have hormone replacement
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therapy. Sterility should not be a problem. Expressing that the client will be fine is a broad and
potentially misleading statement.
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Cognitive Level: Analyzing
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Type: MCSA
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Question 17
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Learning Outcome: 21.4: Differentiate normal from abnormal findings in physical assessment.
During the examination of a male client, the nurse detects a bulge in the right inguinal area as the
client is bearing down. The nurse would correctly interpret this finding as which of the following
conditions?
1. Varicocele
2. Prostatitis
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3. Orchitis
4. Hernia
Correct Answer: 4
Rationale 1: The varicocele is a distention of the spermatic cord. It feels most like a bag of
worms rather than a mass.
Rationale 2: Examination of the prostate gland is performed via the rectum, rather than the
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inguinal area.
Rationale 3: Orchitis refers to an inflammation in the testicular region. This would present as a
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pain and swelling in the scrotal region.
Rationale 4: An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal,
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which indicates a protrusion of the intestine into the groin region.
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Global Rationale: An inguinal hernia feels like a bulge or mass upon palpation of the inguinal
canal, which indicates a protrusion of the intestine into the groin region. A varicocele is a
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distention of the spermatic cord and feels like a bag of worms rather than a mass. Examination of
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inflammation of the testicles.
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the prostate gland is performed via the rectum, rather than the inguinal area. Orchitis refers to an
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 21.4: Differentiate normal from abnormal findings in physical assessment.
Question 18
Type: MCSA
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The nurse is examining a male clients genitalia and notices the scrotum is asymmetric. The left
side hangs lower than the right side. The nurse would correctly choose which of the following
actions?
1. Reassess after increasing the temperature in the room.
2. Report the finding to the healthcare provider.
3. Consider this a normal finding and proceed with palpation of the scrotum.
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4. Ask if the client if has noticed this before.
Correct Answer: 3
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Rationale 1: Elevation in temperatures will facilitate the scrotums dropping away from the body.
It will not correct symmetry issues.
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Rationale 2: The complete assessment findings will need to be shared with the healthcare
provider but the nurse will need to have completed the assessment first to be able to provide
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adequate information.
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Rationale 3: Palpation of the scrotum is indicated to aid in determining other related
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abnormalities.
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Rationale 4: Asking the client for additional subjective information is not the priority action at
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this time.
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Global Rationale: The male scrotum is normally asymmetric due to the longer length of the left
spermatic cord. This finding does not need further subjective data from the client or need to be
reported to the healthcare provider. Although the scrotum does drop away from the body in
elevated temperatures, this will not change its asymmetrical appearance.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 21.4: Differentiate normal from abnormal findings in physical assessment.
Question 19
Type: MCSA
The mother of a toddler expresses concern over her son constantly playing with his penis and
scrotum. The nurse would correctly use which of the following responses to address the mothers
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concern in this situation?
3. Does he know what it means to be a boy or a girl?
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4. These behaviors will go away as he gets older.
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2. Does she see his father doing the same actions?
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1. These practices are normal for a child of this age.
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Correct Answer: 1
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Rationale 1: Children often display curiosity with their genitals throughout all age spans. Parents
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should be reassured that this is normal behavior and part of the childs growth and development.
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Rationale 2: The behaviors being displayed are normal for the age and are not a reflection of
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practices noticed by male role models.
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Rationale 3: The behaviors being displayed are normal for this age and do not reflect any sense
of confusion concerning sexual identity.
Rationale 4: Children often display curiosity with their genitals throughout all age spans. Parents
should be reassured that this is normal behavior and part of the childs growth and development.
Global Rationale: Children often display curiosity with their genitals throughout all age spans.
Parents should be reassured that this is normal behavior and part of the childs growth and
development. Observing that male role models have an interest in their genitals is not associated
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with the behaviors noted. The behaviors noted are not reflective of confusion relating to sexual
identity.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 21.5: Describe developmental, psychosocial, cultural, and environmental
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variations in assessment techniques and findings.
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Question 20
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Type: MCSA
During the examination of an adult male the nurse notes thick, curly hair over the pubis area, a
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pear-shaped scrotum, and slightly darkened skin on the penis. The nurse would correctly choose
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which of the following actions?
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1. Ask the client about recent illnesses.
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2. Ask the client about sexual practices.
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3. Notify the healthcare provider the findings.
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4. Document the findings as normal.
Correct Answer: 4
Rationale 1: There is no need to explore medical health history relating to this normal physical
appearance.
Rationale 2: The sexual practices of the client have no bearing on the normal findings.
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Rationale 3: The assessment findings are normal and do not warrant notification of the
healthcare provider.
Rationale 4: The findings are normal for a healthy adult male.
Global Rationale: According to Tanners Maturation Stages in the male, the findings in this
situation are appropriate for the adult male client. No further subjective information is required
by the nurse. There is no need to explore medical health history relating to this normal physical
appearance. The sexual practices of the client have no bearing on the normal findings. The
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healthcare provider does not need notification.
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Cognitive Level: Analyzing
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Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 21.5: Describe developmental, psychosocial, cultural, and environmental
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variations in assessment techniques and findings.
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Question 21
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Type: MCSA
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A 65-year-old client reports to the ambulatory care clinic for a routine physical examination.
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During the assessment the client reports plans to marry a much younger woman in the coming
weeks. The client voices concerns about his ability to father children. What information may be
provided by the nurse?
1. The client is facing infertility in the next few years as the majority of older men become
infertile by age 70 years.
2. Although the production of sperm may be reduced in the older male, fathering a child is still
possible with advancing age.
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3. There are no changes to fertility of a man associated with aging.
4. Limited studies concerning the fertility of men are available and there is no definitive
information available.
Correct Answer: 2
Rationale 1: Sperm production begins to decline with middle age but the male is still able to
produce adequate quantities of viable sperm to father children. A man of age 70 is able to father
children.
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Rationale 2: Sperm production begins to decline with middle age but the male is still able to
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produce adequate quantities of viable sperm to father children.
Rationale 3: Sperm production begins to decline with middle age but the male is still able to
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produce adequate quantities of viable sperm to father children.
Rationale 4: There is adequate research available to prove the ability of older men to father
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children.
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Global Rationale: Sperm production begins to decline with middle age but the male is still able
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to produce adequate quantities of viable sperm to father children. A man of age 70 is able to
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father children. There is adequate research available to prove the ability of older men to father
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children.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 21.5: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
Question 22
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Type: MCMA
The nurse is preparing a presentation on testicular cancer and wishes to target the age group most
frequently affected. Which of the following settings would be considered appropriate to provide
audiences considered to be at an increased risk for the disease?
Standard Text: Select all that apply.
1. Elementary schools
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2. Colleges
3. Cub Scout groups
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4. High schools
5. Senior assisted living facilities
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Correct Answer: 2,4
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Rationale 1: Elementary schools. Testicular cancer is the most common type of cancer in males
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between the ages of 20 and 35. It is recommended that testicular self-examinations be performed
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monthly beginning in adolescence and continue on through adulthood. Children in elementary
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schools are too young to initiate the examination.
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Rationale 2: Colleges. Testicular cancer is the most common type of cancer in males between
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the ages of 20 and 35. It is recommended that testicular self-examinations be performed monthly
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beginning in adolescence and continue on through adulthood. College-age males are in the target
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group and should be included.
Rationale 3: Cub Scout groups. Testicular cancer is the most common type of cancer in males
between the ages of 20 and 35. It is recommended that testicular self-examinations be performed
monthly beginning in adolescence and continue on through adulthood. Cub scouts is a service
group consisting primarily of elementary schoolaged children. This group is too young to be
considered in the target group.
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Rationale 4: High schools. Testicular cancer is the most common type of cancer in males
between the ages of 20 and 35. It is recommended that testicular self-examinations be performed
monthly beginning in adolescence and continue on through adulthood. Testicular cancer is the
most common type of cancer in males between the ages of 20 and 35. It is recommended that
testicular self-examinations be performed monthly beginning in adolescence and continue on
through adulthood.
Rationale 5: Senior Assisted Living Facilities. Testicular cancer is the most common type of
cancer in males between the ages of 20 and 35. It is recommended that testicular self-
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examinations be performed monthly beginning in adolescence and continue on through
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adulthood.
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Global Rationale: Testicular cancer is the most common type of cancer in males between the
ages of 20 and 35. Self-examinations should begin in adolescence and continue throughout
adulthood. Populations of the target subjects would be available in colleges and high schools.
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Elementary school students are too young for this level of education. The educational process
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should begin before a male reaches advanced age.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Planning
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Learning Outcome: 21.6: Discuss the objectives for the male reproductive system as presented
in Healthy People 2020.
Question 23
Type: MCMA
The nurse is interviewing a male client with an elevated prostate specific antigen level (PSA).
The nurse would correlate potential risk factors for this client by asking which of the following
questions?
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Standard Text: Select all that apply.
1. Do you have a positive family history for prostate cancer?
2. Do you masturbate?
3. How frequently do you have sexual intercourse?
4. Do you smoke?
5. Do you have a history of urinary tract infections?
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Correct Answer: 1,4
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significant risk factor for the development of prostate cancer.
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Rationale 1: Do you have a positive family history for prostate cancer? Family history is a
Rationale 2: Do you masturbate? Masturbation is not considered a risk factor for the
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development of prostate cancer.
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Rationale 3: How frequently do you have sexual intercourse? The frequency of sexual
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intercourse does not have a bearing on the occurrence of prostate cancer.
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Rationale 4: Do you smoke? Smoking has been linked to the development of prostate cancer.
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Rationale 5: Do you have a history of urinary tract infections? Urinary tract infections are
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not linked to the incidence of prostate cancer.
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Global Rationale: Familial links are noted for the development of prostate cancer. Smoking is
also identified as a risk for the development of prostate cancer. Masturbation, the frequency of
sexual intercourse and the incidence of urinary tract infections is not associated with the
development of prostate cancer.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 21.6: Discuss the objectives for the male reproductive system as presented
in Healthy People 2020.
Question 24
Type: MCSA
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The nurse is conducting a health interview for a 55-year-old client who has presented to the
clinic for an annual physical examination. The client questions the need to begin screening for
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prostate cancer at this examination. What response by the nurse is indicated?
1. Unless you are at an increased risk for the development of prostate cancer no additional
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screening indicated.
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2. PSA screening tests should be performed once you reach age 75.
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3. You need to begin having an annual prostate examination.
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4. A cystoscopy should be performed annually to assess for prostate changes at age 55.
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Correct Answer: 3
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Rationale 1: Annual prostate screening is recommended to begin at age 50 years.
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Rationale 2: PSA screening tests are not recommended for men over age 75 years.
Rationale 3: Annual prostate screening is recommended to begin at age 50 years.
Rationale 4: The cystoscopy is a diagnostic test that is used to assess the inside of the bladder. It
is not used to assess for the presence of prostate cancer.
Global Rationale: Annual prostate examination is recommended for males after the age of 50.
The United States Preventive Task Force (USPSTF) (2008) has issued recommendations
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regarding the use of the prostate specific antigen (PSA) screening. The USPSTF recommends
against PSA screening in males 75 years of age and older. In men younger than 75 the
recommendations are to review individual risk factors to determine the use of the test.
Cystoscopy is a diagnostic test that allows for a scope to be inserted through the urethra to view
the bladder. It is not used to diagnose prostate cancer.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 21.6: Discuss the objectives for the male reproductive system as presented
in Healthy People 2020.
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Question 25
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Type: MCSA
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The nurse is assessing a male client who has epididymitis. The nurse would appropriately
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educate the client using which of the following statements?
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1. You will have a decrease in testosterone production.
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2. Your sperm maturity may be affected.
3. There will be a decrease in blood flow to your penis.
4. There may be erectile difficulties.
Correct Answer: 2
Rationale 1: Testosterone is produced within the testes. Inflammation of the epididymis will not
impact testosterone production.
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Rationale 2: The final storage area for sperm is the epididymis. Inflammation of this area may
impact sperm maturity.
Rationale 3: The epididymis does not impact blood flow to the penis.
Rationale 4: The epididymis does not have a role in the achievement of an erection.
Global Rationale: The epididymis does not produce testosterone. The epididymis is the final
area for the storage and maturation of sperm. Inflammation of the epididymis can impact the
sperms maturity. The epididymis does not impact the blood flow to the penis. The epididymis
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does not have an influence on the ability to achieve an erection.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical
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assessment of the male reproductive system.
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Question 26
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Type: MCSA
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During the well-child assessment on a 2-year-old male the nurse notes that the testes are not
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descended. The nurse would correctly choose which of the following actions?
1. Report the finding to the healthcare provider.
2. Ask the parent if the child has had any surgeries.
3. Proceed with palpation of the scrotum.
4. Inquire about the childs voiding patterns.
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Correct Answer: 1
Rationale 1: Undescended testes, called cryptorchidism, is a common finding, especially if the
infant is preterm. The testes should descend spontaneously within the first year of life. If both
testes do not descend, the male will be infertile and will be at a greater risk for the development
of testicular cancer.
Rationale 2: The presence of surgical histories will not influence the condition or the actions
that must be taken next.
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Rationale 3: Palpation of scrotum will not promote the testicles to descend. The healthcare
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provider must be notified.
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Rationale 4: Voiding patterns are not related to the occurrence of cryptorchidism.
Global Rationale: Undescended testes, or cryptochidism, is common in preterm infants, but
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should resolve spontaneously by 1 year of age. If unresolved, the condition can lead to infertility
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in the male and at risk for testicular cancer. This abnormal finding should be reported to the
healthcare provider. Previous surgeries and voiding patterns are not relevant to this situation, and
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Cognitive Level: Analyzing
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palpation will not be possible.
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical
assessment of the male reproductive system.
Question 27
Type: MCSA
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A couple is seeking infertility information from the nurse. Which of the following statements
made by the couple would indicate the need for intervention by the nurse?
1. We have been to two doctors already.
2. We have intercourse at least three times a week.
3. We are using temperature tracking for ovulation prediction.
4. We have been trying to conceive for a year.
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Correct Answer: 4
Rationale 1: The number of healthcare providers being seen by the family are not relevant to the
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nurses immediate actions.
Rationale 2: The couple is engaging in sexual intercourse. This indicates a lack of intercourse
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should not be of issue.
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Rationale 3: The use of the basal body temperature to assess for ovulation is recommended as an
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initial step in attempting to conceive.
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Rationale 4: Couples are not considered for infertility treatment until they have tried to conceive
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for at least one year.
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Global Rationale: Couples are not considered for infertility treatment until they have tried to
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conceive for at least one year. Temperature tracking for ovulation and frequent intercourse are
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suggested when trying to conceive. The number of healthcare providers the couple has been to is
not relevant information in this situation.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical
assessment of the male reproductive system.
Question 28
Type: MCSA
The nurse is examining a male adolescent with suspected spermatic cord torsion. The nurse
would anticipate which of the following as a priority intervention?
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1. Medicate for pain with narcotics.
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2. Prepare for surgery.
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3. Elevate the scrotum.
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4. Administer anti-inflammatory medications.
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Correct Answer: 2
Rationale 1: Medication for pain with narcotics may be ordered by the healthcare provider. It
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does not, however, present a higher priority than preparing the client for surgery.
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Rationale 2: Torsion of the spermatic cord requires immediate surgical intervention, making this
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the priority for the nurse in this situation.
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Rationale 3: The scrotum may be elevated after the procedure but elevation is not a priority in
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the preoperative period.
Rationale 4: The administration of anti-inflammatory medications is not indicated for this client.
Global Rationale: Torsion of the spermatic cord requires immediate surgical intervention,
making this the priority for the nurse in this situation. Medication for pain with narcotics may be
ordered by the healthcare provider. It does not, however, present a higher priority than preparing
the client for surgery. The scrotum may be elevated after the procedure but elevation is not a
priority in the preoperative period. The administration of anti-inflammatory medications is not
indicated for this client.
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Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical
assessment of the male reproductive system.
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Question 29
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Type: MCSA
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following factors may warrant further investigation?
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A male is being seen at the urologist office with concerns relating to his fertility. Which of the
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1. The client was treated for gonorrhea 2 years ago.
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2. The client has a history of genital herpes simplex.
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3. The clients medical history indicates a past history of marijuana use.
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4. The client works in a paint manufacturing company.
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Correct Answer: 4
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Rationale 1: Gonorrhea in a male has not been linked to infertility. In addition, there are no
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factors provided to infer that damage has resulted from the disease.
Rationale 2: Men with genital herpes simplex are not infertile.
Rationale 3: A history of marijuana use is not associated with male-related infertility.
Rationale 4: Chronic exposure to chemicals has been implicated in the development of male
caused infertility.
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Global Rationale: The responsibility of the nurse includes making additional inquiries on
factors that may be related to the concerns associated with infertility. Chronic exposure to
chemicals has been implicated in the development of male-caused infertility. Gonorrhea in a
male has not been linked to infertility. In addition, there are no factors provided to infer that
damage has resulted from the disease. Men with genital herpes simplex are not infertile. A
history of marijuana use is not associated with male-related infertility.
Cognitive Level: Analyzing
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Client Need: Health Promotion and Maintenance
Learning Outcome: 21.7: Apply critical thinking in selected simulations related to physical
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assessment of the male reproductive system.
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Question 30
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Type: MCSA
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The parents of a 9-year-old boy voice concerns about the seemingly advanced level of sexual
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maturity of their son. The examination reveals the child has thick pubic hair and enlarged
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genitalia. Which treatment intervention may be anticipated by the nurse?
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1. Administration of estrogen to reduce the impact of escalating testosterone levels
2. Continued observation of the rate of maturation for the next 6 to 9 months
3. Referral to an endocrinologist
4. Reduction of processed foods in the diet to reduce hormone exposure
Correct Answer: 3
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Rationale 1: Estrogen is not administered to males to manage precocious puberty. A prompt
diagnosis of the condition is warranted.
Rationale 2: A prompt diagnosis of the condition is warranted. It would be inappropriate to
continue observation for the next 6 to 9 months.
Rationale 3: Precocious puberty may be idiopathic or caused by a genetic trait, lesions in the
pituitary gland or hypothalamus, or testicular tumors. Referral to an endocrinologist may be
required for definitive diagnosis.
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scenario will need a prompt diagnosis of this condition.
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Rationale 4: While processed foods may contain excess hormones and chemicals the child in the
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Global Rationale: Precocious puberty is an endocrine disorder characterized by the
development of adult male characteristics in males under age 10. It includes dense pubic hair,
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penile enlargement, and enlargement of the testes. Precocious puberty may be idiopathic or
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caused by a genetic trait, lesions in the pituitary gland or hypothalamus, or testicular tumors.
Referral to an endocrinologist may be required for definitive diagnosis. Estrogen is not
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administered to males to manage precocious puberty. A prompt diagnosis of the condition is
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warranted. It would be inappropriate to continue observation for the next 6 to 9 months. While
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processed foods may contain excess hormones and chemicals the child in the scenario will need
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a prompt diagnosis of this condition.
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Chapter 20. Assessing the Anus and Rectum
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MULTIPLE CHOICE
1. Which statement concerning the anal canal is true? The anal canal:
a. Is approximately 2 cm long in the adult.
b. Slants backward toward the sacrum.
c. Contains hair and sebaceous glands.
d. Is the outlet for the gastrointestinal tract.
ANS: D
The anal canal is the outlet for the gastrointestinal tract and is approximately 3.8 cm long in the
adult. It is lined with a modified skin that does not contain hair or sebaceous glands, and it slants
forward toward the umbilicus.
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DIF: Cognitive Level: Remembering (Knowledge) REF: p. 721
MSC: Client Needs: General
2. Which statement concerning the sphincters is correct?
a. The internal sphincter is under voluntary control.
b. The external sphincter is under voluntary control.
c. Both sphincters remain slightly relaxed at all times.
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d. The internal sphincter surrounds the external sphincter.
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ANS: B
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The external sphincter surrounds the internal sphincter but also has a small section overriding the
tip of the internal sphincter at the opening. The external sphincter is under voluntary control.
Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed.
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DIF: Cognitive Level: Remembering (Knowledge) REF: p. 721
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MSC: Client Needs: General
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3. The nurse is performing an examination of the anus and rectum. Which of these statements
iscorrect and important to remember during this examination?
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a. The rectum is approximately 8 cm long.
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b. The anorectal junction cannot be palpated.
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c. Above the anal canal, the rectum turns anteriorly.
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d. No sensory nerves are in the anal canal or rectum.
ANS: B
The anal columns are folds of mucosa that extend vertically down from the rectum and end in the
anorectal junction. This junction is not palpable but is visible on proctoscopy. The rectum is 12 cm
long; just above the anal canal, the rectum dilates and turns posteriorly.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 721
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. The structure that secretes a thin, milky alkaline fluid to enhance the viability of sperm is the:
a. Cowper gland.
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b. Prostate gland.
c. Median sulcus.
d. Bulbourethral gland.
ANS: B
In men, the prostate gland secretes a thin milky alkaline fluid that enhances sperm viability. The
Cowper glands (also known as bulbourethral glands) secrete a clear, viscid mucus. The median
sulcus is a groove that divides the lobes of the prostate gland and does not secrete fluid.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 722
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MSC: Client Needs: General
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5. A 46-year-old man requires an assessment of his sigmoid colon. Which instrument or technique
is most appropriate for this examination?
a. Proctoscope
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b. Ultrasound
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c. Colonoscope
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d. Rectal examination with an examining finger
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ANS: C
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The sigmoid colon is 40 cm long, and the nurse knows that it is accessible to examination only with
the colonoscope. The other responses are not appropriate for an examination of the entire sigmoid
colon.
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DIF: Cognitive Level: Understanding (Comprehension) REF: p. 722
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
6. The nurse is caring for a newborn infant. Thirty hours after birth, the infant passes a dark green
meconium stool. The nurse recognizes this is important because the:
a. Stool indicates anal patency.
b. Dark green color indicates occult blood in the stool.
c. Meconium stool can be reflective of distress in the newborn.
d. Newborn should have passed the first stool within 12 hours after birth.
ANS: A
The first stool passed by the newborn is dark green meconium and occurs within 24 to 48 hours of
birth, indicating anal patency. The other responses are not correct.
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DIF: Cognitive Level: Understanding (Comprehension) REF: p. 723
MSC: Client Needs: Health Promotion and Maintenance
7. During the assessment of an 18-month-old infant, the mother expresses concern to the nurse
about the infant’s inability to toilet train. What would be the nurse’s best response?
a. “Some children are just more difficult to train, so I wouldn’t worry about it yet.”
“Have you considered reading any of the books on toilet training? They can be very
b. helpful.”
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“This could mean that there is a problem in your baby’s development. We’ll watch her
c. closely for the next few months.”
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“The nerves that will allow your baby to have control over the passing of stools are not
d. developed until at least 18 to 24 months of age.”
ANS: D
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The infant passes stools by reflex. Voluntary control of the external anal sphincter cannot occur
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until the nerves supplying the area have become fully myelinated, usually around 1
age. Toilet training usually starts after the age of 2 years.
to 2 years of
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DIF: Cognitive Level: Applying (Application) REF: p. 723
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MSC: Client Needs: Health Promotion and Maintenance
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8. A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a
friend who just died from cancer of the prostate. He is concerned this will happen to him. How
should the nurse respond?
a. “The swelling in your prostate is only temporary and will go away.”
b. “We will treat you with chemotherapy so we can control the cancer.”
c. “It would be very unusual for a man your age to have cancer of the prostate.”
d. “The enlargement of your prostate is caused by hormonal changes, and not cancer.”
ANS: D
The prostate gland commonly starts to enlarge during the middle adult years. BPH is present in 1 in
10 men at the age of 40 years and increases with age. It is believed that the hypertrophy is caused
by hormonal imbalance that leads to the proliferation of benign adenomas. The other responses are
not appropriate.
DIF: Cognitive Level: Applying (Application) REF: p. 723
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MSC: Client N e e d s : Health Promotion and Maintenance
9. A 30-year-old woman is visiting the clinic because of “pain in my bottom when I have a bowel
movement.” The nurse should assess for which problem?
a. Pinworms
b. Hemorrhoids
c. Colon cancer
d. Fecal incontinence
ANS: B
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DIF: Cognitive Level: Applying (Application) REF: p. 723
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Having painful bowel movements, known as dyschezia, may be attributable to a local condition
(hemorrhoid or fissure) or constipation. The other responses are not correct.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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10. A patient who is visiting the clinic complains of having “stomach pains for 2 weeks” and
describes his stools as being “soft and black” for approximately the last 10 days. He denies taking
any medications. The nurse is aware that these symptoms are mostly indicative of:
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a. Excessive fat caused by malabsorption.
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b. Increased iron intake, resulting from a change in diet.
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c. Occult blood, resulting from gastrointestinal bleeding.
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ANS: C
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d. Absent bile pigment from liver problems.
Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding or
nontarry from ingestion of iron medications (not diet). Excessive fat causes the stool to become
frothy. The absence of bile pigment causes clay-colored stools.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 724
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
11. After completing an assessment of a 60-year-old man with a family history of colon cancer, the
nurse discusses with him early detection measures for colon cancer. The nurse should mention the
need for a(n):
a. Annual proctoscopy.
b. Colonoscopy every 10 years.
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c. Fecal test for blood every 6 months.
d. DREs every 2 years.
ANS: B
Early detection measures for colon cancer include a DRE performed annually after age 50 years, an
annual fecal occult blood test after age 50 years, a sigmoidoscopic examination every 5 years or a
colonoscopy every 10 years after age 50 years, and a PSA blood test annually for men over 50
years old, except beginning at age 45 years for black men (American Cancer Society, 2006).
DIF: Cognitive Level: Applying (Application) REF: p. 725
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MSC: Client Needs: Health Promotion and Maintenance
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12. The mother of a 5-year-old girl tells the nurse that she has noticed her daughter “scratching at
her bottom a lot the last few days.” During the assessment, the nurse finds redness and raised skin
in the anal area. This finding most likely indicates:
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a. Pinworms.
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b. Chickenpox.
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c. Constipation.
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d. Bacterial infection.
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ANS: A
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In children, pinworms are a common cause of intense itching and irritated anal skin. The other
options are not correct.
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DIF: Cognitive Level: Analyzing (Analysis) REF: p. 725
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
13. The nurse is examining only the rectal area of a woman and should place the woman in what
position?
a. Lithotomy
b. Prone
c. Left lateral decubitus
d. Bending over the table while standing
ANS: C
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The nurse should place the female patient in the lithotomy position if the genitalia are being
examined as well. The left lateral decubitus position is used for the rectal area alone.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 725
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
14. While performing an assessment of the perianal area of a patient, the nurse notices that the
pigmentation of anus is darker than the surrounding skin, the anal opening is closed, and a skin sac
that is shiny and blue is noted. The patient mentioned that he has had pain with bowel movements
and has occasionally noted some spots of blood. What would this assessment and
history most likely indicate?
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a. Anal fistula
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b. Pilonidal cyst
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c. Rectal prolapse
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d. Thrombosed hemorrhoid
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ANS: D
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The anus normally looks moist and hairless, with coarse folded skin that is more pigmented than
the perianal skin, and the anal opening is tightly closed. The shiny blue skin sac indicates a
thrombosed hemorrhoid.
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DIF: Cognitive Level: Analyzing (Analysis) REF: p. 726
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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15. The nurse is preparing to palpate the rectum and should use which of these techniques? The
nurse should:
a. Flex the finger, and slowly insert it toward the umbilicus.
b. First instruct the patient that this procedure will be painful.
c. Insert an extended index finger at a right angle to the anus.
d. Place the finger directly into the anus to overcome the tight sphincter.
ANS: A
The nurse should gently place the pad of the index finger against the anal verge. The nurse will feel
the sphincter tighten and then relax. As it relaxes, the nurse should flex the tip of the finger and
slowly insert it into the anal canal in a direction toward the umbilicus. The nurse should never
approach the anus at right angles with the index finger extended; doing so would cause pain. The
nurse should instruct the patient that palpation is not painful but may feel like needing to move the
bowels.
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DIF: Cognitive Level: Understanding (Comprehension) REF: p. 726
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
16. While performing a rectal examination, the nurse notices a firm, irregularly shaped mass. What
should the nurse do next?
a. Continue with the examination, and document the finding in the chart.
b. Instruct the patient to return for a repeat assessment in 1 month.
c. Tell the patient that a mass was felt, but it is nothing to worry about.
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d. Report the finding, and refer the patient to a specialist for further examination.
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ANS: D
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A firm or hard mass with an irregular shape or rolled edges may signify carcinoma. Any mass that
is discovered should be promptly reported for further examination. The other responses are not
correct.
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DIF: Cognitive Level: Applying (Application) REF: p. 734
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MSC: Client Needs: Health Promotion and Maintenance
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b. Flexion of the knees
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a. Jerking of the legs
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17. During an assessment of the newborn, the nurse expects to see which finding when the anal
area is slightly stroked?
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c. Quick contraction of the sphincter
d. Relaxation of the external sphincter
ANS: C
To assess sphincter tone, the nurse should check the anal reflex by gently stroking the anal area and
noticing a quick contraction of the sphincter. The other responses are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 729
MSC: Client Needs: Health Promotion and Maintenance
18. A 13-year-old girl is visiting the clinic for a sports physical examination. The nurse should
remember to include which of these tests in the examination?
a. Testing for occult blood
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b. Valsalva maneuver
c. Internal palpation of the anus
d. Inspection of the perianal area
ANS: D
The perianal region of the school-aged child and adolescent should be inspected during the
examination of the genitalia. Internal palpation is not routinely performed at this age. Testing for
occult blood and performing the Valsalva maneuver are also not necessary.
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DIF: Cognitive Level: Applying (Application) REF: p. 729
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MSC: Client Needs: Health Promotion and Maintenance
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19. During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft
of hair located directly over the coccyx. The nurse knows that this lesion would most likely be a:
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a. Rectal polyp.
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b. Pruritus ani.
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c. Carcinoma.
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d. Pilonidal cyst.
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ANS: D
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A pilonidal cyst or sinus is a hair-containing cyst or sinus located in the midline over the coccyx or
lower sacrum. It often opens as a dimple with a visible tuft of hair and, possibly, an erythematous
halo. (See Table 25-1 for more information, and also for the description of a pruritus ani. See Table
25-2 for the descriptions of rectal polyps and carcinoma.)
DIF: Cognitive Level: Applying (Application) REF: p. 732
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
20. During an examination, the nurse asks the patient to perform the Valsalva maneuver and
notices that the patient has a moist, red, doughnut-shaped protrusion from the anus. The nurse
knows that this finding is consistent with a:
a. Rectal polyp.
b. Hemorrhoid.
c. Rectal fissure.
d. Rectal prolapse.
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ANS: D
In rectal prolapse, the rectal mucous membrane protrudes through the anus, appearing as a moist
red doughnut with radiating lines. It occurs after a Valsalva maneuver, such as straining at passing
stool or with exercising (see Table 25-1). (See Table 25-2 for a description of rectal polyps and
Table 25-1 for the descriptions of a rectal fissure and hemorrhoids.)
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 733
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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21. A 70-year-old man is visiting the clinic for difficulty in passing urine. In the health history, he
indicates that he has to urinate frequently, especially at night. He has burning when he urinates and
has noticed pain in his back. Considering this history, what might the nurse expect to find during
the physical assessment?
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a. Asymmetric, hard, and fixed prostate gland
c. Symmetrically enlarged, soft prostate gland
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b. Occult blood and perianal pain to palpation
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d. Soft nodule protruding from the rectal mucosa
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ANS: A
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Subjective symptoms of carcinoma of the prostate include frequency, nocturia, hematuria, weak
stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and
thighs. Objective symptoms of carcinoma of the prostate include a malignant neoplasm that often
starts as a single hard nodule on the posterior surface, producing asymmetry and a change in
consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels
stone hard and fixed.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 735
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
22. A 40-year-old black man is in the office for his annual physical examination. Which statement
regarding the PSA blood test is true, according to the American Cancer Society? The PSA:
a. Should be performed with this visit.
b. Should be performed at age 45 years.
c. Should be performed at age 50 years.
d. Is only necessary if a family history of prostate cancer exists.
ANS: B
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According to the American Cancer Society (2006), the PSA blood test should be performed
annually for black men beginning at age 45 years and annually for all other men over age 50 years.
DIF: Cognitive Level: Applying (Application) REF: p. 725
MSC: Client Needs: Health Promotion and Maintenance
23. A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He
also reports urethral discharge and a dull aching pain in the perineal and rectal area. These
symptoms are most consistent with which condition?
a. Prostatitis
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b. Polyps
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c. Carcinoma of the prostate
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d. BPH
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ANS: A
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The common presenting symptoms of prostatitis are fever, chills, malaise, and urinary frequency
and urgency. The individual may also have dysuria, urethral discharge, and a dull aching pain in
the perineal and rectal area. These symptoms are not consistent with polyps. (See Table 25-3 for
the descriptions of carcinoma of the prostate and BPH.)
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DIF: Cognitive Level: Analyzing (Analysis) REF: p. 735
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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24. During a discussion for a men’s health group, the nurse relates that the group with the highest
incidence of prostate cancer is:
a. Asian Americans.
b. Blacks.
c. American Indians.
d. Hispanics.
ANS: B
According to the American Cancer Society (2010), black men have a higher rate of prostate cancer
than other racial groups.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 723
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
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25. Which characteristic of the prostate gland would the nurse recognize as an abnormal finding
while palpating the prostate gland through the rectum?
a. Palpable central groove
b. Tenderness to palpation
c. Heart shaped
d. Elastic and rubbery consistency
ANS: B
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DIF: Cognitive Level: Analyzing (Analysis) REF: p. 728
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The normal prostate gland should feel smooth, elastic, and rubbery; slightly movable; heart-shaped
with a palpable central groove; and not be tender to palpation.
MSC: Client Needs: Health Promotion and Maintenance
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26. The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and recalls
that this is caused by:
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a. Occult bleeding.
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b. Absent bile pigment.
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c. Increased fat content.
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d. Ingestion of bismuth preparations.
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ANS: C
Steatorrhea (pale, yellow, greasy stool) is caused by increased fat content in the stools, as in
malabsorption syndrome. Occult bleeding and ingestion of bismuth products cause a black stool,
and absent bile pigment causes a gray-tan stool.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 729
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
27. During a health history of a patient who complains of chronic constipation, the patient asks the
nurse about high-fiber foods. The nurse relates that an example of a high-fiber food would be:
a. Broccoli.
b. Hamburger.
c. Iceberg lettuce.
d. Yogurt.
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ANS: A
High-fiber foods are either soluble type (e.g., beans, prunes, barley, broccoli) or insoluble type
(e.g., cereals, wheat germ). The other examples are not considered high-fiber foods.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 724
MSC: Client Needs: Health Promotion and Maintenance
28. While assessing a patient who is hospitalized and bedridden, the nurse notices that the patient
has been incontinent of stool. The stool is loose and gray-tan in color. The nurse recognizes that
this finding indicates which of the following?
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a. Occult blood
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b. Inflammation
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c. Absent bile pigment
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d. Ingestion of iron preparations
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ANS: C
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The presence of gray-tan stool indicates absent bile pigment, which can occur with obstructive
jaundice. The ingestion of iron preparations and the presence of occult blood turns the stools to a
black color. Jellylike mucus shreds mixed in the stool would indicate inflammation.
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DIF: Cognitive Level: Applying (Application) REF: p. 729
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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29. During a digital examination of the rectum, the nurse notices that the patient has hard feces in
the rectum. The patient complains of feeling “full,” has a distended abdomen, and states that she
has not had a bowel movement “for several days.” The nurse suspects which condition?
a. Rectal polyp
b. Fecal impaction
c. Rectal abscess
d. Rectal prolapse
ANS: B
A fecal impaction is a collection of hard, desiccated feces in the rectum. The obstruction often
results from decreased bowel motility, in which more water is reabsorbed from the stool. (See
Table 25-2 for the descriptions of rectal polyps and abscesses; See Table 25-1 for a description of
rectal prolapse.)
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DIF: Cognitive Level: Applying (Application) REF: p. 734
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
30. During the taking of a health history, the patient states, “It really hurts back there, and
sometimes it itches, too. I have even seen blood on the tissue when I have a bowel movement. Is
there something there?” The nurse should expect to see which of these upon examination of the
anus?
a. Rectal prolapse
b. Internal hemorrhoid
c. External hemorrhoid that has resolved
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d. External hemorrhoid that is thrombosed
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ANS: D
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ng
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These symptoms are consistent with an external hemorrhoid. An external hemorrhoid, when
thrombosed, contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and
bleeds with defecation. When the external hemorrhoid resolves, it leaves a flabby, painless skin sac
around the anal orifice. An internal hemorrhoid is not palpable but may appear as a red mucosal
mass when the person performs a Valsalva maneuver. A rectal prolapse appears as a moist, red
doughnut with radiating lines.
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Chapter 21. Assessing the Newborn & Chapter 22. Assessing the Child and Adolescent
Question 1
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Type: MCSA
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The nurse is performing an assessment on a 13-yearold adolescent. Which of the following
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findings would be unexpected?
1. Apical heart rate of 110 beats per minute
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2. Respiratory rate of 14 breaths per minute
3. Blood pressure of 98/58
4. Temperature of 98.8 degrees Fahrenheit
Correct Answer: 3
Rationale 1: A 13-year-old adolescents heart rate normally ranges from 65 to 120 beats per
minute.
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Rationale 2: A 13-year-old adolescents respiratory rate normally ranges from 14 to 20 breaths
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per minute.
(systolically), and 64 to 84 mm Hg (diastolically).
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Rationale 3: A 13-year-old adolescents blood pressure usually ranges from 110 to 131 mm Hg
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Rationale 4: The 13-year-old adolescents temperature is within normal limits.
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Global Rationale: A 13-year-old adolescents blood pressure usually ranges from 110 to 131 mm
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Hg (systolically), and 64 to 84 mm Hg (diastolically). This 13-year-old adolescents blood
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pressure is low. A 13-year-old adolescents heart rate normally ranges from 65 to 120 beats per
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minute. A 13-year-old adolescents respiratory rate normally ranges from 14 to 20 breaths per
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minute. The 13-year-old adolescents temperature is within normal limits.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.1: Identify anatomical differences between children and adults.
Question 2
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Type: MCSA
The nurse is performing an assessment of a 7 month old. Which of the following findings may be
unexpected?
1. The anterior fontanelle is closed.
2. The posterior fontanelle is closed.
3. The head is disproportionately large in comparison to the body.
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4. There are two baby teeth present.
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Correct Answer: 1
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Rationale 1: The anterior fontanelle usually closes when the infant is between 9 and 18 months
of age. It is an unexpected finding to determine the infants anterior fontanelle is already closed at
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the age of 7 months.
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Rationale 2: The posterior fontanelle usually closes by the age of 2 months.
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approximately 5 years of age.
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Rationale 3: The head remains disproportionately large in comparison to the body until
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Rationale 4: The child should have at least one tooth present in the mouth by 15 months of age.
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Global Rationale: The anterior fontanelle usually closes when the infant is between 9 and 18
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months of age. It is an unexpected finding to determine the infants anterior fontanelle is already
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closed at the age of 7 months. The posterior fontanelle usually closes by the age of 2 months.
The head remains disproportionately large in comparison to the body until approximately 5 years
of age. The child should have at least one tooth present in the mouth by 15 months of age.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.1: Identify anatomical differences between children and adults.
Question 3
Type: MCSA
The nurse is assessing a newborn when the mother asks about the tiny white bumps on the
forehead and nose. The nurse would respond to the mother with which of the following
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statements?
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1. Those are milia and they are very common.
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2. That is lanugo and it is very common.
3. Those are Mongolian spots.
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4. Those are salmon patches.
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Correct Answer: 1
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Rationale 1: Milia are tiny (less than 0.5 mm), smooth, white cysts of the hair follicle found
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commonly on the forehead and nose at birth.
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and back.
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Rationale 2: Lanugo is a covering of fine hair in newborns found on the upper chest, shoulders,
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Rationale 3: Mongolian spots are areas of dark bluish pigmentation and are most commonly
found at the base of the spine.
Rationale 4: Salmon patches, also known as stork bites, are small macules and patches caused
by visible intradermal capillaries and are found on the forehead, eyelids, upper lip, nasal bridge,
and nape of the neck.
Global Rationale: Milia are very small (less than 0.5 mm), smooth, white cysts of the hair
follicle found commonly on the forehead and nose at birth. Milia are normal infant variations.
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Lanugo is a covering of fine hair in newborns found on the upper chest, shoulders, and back.
Mongolian spots are areas of dark bluish pigmentation and are most commonly found at the base
of the spine. Salmon patches, also known as stork bites, are small macules and patches caused by
visible intradermal capillaries and are found on the forehead, eyelids, upper lip, nasal bridge, and
nape of the neck.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 25.1: Identify anatomical differences between children and adults.
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Question 4
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Type: MCSA
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The nurse is preparing to perform an assessment on four children. After reviewing each childs
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admitting diagnosis, which of the following children may have an enlarged spleen?
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1. 14 year old admitted with acute gastroenteritis
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2. 17 year old admitted with an acute exacerbation of asthma
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3. 11 year old admitted with an umbilical hernia
4. 9 year old admitted with a sickle cell crisis
Correct Answer: 4
Rationale 1: It would be unlikely that the 14 year old with acute gastroenteritis would exhibit
splenomegaly (enlarged spleen).
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Rationale 2: It would be unlikely that the 17 year old with an acute exacerbation of asthma
would exhibit splenomegaly (enlarged spleen).
Rationale 3: It would be unlikely that the 11 year old with an umbilical hernia would exhibit
splenomegaly (enlarged spleen).
Rationale 4: Splenomegaly is common in young children with sickle cell disease (SCD). All
children with SCD should be assessed for splenomegaly (enlarged spleen).
Global Rationale: Splenomegaly (enlarged spleen) is common in young children with sickle cell
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disease (SCD). All children with SCD should be assessed for splenomegaly. It would be unlikely
that the 14 year old with acute gastroenteritis would exhibit splenomegaly. It would be unlikely
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that the 17 year old with an acute exacerbation of asthma would exhibit splenomegaly. It would
be unlikely that the 11 year old with an umbilical hernia would exhibit splenomegaly.
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Cognitive Level: Remembering
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Type: MCSA
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Question 5
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Learning Outcome: 25.1: Identify anatomical differences between children and adults.
The parents of a 3-year-old child with a history of frequent otitis media incidences ask the nurse
why their child continues to have this issue. Which of the following is the nurses best response?
1. Children of this age frequently put things in their ears.
2. The eustachian tubes are shorter, more level, and straighter in children this age.
3. Children of this age experience more difficulty washing their hands appropriately.
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4. The child has a hearing problem that is causing this to occur more frequently.
Correct Answer: 2
Rationale 1: Putting objects in the ear is possible, but not necessarily typical of children of this
age.
Rationale 2: Children under 4 years of age are more prone to develop otitis media. The
eustachian tubes of young children are shorter, straighter, and more level than in older children.
Rationale 3: Children of this age probably do experience more difficulty washing their hands
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appropriately. However, the best response for the parents is to discuss the anatomical differences
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in their young childs ears that make the child more likely to develop otitis media.
Rationale 4: A hearing problem would not cause the otitis media, but frequent ear infections
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may result in a hearing problem.
Global Rationale: Children under 4 years of age are more prone to develop otitis media. The
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eustachian tubes of young children are shorter, straighter, and more level than in older children.
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Putting objects in the ear is possible, but not necessarily typical of children of this age. Children
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of this age probably do experience more difficulty washing their hands appropriately. However,
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the best response for the parents is to discuss the anatomical differences in their young childs
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ears that make the child more likely to develop otitis media. A hearing problem would not cause
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the otitis media, but frequent ear infections may result in a hearing problem.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.1: Identify anatomical differences between children and adults.
Question 6
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Type: MCMA
The mother of a 17-year-old female has brought her daughter in for an examination. Which of
the following statements by the client is most consistent with the clients most likely diagnosis?
Standard Text: Select all that apply.
1. I usually just feel so tired.
2. Ive been growing this strange, soft, light-colored fur all over.
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3. Everyone says Im thin, but I dont feel like I look thin.
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4. I perspire all of the time and my skin is so oily.
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5. Im sorry, but I cannot get warm. Can you turn up the heat in this place?
Correct Answer: 1,2,3,5
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Rationale 1: I usually just feel so tired. This young lady is most likely suffering from anorexia
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nervosa. It is common for clients who are suffering from anorexia nervosa to complain of feeling
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weak and tired.
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Rationale 2: Ive been growing this strange, soft, light-colored fur all over. Lanugo is a soft
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white hair growth on the client with anorexia nervosa.
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Rationale 3: Everyone says Im thin, but I dont feel like I look thin. Clients with anorexia
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nervosa commonly feel that they are not underweight, although they are exceedingly thin.
Rationale 4: I perspire all of the time and my skin is so oily. Clients with anorexia nervosa
more commonly complain of dry skin, not excessive perspiration and oily skin.
Rationale 5: Im sorry, but I cannot get warm. Can you turn up the heat in this place? The
client with anorexia nervosa often suffers from cold intolerance.
Global Rationale: This young lady is most likely suffering from anorexia nervosa. It is common
for clients who are suffering from anorexia nervosa to complain of feeling weak and tired.
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Lanugo is a soft white hair growth on the client with anorexia nervosa. Clients with anorexia
nervosa commonly feel that they are not thin, although they are exceedingly thin. Clients with
anorexia nervosa more commonly complain of dry skin, not excessive perspiration. The client
with anorexia nervosa often suffers from cold intolerance.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
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Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
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child.
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Question 7
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Type: MCMA
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The child has been diagnosed with acute otitis media. Which of the following findings by the
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nurse are consistent with this diagnosis?
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Standard Text: Select all that apply.
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1. Temperature is 101.4 degrees Fahrenheit.
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2. The tympanic membrane is pearly gray.
3. The mother states, I cannot get her to eat anything. She just picks at her food.
4. The mother states, She has been so fussy.
5. The mother states, She can sleep only while shes sitting up on my lap while Im in the rocking
chair.
Correct Answer: 1,3,4,5
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Rationale 1: Temperature is 101.4 degrees Fahrenheit. This child has a fever, which is
consistent with acute otitis media.
Rationale 2: The tympanic membrane is pearly gray. The tympanic membrane of a child with
acute otitis media will be orange-red or red and bulging with purulent drainage within the middle
ear space. A pearly gray tympanic membrane is a normal finding.
Rationale 3: The mother states, I cannot get her to eat anything. She just picks at her food.
The child is anorexic and not eating well currently. This is consistent with acute otitis media.
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Rationale 4: The mother states, She has been so fussy. Irritability is associated with acute
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otitis media.
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Rationale 5: The mother states, She can sleep only while shes sitting up on my lap while Im
in the rocking chair. Children with acute otitis media may not be able to sleep while lying
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down.
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Global Rationale: This child has a fever, which is consistent with acute otitis media. The child
is anorexic and not eating well currently. This is consistent with acute otitis media. Irritability is
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associated with acute otitis media. Children with acute otitis media may not be able to sleep
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while lying down. The tympanic membrane of a child with acute otitis media will be orange-red
or red and bulging with purulent drainage within the middle ear space. A pearly gray tympanic
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membrane is a normal finding.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
child.
Question 8
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Type: FIB
The child has been admitted to the Intensive Care Unit following a motor vehicle accident. The
child weighs 39 pounds. Calculate the childs minimum expected urinary output in milliliters over
an 8-hour period. Round to the nearest whole number.
milliliters
Standard Text:
Correct Answer: 142 milliliters
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Rationale: Normal urine output for children is at least 1 ml/kg/hr. The child weighs 39 pounds.
To calculate the childs weight in kilograms, 39 pounds is divided by 2.2. There are 2.2 pounds in
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each kilogram. The child should produce at least 1 milliliter per kilogram each hour. The child
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weighs 17.727 kilograms. Multiply this number by 1 milliliter/kilogram. This is 17.727
milliliters of urine produced each hour. Multiply this number by 8, and it equals 141.818. When
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rounded to a whole number, this is 142 milliliters.
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Global Rationale:
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
child.
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Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
Question 9
Type: MCMA
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An 18-month-old child is brought to the emergency room with difficulty breathing. The
physician diagnoses the child with epiglottitis. Which of the following findings by the nurse are
consistent with this diagnosis?
Standard Text: Select all that apply.
1. Oxygen saturation level is 85% on room air.
2. Respiratory rate is 22 per minute.
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3. Stridor is audible without stethoscope.
4. Apical heart rate is 72 beats per minute.
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5. Temperature is 103.7 degrees Fahrenheit.
Correct Answer: 1,3,5
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Rationale 1: Oxygen saturation level is 85% on room air. The child with epiglottitis may have
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a decreased oxygen saturation level. 85% is lower than normal.
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Rationale 2: Respiratory rate is 22 per minute. The respiratory rate is normal for a child
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between 1 and 2 years old. The child with epiglottitis will more likely exhibit an increased
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respiratory rate.
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epiglottitis.
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Rationale 3: Stridor is audible without stethoscope. Audible stridor is associated with
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Rationale 4: Apical heart rate is 72 beats per minute. The childs heart rate is within normal
limits for the childs age.
Rationale 5: Temperature is 103.7 degrees Fahrenheit. The child has a high fever and this is
associated with epiglottitis.
Global Rationale: The child with epiglottitis may have a decreased oxygen saturation level.
85% is lower than normal. The child with epiglottitis will more likely exhibit an increased
respiratory rate. Audible stridor is associated with epiglottitis. The child has a high fever and this
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is associated with epiglottitis. The respiratory rate is normal for a child between 1 and 2 years
old. The childs heart rate is within normal limits for the childs age.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
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child;
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Question 10
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Type: MCSA
The nurse is assessing the newborn and notes the presence of a bluish discoloration of the hands
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and feet. Which of the following actions would be most important for the nurse to perform next?
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1. Assess the oral mucosa.
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2. Obtain the newborns temperature.
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3. Apply a blanket.
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4. Assess capillary refill.
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Correct Answer: 1
Rationale 1: Acrocyanosis is the bluish discoloration of the hands and feet. It is a common
finding in newborns and infants during times of stress and exposure to cold environments. The
nurse must differentiate this benign finding from true cyanosis by examining the oral mucosa.
Rationale 2: The newborn may be suffering from hypothermia, but the nurse should first
determine if the newborn is experiencing true cyanosis or acrocyanosis.
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Rationale 3: Applying a blanket is important, but the nurse must first determine if the newborn
is experiencing true cyanosis or acrocyanosis.
Rationale 4: Capillary refill is important to assess, but the most important thing to do at this
point, is to determine if the newborn is experiencing true cyanosis or acrocyanosis.
Global Rationale: Acrocyanosis is the bluish discoloration of the hands and feet. It is a common
finding in newborns and infants during times of stress and exposure to cold environments. The
nurse must differentiate this benign finding from true cyanosis by examining the oral mucosa. In
true cyanosis, the oral mucosa, lips, and tongue will also be cyanotic. The newborn may be
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suffering from hypothermia, but the nurse should first determine if the newborn is experiencing
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true cyanosis or acrocyanosis. Applying a blanket is important, but the nurse must first determine
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if the newborn is experiencing true cyanosis or acrocyanosis. Capillary refill is important to
assess, but the most important thing to do at this point is to determine if the newborn is
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experiencing true cyanosis or acrocyanosis.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Question 11
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child.
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Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
Type: MCSA
The nurse has assessed a 7-year-old female. The child has a moderate amount of pubic and
axillary hair. The mother states, I just think she is going through puberty early. I was 11 when I
went through these changes. The nurses best response would be:
1. Your daughter is very young to be experiencing these types of changes.
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2. You are probably right, since you went through these types of changes early.
3. This type of hair growth is normally associated with cardiovascular disorders.
4. Are her friends experiencing the same changes?
Correct Answer: 1
Rationale 1: The presence of pubic, facial, or axillary hair in a prepubescent child is indicative
of endocrinologic disease.
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Rationale 2: The nurse should not give any diagnosis, but alert the mother that this is not a
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normal finding in a child of this age.
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Rationale 3: The presence of pubic, facial, or axillary hair in a prepubescent child is indicative
of endocrinologic disease.
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Rationale 4: Whether or not her friends are experiencing the same changes does not address this
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specific childs issues.
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Global Rationale: The nurse should not give any diagnosis, but alert the mother that this is not a
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normal finding in a child of this age. The mother was not necessarily early to begin changes at 11
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years of age. The presence of pubic, facial, or axillary hair in a prepubescent child is indicative
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of endocrinologic disease. Whether or not her friends are experiencing the same changes does
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not address this specific childs issues.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
child.
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Question 12
Type: FIB
The 5-year-old childs mother asks how much her childs bladder can hold. She states, It seems
like if we visit my mother who lives 2 hours away, we always have to stop once so that my child
can pee. I just wondered how big his bladder may be. Calculate the maximum amount of urine
that the child can hold within the bladder in milliliters.
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milliliters
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Standard Text:
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Correct Answer: 210 milliliters
Rationale: To calculate this number, use the following equation: Age in years + 2 oz = 5 + 2 oz=
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7 oz. There are 30 milliliters in every ounce. 7 oz times 30 milliliters is 210 milliliters.
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Global Rationale:
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
child.
Question 13
Type: MCSA
The mother of a 7-year-old child states, Im concerned because I can feel a few lumps at the base
of his neck. The nurse notes slightly enlarged, firm, nontender, cervical lymph nodes. The lymph
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nodes are easily moveable under the skin. Which of the following interventions would be
appropriate?
1. Speak with the physician about acquiring a throat culture.
2. Assess the clients temperature.
3. Examine the childs tonsils for tonsillitis.
4. Explain to the mother that this is a normal finding.
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Correct Answer: 4
Rationale 1: The client is not exhibiting any clinical manifestations associated with pharyngitis,
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so a throat culture is not warranted.
Rationale 2: The client is not exhibiting any clinical manifestations of an infection that would
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result in hyperthermia.
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Rationale 3: The client is not exhibiting any clinical manifestations of tonsillitis.
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Rationale 4: Shotty lymph nodes are a normal variant in preschool and school-age children, and
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are noninfected, nontender, enlarged nodes that move when palpated.
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Global Rationale: Shotty lymph nodes are a normal variant in preschool and school-age
children, and are noninfected, nontender, enlarged nodes that move when palpated. The client is
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not exhibiting any clinical manifestations associated with pharyngitis, so a throat culture is not
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warranted. The client is not exhibiting any clinical manifestations of an infection that would
result in hyperthermia. The client is not exhibiting any clinical manifestations of tonsillitis.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
child.
Question 14
Type: MCSA
The nurse is interviewing the mother of a 6 month old during a well-child visit. The mother
reports that there is a watery drainage from the infants left eye with some crusting present within
the eyelashes. The nurse inspects the infants left eye and agrees with the mothers assessment. In
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which of the following ways would the nurse accurately document this finding?
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1. Exotropia
2. Esotropia
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3. Dacryostenosis
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4. Congenital cataracts
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Correct Answer: 3
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Rationale 1: Exotropia causes the covered eye to move outward (laterally).
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Rationale 2: Esotropia causes the covered eye to move inward (medially).
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Rationale 3: Dacryostenosis is the congenital blockage of the tear ducts and is a normal variant
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until 9 months of age. The infant with dacryostenosis will present with unilateral tearing and
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non-purulent crusting.
Rationale 4: Congenital cataracts cause the cornea to appear hazy or cloudy.
Global Rationale: Dacryostenosis is the congenital blockage of the tear ducts and is a normal
variant until 9 months of age. The infant with dacryostenosis will present with unilateral tearing
and nonpurulent crusting. Exotropia causes the covered eye to move outward (laterally).
Esotropia causes the covered eye to move inward (medially). Congenital cataracts cause the
cornea to appear hazy or cloudy.
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Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
child.
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Question 15
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Type: MCSA
The nurse is assessing a newborn and abducts the hips and palpates the greater and lesser
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trochanter while flexing the hips and knees at a 90-degree angle. The nurse is assessing which of
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the following?
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1. Barlows maneuver
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2. Knee fracture
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Correct Answer: 4
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4. Ortolanis maneuver
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3. Galeazzi sign
Rationale 1: Barlows maneuver. Barlows maneuver is also used to assess for hip dysplasia. The
nurse utilizes the same hand palpation position while the nurse adducts the hip while gently
lifting the thigh and placing pressure on the trochanter.
Rationale 2: Knee fracture. This assessment is not performed specifically to assess for knee
fractures.
Rationale 3: Galeazzi sign. Galeazzi sign is positive when the infant has differing knee heights.
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Rationale 4: Ortolanis maneuver. The procedure described is called Ortolanis maneuver and is
used to assess dysplasia of the hip.
Global Rationale: The procedure described is called Ortolanis maneuver and is used to assess
dysplasia of the hip. Barlows maneuver, which also assesses hip dysplasia, utilizes the same
hand palpation position while the nurse adducts the hip while gently lifting the thigh and placing
pressure on the trochanter. This assessment is not performed specifically to assess for knee
fractures. Galeazzi sign is positive when the infant has differing knee heights.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
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child.
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Question 16
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Type: MCMA
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The nurse is performing an otoscopic examination in a child and notes the child expressing pain
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as the pinna is manipulated to better examine the tympanic membrane. Which of the following
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findings is consistent with the most likely condition?
Standard Text: Select all that apply.
1. Erythema is noted along the childs ear canal.
2. The tympanic membrane is in a full position, amber-colored, and immobile.
3. The external ear is abnormally protruding forward.
4. Edema is noted within the childs ear canal.
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5. Light yellow drainage is noted within the ear canal.
Correct Answer: 1,4,5
Rationale 1: Erythema is noted along the childs ear canal. Otitis externa results a reddened
ear canal.
Rationale 2: The tympanic membrane is in a full position, amber-colored, and
immobile.Otitis media with effusion appears with non-purulent fluid in the middle ear space,
causing edema in the eustachian tubes.
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Rationale 3: The external ear is abnormally protruding forward. Mastoiditis causes the
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childs external ear to protrude forward.
Rationale 4: Edema is noted within the childs ear canal. Otitis externa results in edema within
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the ear canal.
Rationale 5: Light yellow drainage is noted within the ear canal. Purulent drainage from the
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ear canal can indicate that the child has developed otitis externa.
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Global Rationale: Otitis externa results in pain with pinna manipulation and red, edematous ear
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canals with or without purulent discharge. Otitis media with effusion appears with nonpurulent
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fluid in the middle ear space, causing edema in the eustachian tubes. Mastoiditis causes the
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childs external ear to protrude forward.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
child.
Question 17
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Type: MCSA
The nurse needs to assess the young childs gait and range of motion of the extremities. Which of
the following instructions is a commonly used method during this portion of the childs
assessment?
1. I need you to pretend to be a duck. Squat and move forward while flapping your arms.
2. Let me see you jump in place on both feet.
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3. Please hop across the room on one foot and then come back by hopping on the other foot.
4. Would you please do some jumping jacks for me?
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Correct Answer: 1
Rationale 1: The duck walk involves squatting and moving forward while flapping the upper
arms and can be used to evaluate normal range of motion, muscle strength, and coordination in a
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child.
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of all of the childs extremities.
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Rationale 2: Jumping in place on both feet will not provide information about range of motion
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about range of motion.
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Rationale 3: Hopping on one foot and then the other across a room will not provide information
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Rationale 4: Jumping jacks may be difficult for some young children to perform due to lack of
extremities.
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coordination and is not a commonly used method for assessing gait and range of motion of the
Global Rationale: The duck walk involves squatting and moving forward while flapping the
upper arms and can be used to evaluate normal range of motion, muscle strength, and
coordination in a child. Jumping in place on both feet will not provide information about range
of motion of all of the childs extremities. Hopping on one foot and then the other across a room
will not provide information about range of motion. Jumping jacks may be difficult for some
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young children to perform due to lack of coordination and is not a commonly used method for
assessing gait and range of motion of the extremities.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
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child.
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Question 18
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Type: MCSA
The nurse is examining a child. The childs pharynx is reddened, with yellow exudate noted on
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each tonsil. The tongue is red with enlarged taste buds. Petechiae are visualized on the childs soft
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palate near the uvula. Which of the following physician orders is most important and appropriate
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for this child?
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1. Saline mouth rinses
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3. Dental referral
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2. Throat culture
4. Aspirin for pain
Correct Answer: 2
Rationale 1: Saline mouth rinses may help with the clients discomfort but is not the most
important intervention. This child needs to be started on the appropriate antibiotic if the child has
strep throat.
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Rationale 2: Strep throat infection, caused by group A beta-hemolytic Streptococcus pyogenes,
may cause yellow tonsillar exudates, erythematous and edematous pharynx, red tongue with
prominent taste buds (strawberry tongue), and petechial hemorrhages on the soft palate near the
uvula.
Rationale 3: A dental referral is inappropriate. This child needs to be started on the appropriate
antibiotic if the child has strep throat.
Rationale 4: Aspirin for pain is inappropriate because it can result in Reyes syndrome when
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taken by children.
Global Rationale: Strep throat infection, caused by group A beta-hemolytic Streptococcus
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pyogenes, may cause yellow tonsillar exudates, erythematous and edematous pharynx, red
tongue with prominent taste buds (strawberry tongue), and petechial hemorrhages on the soft
palate near the uvula. Saline mouth rinses may help with the clients discomfort but is not the
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most important intervention. A dental referral is inappropriate. This child needs to be started on
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the appropriate antibiotic if the child has strep throat. Aspirin for pain is inappropriate because it
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can result in Reyes syndrome when taken by children.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
child.
Question 19
Type: MCSA
The nurse is assessing a newborn and notes that the infant has six fingers on the left hand. The
nurse would accurately document this information in which of the following ways?
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1. Syndactyly
2. Polydactyly
3. Brachial plexus injury
4. Erbs palsy
Correct Answer: 2
Rationale 1: Syndactyly is a term used to describe the presence of webbed fingers.
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Rationale 2: Polydactyly is the presence of extra fingers.
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Rationale 3: Entire brachial plexus palsy results in no movement of the shoulder, arm, and hand.
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Unfortunately, this type of brachial plexus injury has a poor prognosis.
Rationale 4: Erbs palsy is one type of brachial plexus injury. It is a transient condition that
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results in paralysis of the shoulder and upper arm.
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Global Rationale: Polydactyly is the presence of extra fingers. Syndactyly is a term used to
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describe the presence of webbed fingers. A brachial plexus injury results in paralysis of the
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shoulder and upper arm from birth trauma. Entire brachial plexus palsy results in no movement
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of the shoulder, arm, and hand. Unfortunately, this type of brachial plexus injury has a poor
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prognosis. Erbs palsy is one type of brachial plexus injury. It is a transient condition that results
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in paralysis of the shoulder and upper arm.
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Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
child.
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Question 20
Type: MCSA
The nurse is assessing the child and notes that there is a depression in the lower part of the
sternum. The nurse would accurately document this finding in which of the following ways?
1. Normal sternal border
2. Pectus carinatum
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3. Barrel chest
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4. Pectus excavatum
Correct Answer: 4
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Rationale 1: A normal sternum does not contain these types of depressions or bowing.
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Rationale 2: Pectus carinatum is also called pigeon chest. It is associated with a bowing of the
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sternum.
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Rationale 3: Barrel chest, or an increased anterioposterior chest diameter, is normally seen in
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infancy, or with chronic respiratory disorders and normal aging.
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Rationale 4: Pectus excavatum is also called funnel chest. It is associated with a depression in
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the lower part of the sternum.
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Global Rationale: Pectus excavatum is also called funnel chest. It is associated with a
depression in the lower part of the sternum. A normal sternum does not contain these types of
depressions or bowing. Pectus carinatum is also called pigeon chest. It is associated with a
bowing of the sternum. Barrel chest, or an increased anterioposterior chest diameter, is normally
seen in infancy, or with chronic respiratory disorders and normal aging.
Cognitive Level: Understanding
Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
child.
Question 21
Type: FIB
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The nurse is educating the childs parents about the importance of limiting the childs intake of
fruit juice to less than 12 ounces each day. Calculate the number of ounces the child has had
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during the last 24 hours.
120 milliliters of orange juice, 60 milliliters of grape juice, 90 milliliters of cranberry-grape juice
ounces
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Standard Text:
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Correct Answer: 9 ounces
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Rationale: There are 30 milliliters in 1 ounce. The child drank 270 milliliters of fruit juice
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during the last 24 hours. 270 milliliters divided by 30 milliliters/ ounce = 9 ounces.
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Global Rationale:
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a
child.
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Question 22
Type: MCSA
The nurse is performing an otoscopic examination of a 3-year-old child. As the nurse prepares to
examine the clients tympanic membrane with the ototscope, the nurse would correctly choose
which of the following techniques?
1. Pull the tragus up and back while inserting the otoscope.
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4. Pull the tragus down and back while inserting the otoscope.
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3. Pull the ear lobe down and back while inserting the otoscope.
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2. Pull the ear lobe up and back while inserting the otoscope.
Correct Answer: 4
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Rationale 1: The tragus should be manipulated up and back when examining an older childs
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tympanic membrane.
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an older childs tympanic membrane.
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Rationale 2: The tragus, not the ear lobe, should be manipulated up and back when examining
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Rationale 3: The nurse should not manipulate the childs ear lobe while inserting the otoscope. It
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would be more helpful to pull the childs tragus down and back to insert the otoscope correctly.
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Rationale 4: In children under the age of 4 years, the tragus should be pulled down and back
while the otoscope is inserted. This allows for the speculum to follow the curve of the auditory
canal.
Global Rationale: In children under the age of 4, the tragus should be pulled down and back
while the otoscope is inserted. This allows for the speculum to follow the curve of the auditory
canal. Manipulating the ear lobe will be less helpful to the nurse who wishes to examine the
childs ear. The tragus, not the ear lobe, should be manipulated up and back when examining an
older childs tympanic membrane.
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Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 25.3: Use techniques that foster child compliance and safety during
physical assessment.
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Question 23
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Type: MCSA
The nurse determines that nutritional education is needed for the family of an 8 month old after
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the history reveals the following: the infant is drinking whole milk 3 times a day from a bottle,
eats table food such as hot dogs and grapes with the 2-year-old sibling, and is allowed gum as a
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1. Consumption of whole milk
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correct for a child of this age?
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reward for good behavior. Which part of the data would the nurse be able to support as being
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2. Eating table foods such as hot dogs and grapes
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3. Has been given gum for good behavior
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4. Drinking from a bottle
Correct Answer: 4
Rationale 1: An infant of this age should be consuming commercial, iron-fo