Questions with 100% Correct Answers | Latest Update
2026/2027 | Graded A+ - Nightingale College
The nurse is interviewing a client who reports having a persistent, productive
cough during the winter caused by bronchitis. Which additional finding should the
nurse assess for bronchitis?
Phlegm production and wheezing.
The nurse is assessing the posterior pharynx during a physical examination. Which
technique should the nurse use?
Press the tongue down one side at a time with a tongue depressor.
The nurse is assessing a client who has a history of mitral stenosis. How should the
nurse assess this client with a stethoscope to listen for this condition?
Place the bell on the 5th intercostal space, left midclavicular line.
Which statement is accurate about assessing the spleen?
,It must be enlarged at least three times normal size for it to be palpable.
During an external examination of the eyes, the nurse gently palpates the eyes
while the client's eyelids are closed. The eyes are both very firm and resist
movement back into the orbit. How should the nurse document this finding?
Abnormal finding.
The nurse is assessing a client with liver disease who is jaundice and exhibits
scleral edema. During the health assessment, the nurse should implement which
technique to determine evidence of hepatomegaly?
Use a bouncing motion to tap the middle finger placed within boundaries of
the liver.
What is the best nursing response to an older client who has not mentioned
incontinence during a genitourinary assessment?
Ask the client specifically about any leakage of urine.
The registered nurse (RN) is caring for an Asian client who refuses to make eye
contact during conversations. How should the RN assess this client's response?
The client is treating the nurse with respect.
,The nurse is assessing a client for a hip flexion contracture. Which finding
indicates a negative Thomas test when the client's right knee is brought toward
the chest? The left leg remains on the table
*The Thomas test is performed by having the client bring one knee toward the
chest while the other leg remains extended on the table. A positive Thomas test
is elicited when the extended leg rises off the table when the opposite leg's
knee is brought up to the client's chest, indicating hip flexor contracture. If
the extended leg (the left leg, in this example) remains on the table, the test is
negative.
Which tool should the nurse use when assessing the neurological status of a client
with traumatic brain injury?
Glasgow Coma Scale.
The nurse is assessing a client who has a history of aortic regurgitation. Where
should the nurse place the stethoscope diaphragm to listen for this condition?
2nd intercostal space along the right sternal border.
, The nurse is assessing a client who has experienced a sudden onset of hearing loss
in the right ear. Which finding should alert the nurse to a potentially serious
medical condition that requires further evaluation?
There is no sign of associated infection.
Which information should the nurse obtain to identify the client's self-perception of
health status?
Health history
During the initial assessment, the nurse notes that a client has blurred vision with
cloudy lenses.
Which condition should the nurse document?
Cataracts.
A client with dark skin is reporting a painful and itching area on the lower left leg.
What should the nurse look for when assessing this client's skin for inflammation?
Change in consistency.