A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with
right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a
brisk 4+ response. Which interpretation of this finding is accurate? - ANSWER Hyperac-
tive response consistent with an upper motor neuron disorder.
A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have
lung cancer or something," and wants to get checked out since, "I can't seem to get rid of
this body-wracking dry cough that has been hanging around for the last six weeks." Which
computer documentation of this client's concerns should the nurse enter? - ANSWER De-
scribe having a "body-wracking dry cough" of 6 weeks duration.
The nurse examines a client's abdomen. Which finding indicates an abnormal response
when palpating the spleen? - ANSWER Firm mass palpated at bottom of left rib cage.
In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the
stethoscope at which location? - ANSWER Place bell of stethoscope over carotid artery
A male client arrives at the clinic for follow-up health assessment after recent antibiotic
treatment for pneumonia without hospitalization. Which technique should the nurse imple-
ment to assess for adventitious lung sounds? - ANSWER Press the stethoscope's dia-
phragm firmly on the skin over each lung field.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled
voice. Which complication should the nurse suspect? - ANSWER Peritonsillar abscess.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy.
While interviewing the client, which assessment technique should the nurse use when
1
, asking about the client's use of illegal drugs and alcohol? - ANSWER Ask specifically about
alcohol, marijuana, cocaine, heroin, and amounts.
The nurse applies pressure over an area of the lower abdomen where the client reports
pain. The client denies pain upon palpation, but reports pain when the pressure is released.
What action should the nurse implement? - ANSWER Notify the healthcare provider of
the rebound tenderness.
A. What type of ulcer is this? Which pathophysiology? venous or arterial? - ANSWER Ve-
nous leg ulcers usually develop on the inner lower leg, above the medial malleolus.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of ei-
ther venous or arterial insufficiency. Which assessment technique should the nurse use to
differentiate the pathophysiology causing the ulcer? - ANSWER Observe the specific loca-
tion and appearance of the ulceration.
B. What type of ulcer is this? Which pathophysiology? venous or arterial? - ANSWER Ar-
terial wounds occur most often on the foot, in between or at the tips of the toes, at pressure
points from foot wear, on the heels and around the lateral malleolus (the bone on the out-
side of the ankle joint).
The nurse is conducting a physical assessment of a young adult. Which information provides
the
best indication of the individual's nutritional status? - ANSWER Condition of hair, nails,
and skin.
The nurse is assessing a healthy adult male during an annual physical examination. The nurse
auscultates the client's abdomen and hears gurgling sound every ten seconds. What action
should the nurse take in response to this finding? - ANSWER Document this normal
bowel sound activity in the record.
2
right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a
brisk 4+ response. Which interpretation of this finding is accurate? - ANSWER Hyperac-
tive response consistent with an upper motor neuron disorder.
A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have
lung cancer or something," and wants to get checked out since, "I can't seem to get rid of
this body-wracking dry cough that has been hanging around for the last six weeks." Which
computer documentation of this client's concerns should the nurse enter? - ANSWER De-
scribe having a "body-wracking dry cough" of 6 weeks duration.
The nurse examines a client's abdomen. Which finding indicates an abnormal response
when palpating the spleen? - ANSWER Firm mass palpated at bottom of left rib cage.
In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the
stethoscope at which location? - ANSWER Place bell of stethoscope over carotid artery
A male client arrives at the clinic for follow-up health assessment after recent antibiotic
treatment for pneumonia without hospitalization. Which technique should the nurse imple-
ment to assess for adventitious lung sounds? - ANSWER Press the stethoscope's dia-
phragm firmly on the skin over each lung field.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled
voice. Which complication should the nurse suspect? - ANSWER Peritonsillar abscess.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy.
While interviewing the client, which assessment technique should the nurse use when
1
, asking about the client's use of illegal drugs and alcohol? - ANSWER Ask specifically about
alcohol, marijuana, cocaine, heroin, and amounts.
The nurse applies pressure over an area of the lower abdomen where the client reports
pain. The client denies pain upon palpation, but reports pain when the pressure is released.
What action should the nurse implement? - ANSWER Notify the healthcare provider of
the rebound tenderness.
A. What type of ulcer is this? Which pathophysiology? venous or arterial? - ANSWER Ve-
nous leg ulcers usually develop on the inner lower leg, above the medial malleolus.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of ei-
ther venous or arterial insufficiency. Which assessment technique should the nurse use to
differentiate the pathophysiology causing the ulcer? - ANSWER Observe the specific loca-
tion and appearance of the ulceration.
B. What type of ulcer is this? Which pathophysiology? venous or arterial? - ANSWER Ar-
terial wounds occur most often on the foot, in between or at the tips of the toes, at pressure
points from foot wear, on the heels and around the lateral malleolus (the bone on the out-
side of the ankle joint).
The nurse is conducting a physical assessment of a young adult. Which information provides
the
best indication of the individual's nutritional status? - ANSWER Condition of hair, nails,
and skin.
The nurse is assessing a healthy adult male during an annual physical examination. The nurse
auscultates the client's abdomen and hears gurgling sound every ten seconds. What action
should the nurse take in response to this finding? - ANSWER Document this normal
bowel sound activity in the record.
2
