HCC TEST 6 REVIEW NCLEX QUESTIONS
WITH ANSWERS RATED A+
Chap 30. Which of the following is an expected finding during assessment of the
older adult? - ANSWER Visual acuity often lessens with age. Facial hair is likely
to become coarser, not finer. The sense of smell becomes less, rather than
more, acute. The respiratory rate and rhythm is regular at rest. However, both
may change quickly with activity and be slow to return to the resting level.
Chap 30. Which of the following assessments would the nurse expect to find
during a well-baby visit for a 12-month-old infant? - ANSWER Physical
assessment of the infant requires a strong knowledge of child growth and
development. It is expected that a 12-month-old infant will have a partially open
anterior fontanel. It should be fully closed by 18 months of age. Infants can
visually follow objects by the age of 4 weeks. The 12-month-old infant is
expected to crawl and to show signs of interest/ability to stand and walk. The
stepping reflex disappears by 6 months. Lanugo is a fine, downy hair that is
present on premature infants. The femoral artery is a large artery and a strong
bilaterally equal pulse is present. Weak femoral pulses may be a sign of a
cardiac anomaly.
Chap 30. Which is the best place to assess for hydration in the older adult? -
ANSWER Hydration status in elders is best assessed over the sternum or
clavicle due to normal loss of peripheral skin turgor.
Chap 30. Most health assessments are performed in a head-to-toe sequence.
The nurse needs to be aware: - ANSWER The nurse must be aware of
physiological changes that occur with the aging process.
Chap 30. Nurses perform physical assessments for different reasons. One of
those reasons is: - ANSWER Nurses perform physical assessments for different
reasons. One of those reasons is to obtain data about the client's functional
abilities.
Chap 30. A client asks the nurse, "What is the purpose of a physical
examination?" Which response by the nurse is not correct? - ANSWER These are
some of the purposes of the physical examination: To obtain baseline data about
the client's functional abilities; To supplement, confirm, or refute data obtained
in the nursing history; To obtain data that will help establish nursing diagnoses
and plans of care; To evaluate the physiologic outcomes of health care and thus
the progress of a client's health problem; To make clinical judgments about a
,client's health status; To identify areas for health promotion and disease
prevention; The nurse collects data to supplement, confirm, or refute data
obtained in the nursing history, during the physical exam. The nurse is not trying
to determine if the client is being dishonest.
Chap 30. Students are taught to follow a head-to-toe assessment. This assists
the student with: - ANSWER Students are taught to follow a head-to-toe
assessment. This assists the student with consistency in performing a
systematic assessment.
Chap 30. Which of the following actions is correct for the nurse assessing a
client who has just had a cast applied to the lower leg? - ANSWER Nursing
Assessments Addressing Selected Client Situations: 1. Client complains of
abdominal pain: Inspect, auscultate, and palpate the abdomen; assess vital
signs. 2. Client is admitted with a head injury: Assess level of consciousness
using Glasgow Coma Scale (see Table 30-10 in the textbook); assess pupils for
reaction to light and accommodation; assess vital signs. 3. The nurse prepares
to administer a cardiotonic drug to a client: Assess apical pulse and compare
with baseline data. 4. The client has just had a cast applied to the lower leg:
Assess peripheral perfusion of toes, capillary blanch test, pedal pulse if able,
and vital signs. 5. The client's fluid intake is minimal: Assess tissue turgor, fluid
intake and output, and vital signs.
Chap 30. Some nurses will prioritize their sequence of performing a health exam
according to: - ANSWER Some nurses will prioritize their sequence of
performing a health exam according to the disease process, beginning with the
body system related to the client's primary concern.
Chap 30. What evidence would most likely indicate to the nurse that a client had
a negative Romberg test? The client: - ANSWER A negative Romberg test would
be indicated when a client was able to maintain an upright posture and foot
stance with minimal swaying. A positive Romberg would show a client who
couldn't maintain foot stance, moved the feet apart to maintain stance, and
exhibited increased swaying.
Chap 30. The nurse documented that a brown-skinned client has pallor. What is
the specific observation for this client? - ANSWER Pallor is most evident in body
areas with the least pigmentation, such as the nail beds, oral mucus
membranes, palms of the hand, and soles of the feet. Pallor in brown-skinned
individuals appears as a yellow- brown tinge, and in black-skinned individuals it
appears as ashen gray.
Chap 30. The nurse explains to the client that the client is in the hospital
following a car accident. Several minutes later, the nurse asks the client,
"Where are you now?" The nurse is assessing the client's: - ANSWER The client
is asked to identify where the client is, which assesses orientation to place.
,Chap 30. Which examination technique is being used when the nurse touches
the client's abdomen to examine the size of the liver? - ANSWER Touching
signifies palpation, inspection is looking, percussion is tapping, and auscultation
is listening.
Chap 30. Auscultation is the: - ANSWER Auscultation is the process of listening
to sounds produced within the body. Inspection is the visual examination—that
is, assessing by using the sense of sight. Palpation is the examination of the
body using the sense of touch. Percussion is the act of striking the body surface
to elicit sounds that can be heard or vibrations that can be felt.
Chap 30. What are the methods used for physical examination? - ANSWER Four
primary techniques are used during the physical examination: inspection,
palpation, percussion, and auscultation. Analysis is not a physical examination
technique.
Chap 30. A nurse is evaluating a nursing student's understanding of cranial
nerves. Which of the following statements demonstrates a need for further
teaching? The assessment method for: - ANSWER Cranial Nerve Functions and
Assessment Methods Assessment of Cranial nerve II would be to ask the client
to read a Snellen-type chart. Cranial nerve I would be to ask the client to close
the eyes and identify different mild aromas, such as coffee, vanilla, peanut
butter, orange/lemon, or chocolate. Cranial nerve VI would be to assess the
client's directions of gaze. Cranial nerve VII would be to ask the client to smile,
raise the eyebrows, frown, puff out the cheeks, and close the eyes tightly.
Chap 30. A nurse asks a client to close her eyes, and then places a paper clip in
the client's palm. The client correctly identifies the object. What test did the
nurse perform? - ANSWER Stereognosis is the act of recognizing objects by
touching and manipulating them. Extinction is failure to perceive touch on one
side of the body when both sides are touched simultaneously. One- and two-
point discrimination entail the ability to sense if one or two areas of the skin,
respectively, are being stimulated by pressure. Paresthesia is an abnormal
sensation, such as burning or pain.
Chap 30. In what sites should the nurse auscultate the heart? - ANSWER The
nurse should auscultate the heart in all four anatomic sites: aortic, pulmonic,
tricuspid, and apical (mitral). Lateral, anterior, and posterior do not refer to
auscultation sites. Carotid, aortic, jugular and coronary refer to arteries and
veins near the heart. Apical and mitral refer to the same site. Sternal and costal
refer to bony landmarks.
Chap 30. After auscultating the abdomen, the nurse should report which of the
following to the primary care provider? - ANSWER A bruit suggests abnormal
turbulence in the aorta, and the primary care provider must be notified. In order
, for absence of bowel sounds to be considered abnormal, the bowels must be
silent for 3 to 5 minutes. Continuous bowel sounds are normally heard over the
ileocecal valve following meals. Bowel sounds are more commonly irregular
than they are regular.
Chap 30. Which of the following indicates a normal finding on auscultation of the
lungs? - ANSWER Resonance is a normal sound over the lung. Tympany would
be heard over the stomach (air filled); hyperresonance is never a normal finding;
and dullness would be heard below (not above) the 10th intercostal space.
Chap 30. In a client with long-term emphysema, the nurse might expect to see
which condition when inspecting the nails? - ANSWER Clubbing is a condition
where the nailbed is at least 180 degrees, often caused by lack of oxygen, such
as in emphysema. Koilonychia is an abnormality where the nail curves upward
from the nail bed, and is often seen in clients with iron-deficiency anemia.
Paronychia is the technical term for "ingrown nail." A slow blanch test (greater
than 2-3 seconds) may indicate circulatory problems.
Chap 34. Before obtaining a capillary blood specimen, in addition to assessing
the client's understanding of the procedure and response to previous testing,
what other factors need to be determined prior to the procedure? - ANSWER
The other factors that need to be determined prior to obtaining a capillary blood
specimen include: medications that may prolong bleeding, status of client's skin,
and circulatory status. It is not necessary to assess the client's complete blood
count. Taking capillary blood samples does not precipitate an insulin reaction.
Factors such as psychotropic medications, cognitive impairment, and the
caregiver's response have no bearing on the capillary blood specimen
collection. It is important to check the equipment prior to doing the procedure.
Medication history is important, but the nurse needs to focus on specific drugs
such as anticoagulants.
Chap 34. The nurse practitioner requests a laboratory blood test to determine
how well a client has controlled the client's diabetes over the past three months.
Which blood test will provide this information? - ANSWER A glycosylated
hemoglobin test would best determine diabetes control over the past three
months. Fasting blood glucose and capillary blood specimen will provide
information about the current blood glucose level. Glucose tolerance test is
used to determine if a client has diabetes.
Chap 34. As a nurse obtains a capillary glucose reading, the nurse knows that
the meter: - ANSWER As a nurse obtains a capillary glucose reading, the nurse
knows that the meter must be calibrated or it will give an inaccurate reading.
Chap 34. The client has a urinary health problem. Which of the following
procedures is performed using indirect visualization? - ANSWER KUB is an x-ray
of the kidneys, ureters, and bladder. An IVP and retrograde pyelography use
WITH ANSWERS RATED A+
Chap 30. Which of the following is an expected finding during assessment of the
older adult? - ANSWER Visual acuity often lessens with age. Facial hair is likely
to become coarser, not finer. The sense of smell becomes less, rather than
more, acute. The respiratory rate and rhythm is regular at rest. However, both
may change quickly with activity and be slow to return to the resting level.
Chap 30. Which of the following assessments would the nurse expect to find
during a well-baby visit for a 12-month-old infant? - ANSWER Physical
assessment of the infant requires a strong knowledge of child growth and
development. It is expected that a 12-month-old infant will have a partially open
anterior fontanel. It should be fully closed by 18 months of age. Infants can
visually follow objects by the age of 4 weeks. The 12-month-old infant is
expected to crawl and to show signs of interest/ability to stand and walk. The
stepping reflex disappears by 6 months. Lanugo is a fine, downy hair that is
present on premature infants. The femoral artery is a large artery and a strong
bilaterally equal pulse is present. Weak femoral pulses may be a sign of a
cardiac anomaly.
Chap 30. Which is the best place to assess for hydration in the older adult? -
ANSWER Hydration status in elders is best assessed over the sternum or
clavicle due to normal loss of peripheral skin turgor.
Chap 30. Most health assessments are performed in a head-to-toe sequence.
The nurse needs to be aware: - ANSWER The nurse must be aware of
physiological changes that occur with the aging process.
Chap 30. Nurses perform physical assessments for different reasons. One of
those reasons is: - ANSWER Nurses perform physical assessments for different
reasons. One of those reasons is to obtain data about the client's functional
abilities.
Chap 30. A client asks the nurse, "What is the purpose of a physical
examination?" Which response by the nurse is not correct? - ANSWER These are
some of the purposes of the physical examination: To obtain baseline data about
the client's functional abilities; To supplement, confirm, or refute data obtained
in the nursing history; To obtain data that will help establish nursing diagnoses
and plans of care; To evaluate the physiologic outcomes of health care and thus
the progress of a client's health problem; To make clinical judgments about a
,client's health status; To identify areas for health promotion and disease
prevention; The nurse collects data to supplement, confirm, or refute data
obtained in the nursing history, during the physical exam. The nurse is not trying
to determine if the client is being dishonest.
Chap 30. Students are taught to follow a head-to-toe assessment. This assists
the student with: - ANSWER Students are taught to follow a head-to-toe
assessment. This assists the student with consistency in performing a
systematic assessment.
Chap 30. Which of the following actions is correct for the nurse assessing a
client who has just had a cast applied to the lower leg? - ANSWER Nursing
Assessments Addressing Selected Client Situations: 1. Client complains of
abdominal pain: Inspect, auscultate, and palpate the abdomen; assess vital
signs. 2. Client is admitted with a head injury: Assess level of consciousness
using Glasgow Coma Scale (see Table 30-10 in the textbook); assess pupils for
reaction to light and accommodation; assess vital signs. 3. The nurse prepares
to administer a cardiotonic drug to a client: Assess apical pulse and compare
with baseline data. 4. The client has just had a cast applied to the lower leg:
Assess peripheral perfusion of toes, capillary blanch test, pedal pulse if able,
and vital signs. 5. The client's fluid intake is minimal: Assess tissue turgor, fluid
intake and output, and vital signs.
Chap 30. Some nurses will prioritize their sequence of performing a health exam
according to: - ANSWER Some nurses will prioritize their sequence of
performing a health exam according to the disease process, beginning with the
body system related to the client's primary concern.
Chap 30. What evidence would most likely indicate to the nurse that a client had
a negative Romberg test? The client: - ANSWER A negative Romberg test would
be indicated when a client was able to maintain an upright posture and foot
stance with minimal swaying. A positive Romberg would show a client who
couldn't maintain foot stance, moved the feet apart to maintain stance, and
exhibited increased swaying.
Chap 30. The nurse documented that a brown-skinned client has pallor. What is
the specific observation for this client? - ANSWER Pallor is most evident in body
areas with the least pigmentation, such as the nail beds, oral mucus
membranes, palms of the hand, and soles of the feet. Pallor in brown-skinned
individuals appears as a yellow- brown tinge, and in black-skinned individuals it
appears as ashen gray.
Chap 30. The nurse explains to the client that the client is in the hospital
following a car accident. Several minutes later, the nurse asks the client,
"Where are you now?" The nurse is assessing the client's: - ANSWER The client
is asked to identify where the client is, which assesses orientation to place.
,Chap 30. Which examination technique is being used when the nurse touches
the client's abdomen to examine the size of the liver? - ANSWER Touching
signifies palpation, inspection is looking, percussion is tapping, and auscultation
is listening.
Chap 30. Auscultation is the: - ANSWER Auscultation is the process of listening
to sounds produced within the body. Inspection is the visual examination—that
is, assessing by using the sense of sight. Palpation is the examination of the
body using the sense of touch. Percussion is the act of striking the body surface
to elicit sounds that can be heard or vibrations that can be felt.
Chap 30. What are the methods used for physical examination? - ANSWER Four
primary techniques are used during the physical examination: inspection,
palpation, percussion, and auscultation. Analysis is not a physical examination
technique.
Chap 30. A nurse is evaluating a nursing student's understanding of cranial
nerves. Which of the following statements demonstrates a need for further
teaching? The assessment method for: - ANSWER Cranial Nerve Functions and
Assessment Methods Assessment of Cranial nerve II would be to ask the client
to read a Snellen-type chart. Cranial nerve I would be to ask the client to close
the eyes and identify different mild aromas, such as coffee, vanilla, peanut
butter, orange/lemon, or chocolate. Cranial nerve VI would be to assess the
client's directions of gaze. Cranial nerve VII would be to ask the client to smile,
raise the eyebrows, frown, puff out the cheeks, and close the eyes tightly.
Chap 30. A nurse asks a client to close her eyes, and then places a paper clip in
the client's palm. The client correctly identifies the object. What test did the
nurse perform? - ANSWER Stereognosis is the act of recognizing objects by
touching and manipulating them. Extinction is failure to perceive touch on one
side of the body when both sides are touched simultaneously. One- and two-
point discrimination entail the ability to sense if one or two areas of the skin,
respectively, are being stimulated by pressure. Paresthesia is an abnormal
sensation, such as burning or pain.
Chap 30. In what sites should the nurse auscultate the heart? - ANSWER The
nurse should auscultate the heart in all four anatomic sites: aortic, pulmonic,
tricuspid, and apical (mitral). Lateral, anterior, and posterior do not refer to
auscultation sites. Carotid, aortic, jugular and coronary refer to arteries and
veins near the heart. Apical and mitral refer to the same site. Sternal and costal
refer to bony landmarks.
Chap 30. After auscultating the abdomen, the nurse should report which of the
following to the primary care provider? - ANSWER A bruit suggests abnormal
turbulence in the aorta, and the primary care provider must be notified. In order
, for absence of bowel sounds to be considered abnormal, the bowels must be
silent for 3 to 5 minutes. Continuous bowel sounds are normally heard over the
ileocecal valve following meals. Bowel sounds are more commonly irregular
than they are regular.
Chap 30. Which of the following indicates a normal finding on auscultation of the
lungs? - ANSWER Resonance is a normal sound over the lung. Tympany would
be heard over the stomach (air filled); hyperresonance is never a normal finding;
and dullness would be heard below (not above) the 10th intercostal space.
Chap 30. In a client with long-term emphysema, the nurse might expect to see
which condition when inspecting the nails? - ANSWER Clubbing is a condition
where the nailbed is at least 180 degrees, often caused by lack of oxygen, such
as in emphysema. Koilonychia is an abnormality where the nail curves upward
from the nail bed, and is often seen in clients with iron-deficiency anemia.
Paronychia is the technical term for "ingrown nail." A slow blanch test (greater
than 2-3 seconds) may indicate circulatory problems.
Chap 34. Before obtaining a capillary blood specimen, in addition to assessing
the client's understanding of the procedure and response to previous testing,
what other factors need to be determined prior to the procedure? - ANSWER
The other factors that need to be determined prior to obtaining a capillary blood
specimen include: medications that may prolong bleeding, status of client's skin,
and circulatory status. It is not necessary to assess the client's complete blood
count. Taking capillary blood samples does not precipitate an insulin reaction.
Factors such as psychotropic medications, cognitive impairment, and the
caregiver's response have no bearing on the capillary blood specimen
collection. It is important to check the equipment prior to doing the procedure.
Medication history is important, but the nurse needs to focus on specific drugs
such as anticoagulants.
Chap 34. The nurse practitioner requests a laboratory blood test to determine
how well a client has controlled the client's diabetes over the past three months.
Which blood test will provide this information? - ANSWER A glycosylated
hemoglobin test would best determine diabetes control over the past three
months. Fasting blood glucose and capillary blood specimen will provide
information about the current blood glucose level. Glucose tolerance test is
used to determine if a client has diabetes.
Chap 34. As a nurse obtains a capillary glucose reading, the nurse knows that
the meter: - ANSWER As a nurse obtains a capillary glucose reading, the nurse
knows that the meter must be calibrated or it will give an inaccurate reading.
Chap 34. The client has a urinary health problem. Which of the following
procedures is performed using indirect visualization? - ANSWER KUB is an x-ray
of the kidneys, ureters, and bladder. An IVP and retrograde pyelography use
