Module 2 Exam with Rationale GRADED A VERIFIED

Questions 1.
ID: 3
A nurse performing a physical assessment of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data? 
 A The client appears anxious. B Blood pressure is 170/80 mm Hg. C The client states that he has a rash. Correct D The client has diminished reflexes in the legs. 


Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Test-Taking Strategy: Eliminate the options that are comparable or alike and include data that the nurse would obtain during the physical examination. Review: the difference between subjective and objective data . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 




 2.
ID: 7
A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? 
 A The client is allergic to strawberries. B The last menstrual period was 30 days ago. C The client takes acetaminophen (Tylenol) for headaches. D A 1 × 2-inch scar is present on the lower right portion of the abdomen. Correct 


Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. Test-Taking Strategy: Eliminate the options that are comparable or alike and include data that the nurse would obtain from the client during the health history. Review: the difference between subjective and objective data . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 




 3.
ID: 9
A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? 
 A Episodic B Follow-up C Emergency D Complete Correct 


Rationale: A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting such as a pediatric or family practice clinic, an independent or group private practice, a college health service, a women’s healthcare agency, a visiting nurse agency, or a community health agency. An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or one body system. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed. Test-Taking Strategy: Noting the words “initial home visit” in the question will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p.8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Technology and Informatics HESI Concepts: Evidence-Based Practice/Evidence, Informatics/Technology Awarded 1.0 points out of 1.0 possible points. 




 4.
ID: 1
A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which? 
 A Data related to follow-up care B A complete (total health) database C Data related to the respiratory system Correct D Data related to the treatment for the cold 


Rationale: An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. Test-Taking Strategy: Focusing on the data in the question and noting the words “now complaining of chest congestion and cough” will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Gas Exchange HESI Concepts: Evidence-Based Practice/Evidence, Oxygenation/Gas Exchange Awarded 1.0 points out of 1.0 possible points. 




 5.
ID: 1
A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? 
 A Collect health history information first, then perform the physical examination B Ask health history questions while performing the examination and initiating emergency measures Correct C Collect all information requested on the history form, including social support, strengths, and coping patterns D Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room 


Rationale: If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client’s immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment. Test-Taking Strategy: Focus on the data in the question and note the words “alert and cooperative.” Noting that the client has not sustained life-threatening injuries will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Health Care Quality HESI Concepts: Evidence-Based Practice/Evidence, Health Policy/Systems—Health Care Quality Awarded 1.0 points out of 1.0 possible points. 




 6.
ID: 3
A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? 
 A Emergency B Follow-up Correct C Complete (total) D Problem-centered 


Rationale: A follow-up database is compiled to evaluate the status of an identified problem at regular and appropriate intervals. An emergency database calls for rapid collection of the data, often at the same time lifesaving measures are being performed. A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. An episodic database (problem-centered) is compiled for a limited or short-term problem. It is focused mainly on one problem or body system. Test-Taking Strategy: Focus on the subject, a checkup 3 months after a diagnosis. Noting the words “at the clinic for a check-up” in the question will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Technology and Informatics HESI Concepts: Evidence-Based Practice/Evidence, Informatics/Technology Awarded 1.0 points out of 1.0 possible points. 




 7.
ID: 5
A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. What is the primary purpose of including cultural information in the health assessment? 
 A Confirm the medical diagnosis B Make accurate nursing diagnoses C Identify any hereditary traits related to the epilepsy D Determine what the client believes has caused the epilepsy Correct 


Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican-American culture, epilepsy is seen as a reflection of physical imbalance. Although the nurse may obtain data related to family history (hereditary) and formulate nursing diagnoses, these are not the primary reasons for including cultural information in the health assessment. A nurse gathers assessment data but does not confirm a medical diagnosis. Test-Taking Strategy: Eliminate the option that indicates to confirm a medical diagnosis, because this is not the role of the nurse. To select from the remaining options, recall that cultural beliefs exist in relation to the cause of a disease; this will direct you to the correct option. Review: the nurse’s role in data collection and cultural considerations . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 52). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Cultural Awareness Priority Concepts: Culture, Evidence HESI Concepts: Cultural/Spiritual, Evidence-Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 




 8.
ID: 1
A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. What does the nurse determine? 
 A The client has a fever B The skin temperature is normal Correct C The client needs to drink additional fluids D The client needs to have the blanket removed 


Rationale: To assess skin temperature, the nurse would first note the temperature of his or her own hands, then use the backs (dorsa) of the hands to palpate the client’s skin bilaterally. The skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. The hands and feet may feel slightly cooler in a cool environment. Giving the client additional fluids, removing the blanket, and checking for a fever are all incorrect responses to this finding. Test-Taking Strategy: Focus on the data in the question. Note the word “warm.” Recalling that warmth suggests normal circulatory status will direct you to the correct option. Review: normal skin temperature . References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 467). St. Louis: Saunders. Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 232). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Integumentary Priority Concepts: Evidence, Thermoregulation HESI Concepts: Evidence-Based Practice/Evidence, Intracranial Regulation—Thermoregulation Awarded 1.0 points out of 1.0 possible points. 




 9.
ID: 9
A nurse performing a skin assessment notes that the client's skin is very dry. How should the nurse document this finding? 
 A Xerosis Correct B Pruritus C Seborrhea D Actinic keratoses 


Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Causes include too-frequent bathing, low humidity, and decreased production of sebum in aging skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin. Seborrhea is one of several common skin conditions in which an overproduction of sebum results in excessive oiliness or dry scales. Actinic keratoses are red-tan scaly plaques that grow over the years, becoming raised and roughened. A silvery-white scale may adhere to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. Actinic keratoses are premalignant and may develop into squamous cell carcinoma. Test-Taking Strategy: Knowledge of the characteristics of various skin conditions and lesions is needed to answer this question. This knowledge and noting the words “very dry” in the question will direct you to the correct option. Review: the conditions identified in the options . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 465, 480). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Integumentary Priority Concepts: Evidence, Tissue Integrity HESI Concepts: Evidence-Based Practice/Evidence, Tissue Integrity Awarded 1.0 points out of 1.0 possible points. 




 10.
ID: 3
A nurse is preparing to perform a skin examination with the use of a Wood light. Which action should the nurse perform to prepare for this diagnostic test? 
 A Darken the room Correct B Obtain informed consent from the client C Obtain a scalpel and a slide for diagnostic evaluation D Obtain medication to anesthetize the skin area before proceeding with the examination 


Rationale: A handheld long-wavelength ultraviolet (black) light, or Wood light, is sometimes used during physical examination of the skin. Areas of blue-green or red fluorescence are associated with certain skin conditions. Hypopigmented skin appears more prominent when it is viewed under black light, greatly facilitating the evaluation of pigment changes in fair-skinned clients. Examination of the skin is always carried out in a darkened room. The test is noninvasive, and the nurse should reassure the client that no discomfort is associated with a Wood light examination. Test-Taking Strategy: Focus on the subject, the name of the test. Recalling that this test is noninvasive will assist you in eliminating the incorrect options. Review: the procedure for performing a Wood light test . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 477). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Adult Health/Integumentary Priority Concepts: Evidence, Tissue Integrity HESI Concepts: Evidence-Based Practice/Evidence, Tissue Integrity Awarded 1.0 points out of 1.0 possible points. 




 11.
ID: 8
A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. How should the nurse document this finding? 
 A Anasarca Correct B Ecchymosis C Unilateral edema D Increased vascularity of the skin tissue 


Rationale: Bilateral edema, or edema that is generalized over the entire body, is known as anasarca. This finding is indicative of a central problem such as congestive heart failure or kidney failure. It does not indicate increased vascularity of skin tissue. Ecchymosis is a large patch of capillary bleeding into the tissues (bruise). Test-Taking Strategy: Focusing on the words “appearance of generalized edema” in the question and visualizing the appearance of each condition in the options will help you answer correctly. Review: the terms related to edema . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 714). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Renal Priority Concepts: Evidence, Fluid and Electrolyte Balance HESI Concepts: Evidence-Based Practice/Evidence, Fluids and Electrolytes Awarded 1.0 points out of 1.0 possible points. 




 12.
ID: 3
A nurse reviewing the medical record of a client with the diagnosis of heart failure notes documentation indicating that the client has deep pitting edema, that the indentation remains for a short time, and that the leg looks swollen. How should the nurse document this finding? 
 A 1+ edema B 2+ edema C 3+ edema Correct D 4+ edema 


Rationale: Edema, the accumulation of fluid in the intercellular spaces, is not normally present. To check for edema, the nurse presses his or her thumbs firmly against the ankle malleolus or the tibia. Normally the skin surface stays smooth. If the pressure leaves a dent in the skin, “pitting” edema is present. Its presence is graded on the following 4-point scale: 1+ denotes mild pitting and slight indentation but no perceptible swelling of the leg, 2+ indicates moderate pitting in which the indentation subsides rapidly, 3+ indicates deep pitting in which the indentation remains for a short time and the leg looks swollen, and 4+ denotes very deep pitting in which the indentation lasts a long time and the leg is very swollen. Test-Taking Strategy: Focus on the data in the question. Noting the words “indentation remains for a short time” in the question will help direct you to the correct option. Review: the grading scale for edema . References: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 233). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 569). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Cardiovascular Priority Concepts: Evidence, Fluid and Electrolyte Balance HESI Concepts: Evidence-Based Practice/Evidence, Fluids and Electrolytes Awarded 1.0 points out of 1.0 possible points. 




 13.
ID: 9
A client complains that her skin is redder than normal. The nurse assesses the client’s skin, documents hyperemia, and explains to the client that this condition is caused by which? 
 A Contraction of the underlying blood vessels B A reduced amount of bilirubin in the blood C Diminished perfusion of the surrounding tissues D Excess blood in the dilated superficial capillaries Correct 


Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. A reduced amount of bilirubin in the blood, diminished perfusion of the surrounding tissues, and contraction of the underlying blood vessels are all incorrect explanations for hyperemia. Test-Taking Strategy: Note the relationship between the words “skin is redder” in the question and “excess blood” in the correct option. Review: the description and cause of hyperemia . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 312, 839). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Priority Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Awarded 1.0 points out of 1.0 possible points. 




 14.
ID: 3
A clinic nurse about to meet a new client and plans to gather subjective data regarding the client's health history. Which actions should the nurse take to help ensure the success of the interview? Select all that apply. 
 A Ensuring that the room is private Correct B Seeing that distracting objects are removed from the room Correct C Having the client sit across a desk or table to give the client some personal space D Maintaining a distance of 2 feet or closer between the nurse and client E Switching on a dim light that will make the room cozier and help the client relax 


Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained, that there are no interruptions during the interview, that the room temperature is comfortable, that lighting is sufficient, that ambient noise is reduced, and that distracting objects are removed from the room. The nurse also ensures that the client and nurse are seated comfortably, eye to eye, without a desk or table between them, because a desk or table would act as a barrier. The nurse should maintain a distance of 4 to 5 feet from the client to avoid invading the client’s private space, which might create anxiety on the part of the client. Test-Taking Strategy: Eliminate the options that are comparable or alike and involves personal space (2 feet or closer and the client sits across a desk or table). To select from the remaining options, recall that adequate lighting is important for the nurse to observe the client during the interview and a private room without distractions is important. Review: the physical environment and its effect on a client interview . References: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 57). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 236-239). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Technology and Informatics HESI Concepts: Evidence-Based Practice/Evidence, Informatics/Technology Awarded 2.0 points out of 2.0 possible points. 




 15.
ID: 4
A nurse conducting an interview with a client collects subjective data. During the interview, which action should the nurse take? 
 A Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors Correct B Takes a great deal of notes to allow the client to continue at his or her own pace as the nurse records what he or she is saying C Takes notes because this allows the nurse to break eye contact with the client, which may increase the client's level of comfort D Takes notes to allow the nurse to shift attention away from the client, which may make the nurse more comfortable 


Rationale: During an interview, the nurse keeps note-taking to a minimum and tries to focus his or her attention on the client. Any note-taking should be secondary to the dialogue and should not interfere with the client’s dialogue. Note-taking during an interview breaks eye contact too often; shifts the nurse’s attention away from the client, diminishing his or her sense of importance; interrupts the client’s narrative flow; impedes the nurse’s observation of the client’s nonverbal behaviors; and may be threatening to the client during the discussion of sensitive issues. Test-Taking Strategy: Noting the word “minimal” will direct you to the correct option. Review: the nurse’s role with regard to note-taking during an interview . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 57). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 236-239). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam Priority Concepts: Health Care Quality, Technology and Informatics HESI Concepts: Health Policy/Systems—Health Care Quality, Informatics/Technology Awarded 1.0 points out of 1.0 possible points. 




 16.
ID: 3
A nurse is preparing to screen a client’s vision with the use of a Snellen chart. Which action should the nurse take? 
 A Tests the right eye, then tests the left eye, and finally tests both eyes together Correct B Assesses both eyes together, then assesses the right and left eyes separately C Asks the client to stand 40 feet from the chart and read the largest line on the chart D Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision 


Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot with the chart at the client’s eye level. The client is positioned on a mark exactly 20 feet from the chart. The client uses an opaque card to shield one eye at a time during the test; after each eye is tested, both eyes are assessed together. The client is asked to read through the chart to the smallest line of letters he or she can discern. The client is encouraged to read the next smallest line as well. Therefore the other options are incorrect. Test-Taking Strategy: Focus on the subject, a vision screening test. Visualizing each of the descriptions in the options will direct you to the correct one. Review: the procedure for using the Snellen eye chart . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. ). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 17.
ID: 5
A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. How should the nurse interpret this data? 
 A Is legally blind B Has normal vision C Can read at a distance of 20 feet what a client with normal vision can read at 80 feet Correct D Can read at a distance of 80 feet what a client with normal vision can read at 20 feet 


Rationale: When recording the results of visual acuity testing with the use of the Snellen chart, the nurse would use the numeric fraction noted at the end of the last line on the chart read successfully by the client. The top number (numerator) indicates the distance the client is standing from the chart; the denominator is the distance at which a normal eye could have read that particular line. Therefore a reading of 20/80 means that the client can read at a distance of 20 feet what a client with normal vision can read at 80 feet.. Legal blindness is defined as the best corrected vision in the better eye of 20/200 or worse. Normal visual acuity is 20/20. Test-Taking Strategy: Recalling that the client stands 20 feet from the Snellen chart when visual acuity is being tested will direct you to the correct option. Review: the procedure for interpreting the results from this visual acuity test . References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1686). St. Louis: Saunders. Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 308-309). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 18.
ID: 1
A nurse is examining the peripheral vision of a client using the confrontation test. How should the nurse carry out this procedure? 
 A Asks the client to discriminate numbers on a chart composed of colored dots B Darkens the room and asks the client to identify colored blocks and shapes that appear in the visual field C Has both the client and nurse cover the right eye, stare at each other's uncovered eye, and bring a small object into the visual field, then repeat the test with the left eye D Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field Correct 


Rationale: The confrontation test is a gross measure of peripheral vision. It compares the client’s peripheral vision with the examiner’s vision under the assumption that the examiner’s vision is normal. The examiner positions himself or herself at eye level with the client, about 2 feet away. The examiner directs the client to cover one eye with an opaque card and look straight at the examiner with the other. The examiner covers his or her own eye opposite the client’s covered one. Next the examiner holds a pencil or flicking finger as a target midline between himself or herself and the client and slowly advances it from the periphery in several directions. The examiner asks the client to say “now” as the target is first seen. This sighting should occur just as the examiner sees the object for the first time. Asking the client to discriminate numbers on a chart composed of colored dots and darkening the room and asking the client to identify colored blocks and shapes that appear in the visual field are both components of testing for color vision. Test-Taking Strategy: Focus on the subject, the confrontation test, which assesses peripheral vision. This will assist you in eliminating the options that do not address this concept. To select from the remaining options, visualize each. This will direct you to the correct option. Review: this vision test . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 310). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 19.
ID: 7
A nurse performing an eye examination uses an ophthalmoscope to best visualize which area? 
 A Iris B Cornea C Optic disc Correct D Conjunctiva 


Rationale: The ophthalmoscope enlarges the examiner’s view of the eye so that the media (anterior chamber, lens, vitreous humor) and the ocular fundus (the internal surface of the retina) can be examined. The optic disc is located on the internal surface of the retina. The iris, conjunctiva, and cornea can be examined without the use of an ophthalmoscope. Test-Taking Strategy: Think about the anatomical structures of the eye. Recalling that the optic disc is located on the internal surface of the retina will direct you to the correct option. Review: the structures that need to be examined with the use of an ophthalmoscope . Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 580). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 20.
ID: 7
A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. How should the nurse interpret this data? 
 A Normal near vision B Normal central vision C Normal peripheral vision D Normal ocular movements Correct 


Rationale: Leading the client’s eyes through the six cardinal fields of gaze will elicit any muscle weakness during movement. This test assesses the function of the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Near vision is tested with the use of a handheld vision screener that contains various sizes of print. Central vision is measured with the use of a Snellen chart. Peripheral vision is measured with the confrontation test. Test-Taking Strategy: Recalling that the six cardinal fields of gaze are used to test for muscle weakness will direct you to the correct option. Also note the relationship of the words “moved” in the question and “movements” in the correct option. Review: this test . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. ). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Eye Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 21.
ID: 3
A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. How should the nurse document this finding? 
 A Ptosis B Nystagmus Correct C Scleral icterus D Exophthalmos 


Rationale: Nystagmus is a fine oscillating movement, most notable around the iris. The nurse checks for nystagmus when assessing a client for ocular muscle weakness. Mild nystagmus at extreme lateral gaze is normal; nystagmus at any other position is not. Ptosis is a drooping of the eyelid. Scleral icterus is a yellowing of the sclera, extending up to the cornea, that indicates jaundice. Exophthalmos, a noticeable protrusion of the eyeball, is a characteristic sign of hyperthyroidism. Test-Taking Strategy: Recalling that exophthalmos is a protrusion of the eyeball associated with hyperthyroidism will assist you in eliminating this option. To select from the remaining options, focus on the words “oscillating movements” in the question and read each option carefully to find the correct one. Review: the description of nystagmus . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. ). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Eye Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 22.
ID: 3
A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding? 
 A Myopia B Hyperopia C Photophobia D Accommodation Correct 


Rationale: Accommodation is adaptation of the eye for near vision. Movement of the ciliary muscles increases the curvature of the lens. To observe accommodation, the examiner notes convergence (motion toward) of the axes of the eyeballs and pupillary constriction. Myopia is nearsightedness. Hyperopia is farsightedness. Photophobia is abnormal sensitivity to light, especially of the eyes. Test-Taking Strategy: Focus on the data in the question. Note the relationship between the data “pupils get larger” and “become smaller” in the question and the correct option. Review: the description of accommodation . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 1074). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Eye Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 23.
ID: 5
A nurse is using an otoscope to examine the ears of a client. Which finding indicates to the nurse that the tympanic membrane is normal? 
 A Correct B C D 


Rationale: The tympanic membrane is shiny and translucent, with a pearly gray color. The appearance of a yellow clump of material indicates the presence of a piece of cerumen in the external meatus. An excessive amount of cerumen in the external auditory canal appears dark and covers a large part of the canal and tympanic membrane. A hole in the tympanic membrane indicates perforation of the membrane. Test-Taking Strategy: Knowledge regarding the appearance of the tympanic membrane is needed to answer the question. It is necessary to recall that the normal tympanic membrane is pearly gray in color. Review: the normal findings on otoscopic examination of the ear . Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1673). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 24.
ID: 1
An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client? 
 A Loud music B Use of power tools C Occupational noise D Exposure to cigarette smoke Correct 


Rationale: Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include youth (otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. Loud music, the use of power tools, and occupational noise can all cause hearing loss. Hearing loss may occur as a result of an acute loud noise (acoustic trauma) or long-term exposure to loud noise (noise-induced hearing loss). Test-Taking Strategy: Use the process of elimination and focus on the word “infection” in the question. Eliminate the options that are comparable or alike and refer to noise. Review: the causes of middle ear infections . Reference: Copstead, L., & Banasik, J. (2010). Pathophysiology (4th ed., p. 1092). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Ear Priority Concepts: Infection, Sensory Perception HESI Concepts: Infection, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 25.
ID: 8
A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse take before inserting the otoscope? 
 A Pulling the pinna up and back Correct B Pulling the pinna down and forward C Tipping the client's head down and toward the examiner D Tipping the client's head down and away from the examiner 


Rationale: In an adult client, the nurse pulls the pinna up and back to help straighten the S shape of the ear canal. The client’s head is tilted slightly away from the examiner, toward the client’s opposite shoulder. The nurse holds the pinna gently and firmly until the examination is complete and the otoscope has been removed from the client’s ear. The nurse pulls the pinna down when examining an infant or a child younger than 3 years. Test-Taking Strategy: Focus on the subject, examining the ear of an adult client with an otoscope. Visualize the descriptions in each of the options to direct you to the correct option. Review: the procedure for using an otoscope . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 1115). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 26.
ID: 7
A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat which kind of words? 
 A Spoken in a soft tone of voice by the nurse about 5 feet in front of the client B Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested Correct C Spoken by the nurse from the client's side in a normal tone of voice about 10 feet from the ear being tested D Whispered at a distance of 20 feet by the nurse while he or she is standing in front of the client 


Rationale: In performing the voice test, the nurse tests one ear at a time while masking hearing in the other ear to prevent transmission around the head. The nurse shields his or her lips so that the client cannot compensate for hearing loss (consciously or unconsciously) by lip-reading or using the “good” ear. The nurse stands 1 to 2 feet from the client’s ear, exhales, and slowly whispers some two-syllable words. A client with normal hearing repeats each word correctly. Test-Taking Strategy: Visualize each option. Eliminate the options that indicate that the nurse must stand in front of the client; if the nurse did this, the client would be able to lip-read. To select from the remaining options, note the words “about 10 feet”; this will help you eliminate this option. Review: the procedure for the voice test . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. ). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 27.
ID: 4
A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork? 
 A On the client's teeth B On the client's forehead C On the client's mastoid bone Correct D On the midline of the client's skull 


Rationale: In the Rinne test, the base of an activated tuning fork is held first against the mastoid bone, behind the ear, and then in front of the ear canal (0.5 to 2 inches). When the client no longer perceives the sound behind the ear, the fork is moved in front of the ear canal until the client indicates that the sound can no longer be heard. The client reports whether the sound from the tuning fork is louder behind the ear (on the mastoid bone) or in front of the ear canal. In the Weber test, an activated tuning fork is placed on the midline of the skull, the forehead, or the teeth. Test-Taking Strategy: Focus on the subject of the question, the Rinne test. Visualizing the procedure for performing this test will direct you to the correct option. Review: this hearing test . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 1116). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 28.
ID: 2
A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. What should the nurse check for when inspecting the ears for cerumen impaction? 
 A Redness and swelling of the tympanic membrane B An external auditory canal that is longer than normal C The presence of edema in the external auditory canal D A yellowish or brownish waxy material in the external auditory canal Correct 


Rationale: Cerumen (ear wax) is a yellowish or brownish waxy secretion produced by vestigial apocrine sweat glands in the external ear canal. It becomes impacted because of the narrow tortuous canal or as a result of poor cleaning methods. Cerumen may partially obscure the eardrum or totally occlude the ear canal. Even when the canal is 90% to 95% blocked, hearing is normal, but when the last 5% to 10% becomes occluded (e.g., when cerumen expands after the client swims or showers), the client experiences sudden hearing loss and a feeling of fullness in the ear. Redness and swelling of the tympanic membrane, edema in the external auditory canal, and an external auditory canal that is longer than normal are not descriptions of cerumen. Test-Taking Strategy: Focus on the word “cerumen” in the question. Recalling that cerumen is ear wax will direct you to the correct option. Review: the characteristics of cerumen . References: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 344, 366). St. Louis: Saunders. Mosby’s Dictionary of medicine nursing & health professions (2009) (8th ed., p. 341). St. Louis: Elsevier. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 29.
ID: 6
A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal? 
 A Firm pressure Correct B Pain behind the eyes C Pain during palpation D Pressure producing an acute headache 


Rationale: The client would normally feel a firm pressure as the nurse palpates his or her sinuses. Pain experienced during palpation of the sinuses is an indication of acute sinusitis. Headaches that vary in intensity with position changes or when secretions drain indicate acute sinusitis. An acute headache should not occur with palpation of the sinuses. Test-Taking Strategy: Note the strategic words “if the sinuses are normal” in the query of the question. Eliminate the options that are comparable or alike and indicate the presence of discomfort on palpation of the sinuses. Review: the expected findings when palpating the sinuses . Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1532). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 30.
ID: 7
A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve? 
 A Asking the client to stick out his or her tongue and watching the client for tremors B Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex C Depressing the client’s tongue with a tongue blade and noting pharyngeal function as the client says “ah.” D Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands Correct 


Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size. The nurse checks that these muscles are equal in strength by asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse’s hands. Asking the client to stick out the tongue and watching for tremors is the method for assessing the function of cranial nerve XII (hypoglossal nerve). Assessment of pharyngeal function reveals the function of cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). Test-Taking Strategy: Eliminate the options that are comparable or alike and address pharyngeal function. To select from the remaining options, recall that cranial nerve XI is the spinal accessory nerve, which will direct you to the correct option. Review: the procedure for assessing the function of cranial nerve XI . Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1775). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 31.
ID: 1
A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve? 
 A Coffee Correct B A tuning fork C A wisp of cotton D An ophthalmoscope 


Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse tests the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client’s nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client’s eyes closed, the nurse occludes one nostril and presents a nonnoxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. A tuning fork is used to assess the function of cranial nerve VIII (acoustic nerve). A wisp of cotton is used to assess the sensory function of cranial nerve V (trigeminal nerve). An ophthalmoscope is used to assess the internal structures of the eye. Test-Taking Strategy: Recalling that cranial nerve I is the olfactory nerve will direct you to the correct option. Review: cranial nerve I and the method of testing its function . References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1775). St. Louis: Saunders. Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 666-667). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Assessment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 32.
ID: 7
A nurse inspecting a client’s throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which nerve? 
 A Cranial nerve V B Cranial nerve XII C Cranial nerves I and II D Cranial nerves IX and X Correct 


Rationale: The motor function of cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) is tested by depressing the tongue with a tongue blade and noting the pharyngeal movement as the client says “ah.” Motor function of these nerves is also tested by touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Eliciting a response from cranial nerve V (trigeminal nerve) tests the muscles of mastication. Eliciting a response from cranial nerve I (olfactory nerve) tests the function of smell. Eliciting a response from cranial nerve II (optic nerve) involves eye examinations. In testing cranial nerve XII (hypoglossal nerve), the examiner inspects symmetry and movement of the tongue. Test-Taking Strategy: Focus on the data in the question. Recalling that cranial nerve IX is the glossopharyngeal nerve and cranial nerve X is the vagus nerve will direct you to the correct option. Review: these cranial nerves . Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes. (8th ed., p. 1775). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Sensory Perception HESI Concepts: Assessment, Sensory/Perception Awarded 1.0 points out of 1.0 possible points. 




 33.
ID: 5
A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing? 
 A Cranial nerve X B Cranial nerve V C Cranial nerve IX D Cranial nerve XII Correct 


Rationale: To test cranial nerve XII (hypoglossal nerve), the examiner inspects symmetry and movement of the tongue. The nurse looks for a forward thrust in the midline as the client sticks out the tongue. The examiner tests the motor function of cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve) by depressing the client’s tongue with a tongue blade and noting the pharyngeal movement as the client says “ah.” Motor function of these nerves is also tested by touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Eliciting a response from cranial nerve V (trigeminal nerve) tests the muscles of mastication. Test-Taking Strategy: Focus on the data in the question. Recalling that cranial nerve XII is the hypoglossal nerve will direct you to the correct option. Review: the method of testing this cranial nerve . Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1775). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0 possible points. 




 34.
ID: 9
A nurse is preparing to listen to the breath sounds of a client. The nurse should: 
 A Ask the client to lie prone B Ask the client to breathe in and out through the nose C Hold the bell of the stethoscope lightly against the chest D Listen for at least one full respiration in each location on the chest Correct 


Rationale: To best listen to breath sounds, the nurse asks the client to sit, leaning slightly forward, with the arms resting comfortably across the lap. The client is instructed to breathe through the mouth, a little deeper than usual, but to stop if he or she feels dizzy. The flat diaphragm endpiece of the stethoscope is held firmly against the client’s chest wall. The nurse listens for at least one full respiration in each location on the chest. Side-to-side comparison is most important in the assessment of breath sounds. Test-Taking Strategy: Read carefully and visualize each of the options. Thinking about the procedure for listening to breath sounds and noting the words “one full respiration” will direct you to the correct option. Review: the procedure for listening to breath sounds . Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1534). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0 possible points. 




 35.
ID: 9
A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as: 
 A Normal egophony B Abnormal vesicular breath sounds C Abnormal bronchophony Correct D Normal whispered pectoriloquy 


Rationale: The quality of voice resonance can be performed by testing for the presence of bronchophony, egophony, and whispered pectoriloquy. In bronchophony, the nurse asks the client to repeat the word "ninety-nine" as the nurse listens to the client’s chest with a stethoscope. Normal voice transmission is soft, muffled, and indistinct. The nurse normally hears sound through the stethoscope but cannot distinguish exactly what is being said. A pathologic condition that increases lung density enhances the transmission of voice sounds; in such a case, the nurse will hear "ninety-nine" clearly. Vesicular breath sounds are heard over peripheral lung fields where air flows through smaller bronchioles and alveoli. In egophony, the client’s chest is auscultated while the client phonates a long "ee-ee-ee-ee" sound. Normally the nurse hears "eeeeee" through the stethoscope. In whispered pectoriloquy, the client is asked to whisper a phrase such as "one-two-three" as the nurse listens to the chest. The normal response is a muffled, almost inaudible sound. Test-Taking Strategy: Knowledge of the methods for determining the quality of breath sounds is needed to answer this question. For this question it is necessary to remember that in bronchophony normal voice transmission is soft, muffled, and indistinct. Review: bronchophony, egophony, and whispered pectoriloquy and the normal findings . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 457). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0 possible points. 




 36.
ID: 7
A nurse is preparing to check the breath sounds of a client. Over which anatomic area does the nurse place the stethoscope when auscultating for bronchial breath sounds? 
 A 1 B 2 Correct C 3 D 4 


Rationale: Bronchial (tracheal) breath sounds are located over the trachea and larynx. Bronchovesicular breath sounds are located over major bronchi. Vesicular breath sounds are located over the peripheral lung fields. The upper sternal area is where main bronchi are located. Breath sounds are normally not heard over the cricoid cartilage. Test-Taking Strategy: Eliminate the options that are comparable or alike. From the remaining options, recall that bronchial breath sounds are also noted as tracheal sounds; this will direct you to the correct option. Review: the location of normal breath sounds . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 561, 562). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0 possible points. 




 37.
ID: 1
A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be? 
 A Harsh B Hollow C Tubular D Rustling Correct 


Rationale: Vesicular breath sounds are rustling and sound like wind blowing through trees. Bronchial (tracheal) breath sounds are harsh, hollow, tubular sounds. Test-Taking Strategy: Eliminate the options that are comparable or alike (tubular and hollow). In considering the remaining options, think about the location of vesicular breath sounds. This will help direct you to the correct option. Review: the normal quality of vesicular breath sounds . Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 562). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0 possible points. 




 38.
ID: 5
A nurse sees documentation in the client's record indicating that the physician has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds are: 
 A Normally heard in the lungs B Hollow sounds heard over the trachea and larynx C Rustling sounds heard over the peripheral lung fields D Abnormal sounds that should not be heard in the lungs Correct 


Rationale: Adventitious breath sounds are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused when moving air collides with secretions in the