1530 physical assessment exam 2
REVIEW QUESTIONS AND VERIFIED
CORRECT ANSWERS GRADED A+
LATEST 100% GUARANTEED PASS
The nurse is conducting an interview with a client who speaks limited English. What action
should the nurse implement? - CORRECT ANSWER-Seek the assistance of a healthcare team
member who speaks the client's preferred language
A client reports a recent onset of nausea and vomiting. What subjective information is
important for the nurse to ascertain? - CORRECT ANSWER-Ask whether the client has been in a
foreign country recently
The nurse is conducting a family history as part of the assessment interview. Which action
should the nurse take to ensure that sufficient information about the client's blood relatives is
obtained? - CORRECT ANSWER-Document at least 3 generations of the client's family medical
history.
An older client has just returned to the room following a surgical procedure. Which pain scale
should the nurse use when assessing the client's pain level? - CORRECT ANSWER-verbal
descriptor scale
A client reports lower abdominal pain and a feeling of pressure in the bladder. Which
assessment finding indicates acute urinary retention? - CORRECT ANSWER-dull sound percussed
over bladder
Which term should the nurse use to document the condition of a client who reports waking up
frequently during the night to urinate? - CORRECT ANSWER-nocturia
,Which procedure should the nurse use to assess for a pulse deficit? - CORRECT ANSWER-
measure the apical pulse and compare it to the peripheral pulse
Which term should the nurse use to document in the client's medical record for a high-pitched
scratchy sound during auscultation of the heart? - CORRECT ANSWER-friction rub
A client is in the clinical for a yearly physical examination. Which action should the nurse take
when preparing to examine the client's abdomen? - CORRECT ANSWER-ask the client to urinate
before examining
the nurse is assessing for the presence of a hernia. Which action should the nurse ask the client
to perform while lying supine? - CORRECT ANSWER-use abdominal muscles to sit up
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds
in the right upper quadrant. What action should the nurse take next? - CORRECT ANSWER-note
the character and frequency of bowel sounds
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to
complete a head-to-toe assessment and will begin at the head of the client. Which technique
should the nurse use to begin the assessment? - CORRECT ANSWER-inspect the hair and skin
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indication of osteoporosis? - CORRECT ANSWER-height reduction of 1.5
inches
The nurse examines the skin of an older adult client. Which skin variation is considered a normal
finding for a client in this age group? - CORRECT ANSWER-Lentigines
what is lentigines? - CORRECT ANSWER-a condition marked by small brown patches on the skin
,The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator
of a rotator cuff tear? - CORRECT ANSWER-inability to slowly lower the arm when abducted
The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse
be able to visualize? - CORRECT ANSWER-Pharynx
When assessing a client with dyspnea, the nurse hears an audible inspiratory crowing sound.
Which lung sound should the nurse document? - CORRECT ANSWER-stridor
Which respiratory condition should the nurse document after measuring a respiratory rate of 8
breaths/minute? - CORRECT ANSWER-bradypnea
The nurse performs the Weber and Rinne tests to assess which cranial nerve? - CORRECT
ANSWER-VIII
During a skin assessment, the nurse notes, round and discrete lesions that are dark red in color
and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the
nurse should ask the client? - CORRECT ANSWER-"Have you noticed any unusual bleeding?"
The nurse is requesting the client to perform a Romberg Test to assess neurological status.
During the test, the nurse notes that the client sways slightly. What is the nurses next action? -
CORRECT ANSWER-document the normal finding
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50
inches. What important message should the nurse explain to the client to promote health
promotion? - CORRECT ANSWER-"A waist circumference is greater than 35 inches in women
puts you at greater for type 2 diabetes and heart disease"
, The nurse observes peristaltic movement in the left lower quadrant of a client's abdomen.
Which further assessment of the area should the nurse perform? - CORRECT ANSWER-observe
the direction of movement
During a health history interview, a male client reports that he smokes cigarettes and does not
plan to quit. Which action is most important for the nurse to take? - CORRECT ANSWER-
Calculate the clients pack history
a client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should
the nurse expect to hear when percussing over the client's lower lobes? - CORRECT ANSWER-
dull, thud-like
During cardiac auscultation, the nurse hears a split in the second heart sound when listening at
the second left intercostal space of a male client. To assess this sound more fully, what action
should the nurse implement? - CORRECT ANSWER-listen to the sound while observing the
clients respirations
A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds
during the examination. How should the RN respond? - CORRECT ANSWER-request a male
nurse or healthcare provider to perform the exam
The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which
assessment findings should the RN document that are consistent with diminished peripheral
circulation? - CORRECT ANSWER-diminished hair on legs and skin cool to the touch
The registered nurse (RN) uses the mini-mental state examination (MMSE) when assessing a
client for admission to an assisted living facility. Which finding is the RN assessing when
requesting the client to count by 7s? - CORRECT ANSWER-attention to details
Which technique should the nurse use to assess a client for scoliosis? - CORRECT ANSWER-
observe spine while the client is erect and bent forward
REVIEW QUESTIONS AND VERIFIED
CORRECT ANSWERS GRADED A+
LATEST 100% GUARANTEED PASS
The nurse is conducting an interview with a client who speaks limited English. What action
should the nurse implement? - CORRECT ANSWER-Seek the assistance of a healthcare team
member who speaks the client's preferred language
A client reports a recent onset of nausea and vomiting. What subjective information is
important for the nurse to ascertain? - CORRECT ANSWER-Ask whether the client has been in a
foreign country recently
The nurse is conducting a family history as part of the assessment interview. Which action
should the nurse take to ensure that sufficient information about the client's blood relatives is
obtained? - CORRECT ANSWER-Document at least 3 generations of the client's family medical
history.
An older client has just returned to the room following a surgical procedure. Which pain scale
should the nurse use when assessing the client's pain level? - CORRECT ANSWER-verbal
descriptor scale
A client reports lower abdominal pain and a feeling of pressure in the bladder. Which
assessment finding indicates acute urinary retention? - CORRECT ANSWER-dull sound percussed
over bladder
Which term should the nurse use to document the condition of a client who reports waking up
frequently during the night to urinate? - CORRECT ANSWER-nocturia
,Which procedure should the nurse use to assess for a pulse deficit? - CORRECT ANSWER-
measure the apical pulse and compare it to the peripheral pulse
Which term should the nurse use to document in the client's medical record for a high-pitched
scratchy sound during auscultation of the heart? - CORRECT ANSWER-friction rub
A client is in the clinical for a yearly physical examination. Which action should the nurse take
when preparing to examine the client's abdomen? - CORRECT ANSWER-ask the client to urinate
before examining
the nurse is assessing for the presence of a hernia. Which action should the nurse ask the client
to perform while lying supine? - CORRECT ANSWER-use abdominal muscles to sit up
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds
in the right upper quadrant. What action should the nurse take next? - CORRECT ANSWER-note
the character and frequency of bowel sounds
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to
complete a head-to-toe assessment and will begin at the head of the client. Which technique
should the nurse use to begin the assessment? - CORRECT ANSWER-inspect the hair and skin
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indication of osteoporosis? - CORRECT ANSWER-height reduction of 1.5
inches
The nurse examines the skin of an older adult client. Which skin variation is considered a normal
finding for a client in this age group? - CORRECT ANSWER-Lentigines
what is lentigines? - CORRECT ANSWER-a condition marked by small brown patches on the skin
,The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator
of a rotator cuff tear? - CORRECT ANSWER-inability to slowly lower the arm when abducted
The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse
be able to visualize? - CORRECT ANSWER-Pharynx
When assessing a client with dyspnea, the nurse hears an audible inspiratory crowing sound.
Which lung sound should the nurse document? - CORRECT ANSWER-stridor
Which respiratory condition should the nurse document after measuring a respiratory rate of 8
breaths/minute? - CORRECT ANSWER-bradypnea
The nurse performs the Weber and Rinne tests to assess which cranial nerve? - CORRECT
ANSWER-VIII
During a skin assessment, the nurse notes, round and discrete lesions that are dark red in color
and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the
nurse should ask the client? - CORRECT ANSWER-"Have you noticed any unusual bleeding?"
The nurse is requesting the client to perform a Romberg Test to assess neurological status.
During the test, the nurse notes that the client sways slightly. What is the nurses next action? -
CORRECT ANSWER-document the normal finding
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50
inches. What important message should the nurse explain to the client to promote health
promotion? - CORRECT ANSWER-"A waist circumference is greater than 35 inches in women
puts you at greater for type 2 diabetes and heart disease"
, The nurse observes peristaltic movement in the left lower quadrant of a client's abdomen.
Which further assessment of the area should the nurse perform? - CORRECT ANSWER-observe
the direction of movement
During a health history interview, a male client reports that he smokes cigarettes and does not
plan to quit. Which action is most important for the nurse to take? - CORRECT ANSWER-
Calculate the clients pack history
a client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should
the nurse expect to hear when percussing over the client's lower lobes? - CORRECT ANSWER-
dull, thud-like
During cardiac auscultation, the nurse hears a split in the second heart sound when listening at
the second left intercostal space of a male client. To assess this sound more fully, what action
should the nurse implement? - CORRECT ANSWER-listen to the sound while observing the
clients respirations
A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds
during the examination. How should the RN respond? - CORRECT ANSWER-request a male
nurse or healthcare provider to perform the exam
The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which
assessment findings should the RN document that are consistent with diminished peripheral
circulation? - CORRECT ANSWER-diminished hair on legs and skin cool to the touch
The registered nurse (RN) uses the mini-mental state examination (MMSE) when assessing a
client for admission to an assisted living facility. Which finding is the RN assessing when
requesting the client to count by 7s? - CORRECT ANSWER-attention to details
Which technique should the nurse use to assess a client for scoliosis? - CORRECT ANSWER-
observe spine while the client is erect and bent forward
