N206 Exam 3 CoursePoint—
Assessment with Complete Solutions
A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment
of each client prior to the client's scheduled surgery. The nurse would document an
unexpected finding if unable to palpate a client's:
a) peripheral pulses
b) liver
c) lymph nodes
d) thyroid gland - ANS-peripheral pulses
Nonpalpable peripheral pulses are an unexpected finding, which warrants further
assessment and follow-up. The liver, lymph nodes, and thyroid are not normally
palpable in healthy individuals.
A nurse has explained her intention to conduct a Weber test and Rinne test. Which
pieces of equipment will the nurse require
a) Tuning fork
b) Snellen chart
c) Otoscope
d) Ophthalmoscope - ANS-Tuning fork
Weber test and Rinne test are performed in order to assess sound conduction; both
require a tuning fork.
To gather subjective data on a client's nutrition and metabolic pattern, the nurse should:
a) weigh the client and measure his height
b) ask the client for a 24-hour diet recall
c) examine the hygiene of the client's teeth
d) inspect the client's abdomen for symmetry. - ANS-ask the client for a 24-hour diet
recall.
Interview questions that will focus a nutrition-metabolism assessment might include
asking the client to disclose what he has eaten in the last 24 hours.
To obtain data about an adult client's sexuality and reproductive pattern, the nurse
should ask the client:
a) "How often do you have sexual intercourse?"
,b) "What arouses you when you have intercourse?"
c) "How many children do you have, both living and dead?"
d) "Has anything changed your sexual performance?" - ANS-"Has anything changed
your sexual performance?"
The sexual assessment is not meant to illuminate nonexistent problems. Rather, the
client is, in effect, given permission and encouragement to present sexually related
questions.
A nurse collects objective data on a client during a health assessment that includes the
client's:
a) blood pressure
b) fatigue level
c) presence of pain
d) symptoms of nausea. - ANS-blood pressure.
Fatigue, pain, and nausea are subjective symptoms. Blood pressure is measured
through auscultation and is an objective assessment.
A grating feel and noise with joint movement, particularly in the temporomandibular
joint, is called what?
a) Inflammation
b) Arthritis
c) Crepitus
d) Fremitus - ANS-Crepitus
Problems with the temporomandibular joint include pain or a grating feeling called
crepitus.
Peripheral cyanosis and clubbing of the nails are symptoms of:
a) normal aging
b) increased cholesterol
c) hypertension
d) chronic hypoxia - ANS-chronic hypoxia.
Hypoxia of the tissues changes normal, pink-color skin to a grayish or bluish color.
The acute care nurse is assessing a newly admitted client's abdomen. Which finding
would indicate the need to contact the primary care provider?
a) Auscultation of a bruit
b) Percussion of tympanic sounds over the intestines
c) Auscultation of peristalsis sounds
, d) Percussion of dull sounds over the right upper quadrant - ANS-Auscultation of a bruit
A bruit on auscultation suggests an aneurysm or arterial stenosis.
A 30-year-old janitor from Russia tells the nurse in the clinic that he drinks a fifth of
vodka daily and that he's had a recent weight gain of 3 lb (1.35 kg) in 3 days. Further
questioning by the nurse reveals that he was an intravenous drug user in the past but is
now "clean." His sclerae and skin have a yellowish tinge, and he has a large abdominal
girth. Which assessment finding supports the nurse's conclusion that the client has liver
dysfunction?
a) Cyanosis
b) Erythema
c) Jaundice
d) Pallor - ANS-Jaundice
Jaundice is a yellow color of the skin resulting from elevated amounts of bilirubin in the
blood. It is associated with liver and gallbladder disease, some types of anemia, and
excessive hemolysis. Cyanosis is a bluish or grayish discoloration of the skin in
response to inadequate oxygenation. Erythema, redness of the skin, is caused by
dilation of superficial blood vessels. It is associated with sunburn, inflammation, fever,
trauma, and allergic reactions. Pallor is caused by decreased hemoglobin in the
circulating blood and causes inadequate oxygenation of the body tissues.
A 66-year-old female client is reporting abdominal pain. The nurse assesses the client's
abdomen by first inspecting the abdomen. What should the nurse do next?
a) Palpate the abdomen
b) Auscultate the abdomen
c) Measure abdominal girth
d) Percuss the abdomen. - ANS-Auscultate the abdomen
The sequence of techniques used to assess the abdomen is inspection, auscultation,
percussion, and palpation. Percussion and palpation are done after auscultation
because they stimulate bowel sounds.
A 33-year-old male client returns to the medical surgical unit following a thyroidectomy.
Which assessment finding requires an immediate intervention by the nurse?
a) The client makes noises when he breathes.
b) The client is sleepy from the anesthesia.
c) The client reports pain at the surgical site.
d) The client complains of thirst. - ANS-The client makes noises when he breathes.
Noisy respirations are a sign of a narrowed airway that could be caused by
postoperative bleeding or edema. This finding requires an immediate intervention.
Assessment with Complete Solutions
A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment
of each client prior to the client's scheduled surgery. The nurse would document an
unexpected finding if unable to palpate a client's:
a) peripheral pulses
b) liver
c) lymph nodes
d) thyroid gland - ANS-peripheral pulses
Nonpalpable peripheral pulses are an unexpected finding, which warrants further
assessment and follow-up. The liver, lymph nodes, and thyroid are not normally
palpable in healthy individuals.
A nurse has explained her intention to conduct a Weber test and Rinne test. Which
pieces of equipment will the nurse require
a) Tuning fork
b) Snellen chart
c) Otoscope
d) Ophthalmoscope - ANS-Tuning fork
Weber test and Rinne test are performed in order to assess sound conduction; both
require a tuning fork.
To gather subjective data on a client's nutrition and metabolic pattern, the nurse should:
a) weigh the client and measure his height
b) ask the client for a 24-hour diet recall
c) examine the hygiene of the client's teeth
d) inspect the client's abdomen for symmetry. - ANS-ask the client for a 24-hour diet
recall.
Interview questions that will focus a nutrition-metabolism assessment might include
asking the client to disclose what he has eaten in the last 24 hours.
To obtain data about an adult client's sexuality and reproductive pattern, the nurse
should ask the client:
a) "How often do you have sexual intercourse?"
,b) "What arouses you when you have intercourse?"
c) "How many children do you have, both living and dead?"
d) "Has anything changed your sexual performance?" - ANS-"Has anything changed
your sexual performance?"
The sexual assessment is not meant to illuminate nonexistent problems. Rather, the
client is, in effect, given permission and encouragement to present sexually related
questions.
A nurse collects objective data on a client during a health assessment that includes the
client's:
a) blood pressure
b) fatigue level
c) presence of pain
d) symptoms of nausea. - ANS-blood pressure.
Fatigue, pain, and nausea are subjective symptoms. Blood pressure is measured
through auscultation and is an objective assessment.
A grating feel and noise with joint movement, particularly in the temporomandibular
joint, is called what?
a) Inflammation
b) Arthritis
c) Crepitus
d) Fremitus - ANS-Crepitus
Problems with the temporomandibular joint include pain or a grating feeling called
crepitus.
Peripheral cyanosis and clubbing of the nails are symptoms of:
a) normal aging
b) increased cholesterol
c) hypertension
d) chronic hypoxia - ANS-chronic hypoxia.
Hypoxia of the tissues changes normal, pink-color skin to a grayish or bluish color.
The acute care nurse is assessing a newly admitted client's abdomen. Which finding
would indicate the need to contact the primary care provider?
a) Auscultation of a bruit
b) Percussion of tympanic sounds over the intestines
c) Auscultation of peristalsis sounds
, d) Percussion of dull sounds over the right upper quadrant - ANS-Auscultation of a bruit
A bruit on auscultation suggests an aneurysm or arterial stenosis.
A 30-year-old janitor from Russia tells the nurse in the clinic that he drinks a fifth of
vodka daily and that he's had a recent weight gain of 3 lb (1.35 kg) in 3 days. Further
questioning by the nurse reveals that he was an intravenous drug user in the past but is
now "clean." His sclerae and skin have a yellowish tinge, and he has a large abdominal
girth. Which assessment finding supports the nurse's conclusion that the client has liver
dysfunction?
a) Cyanosis
b) Erythema
c) Jaundice
d) Pallor - ANS-Jaundice
Jaundice is a yellow color of the skin resulting from elevated amounts of bilirubin in the
blood. It is associated with liver and gallbladder disease, some types of anemia, and
excessive hemolysis. Cyanosis is a bluish or grayish discoloration of the skin in
response to inadequate oxygenation. Erythema, redness of the skin, is caused by
dilation of superficial blood vessels. It is associated with sunburn, inflammation, fever,
trauma, and allergic reactions. Pallor is caused by decreased hemoglobin in the
circulating blood and causes inadequate oxygenation of the body tissues.
A 66-year-old female client is reporting abdominal pain. The nurse assesses the client's
abdomen by first inspecting the abdomen. What should the nurse do next?
a) Palpate the abdomen
b) Auscultate the abdomen
c) Measure abdominal girth
d) Percuss the abdomen. - ANS-Auscultate the abdomen
The sequence of techniques used to assess the abdomen is inspection, auscultation,
percussion, and palpation. Percussion and palpation are done after auscultation
because they stimulate bowel sounds.
A 33-year-old male client returns to the medical surgical unit following a thyroidectomy.
Which assessment finding requires an immediate intervention by the nurse?
a) The client makes noises when he breathes.
b) The client is sleepy from the anesthesia.
c) The client reports pain at the surgical site.
d) The client complains of thirst. - ANS-The client makes noises when he breathes.
Noisy respirations are a sign of a narrowed airway that could be caused by
postoperative bleeding or edema. This finding requires an immediate intervention.
