,NUR 2356 Exam 1 | Multidimensional Care I (2026)
Actual Q&A PDF | Rasmussen College
1. A nurse is preparing to perform a head-to-toe assessment on a newly admitted client.
Which action should the nurse take first?
A) Inspect the skin for color and lesions
B) Obtain the client's vital signs
C) Palpate the abdomen for tenderness
D) Auscultate lung sounds bilaterally
Correct Answer: Obtain the client's vital signs
Rationale: Obtaining vital signs establishes a baseline and identifies immediate
physiological instability before proceeding with the full assessment. Inspection, palpation,
and auscultation follow once the client's stability is confirmed. Vital signs guide the urgency
and focus of the remaining examination.
2. A client reports chest pain rated 8/10 that radiates to the left arm. How should the nurse
document this type of pain?
A) Referred pain
B) Phantom pain
C) Radiating pain
D) Neuropathic pain
Correct Answer: Radiating pain
Rationale: Radiating pain moves from its origin to another area, commonly seen in
myocardial ischemia where chest pain radiates to the arm, jaw, or back. Referred pain is felt
,in a location distant from the source but not along a nerve path. Phantom pain occurs after
amputation, and neuropathic pain results from nerve damage.
3. While assessing a client's pupils, the nurse notes they are equal, round, and reactive to
light and accommodation. Which abbreviation should the nurse use to document this
finding?
A) PERLA
B) PERRLA
C) PERRL
D) PEARL
Correct Answer: PERRLA
Rationale: PERRLA stands for Pupils Equal, Round, Reactive to Light and
Accommodation. This is the standard ophthalmic assessment abbreviation. PERLA omits
the second "R" for round. The other options are incomplete or incorrect abbreviations.
4. A nurse is preparing to initiate a bladder-retraining program for a client who has
incontinence. Which action should the nurse take?
A) Restrict the client's fluid intake during the daytime
B) Have the client record urination times
C) Gradually increase the urination intervals
D) Remind the client to hold urine until the next scheduled urination time
E) Provide a sterile container for urine
Correct Answer: Gradually increase the urination intervals
, Rationale: Bladder retraining involves gradually increasing the time between urination
to improve bladder capacity and control. Recording urination times helps identify patterns
but is not the primary intervention. Fluid restriction and holding urine for extended
periods can be counterproductive. A sterile container is for specimen collection, not
retraining.
5. A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a
client who has recurrent UTIs. Which factors should the nurse include?
A) Frequent sexual intercourse
B) Lowering of testosterone levels
C) Wiping from front to back to clean the perineum
D) Location of the urethra closer to the anus
E) Frequent catheterization
Correct Answer: Location of the urethra closer to the anus
Rationale: In females, the urethra is shorter and closer to the anus, increasing the risk of
bacterial contamination and UTIs. Frequent sexual intercourse and frequent catheterization
also increase risk, but the anatomical factor is a primary risk. Wiping front to back reduces
risk. Lowering testosterone levels is not a primary UTI risk factor.
6. A nurse is teaching a client who reports stress urinary incontinence. Which instructions
should the nurse include?
A) Limit total daily fluid intake
B) Decrease or avoid caffeine
C) Take calcium supplements
D) Avoid drinking alcohol
E) Use the Crede maneuver
Actual Q&A PDF | Rasmussen College
1. A nurse is preparing to perform a head-to-toe assessment on a newly admitted client.
Which action should the nurse take first?
A) Inspect the skin for color and lesions
B) Obtain the client's vital signs
C) Palpate the abdomen for tenderness
D) Auscultate lung sounds bilaterally
Correct Answer: Obtain the client's vital signs
Rationale: Obtaining vital signs establishes a baseline and identifies immediate
physiological instability before proceeding with the full assessment. Inspection, palpation,
and auscultation follow once the client's stability is confirmed. Vital signs guide the urgency
and focus of the remaining examination.
2. A client reports chest pain rated 8/10 that radiates to the left arm. How should the nurse
document this type of pain?
A) Referred pain
B) Phantom pain
C) Radiating pain
D) Neuropathic pain
Correct Answer: Radiating pain
Rationale: Radiating pain moves from its origin to another area, commonly seen in
myocardial ischemia where chest pain radiates to the arm, jaw, or back. Referred pain is felt
,in a location distant from the source but not along a nerve path. Phantom pain occurs after
amputation, and neuropathic pain results from nerve damage.
3. While assessing a client's pupils, the nurse notes they are equal, round, and reactive to
light and accommodation. Which abbreviation should the nurse use to document this
finding?
A) PERLA
B) PERRLA
C) PERRL
D) PEARL
Correct Answer: PERRLA
Rationale: PERRLA stands for Pupils Equal, Round, Reactive to Light and
Accommodation. This is the standard ophthalmic assessment abbreviation. PERLA omits
the second "R" for round. The other options are incomplete or incorrect abbreviations.
4. A nurse is preparing to initiate a bladder-retraining program for a client who has
incontinence. Which action should the nurse take?
A) Restrict the client's fluid intake during the daytime
B) Have the client record urination times
C) Gradually increase the urination intervals
D) Remind the client to hold urine until the next scheduled urination time
E) Provide a sterile container for urine
Correct Answer: Gradually increase the urination intervals
, Rationale: Bladder retraining involves gradually increasing the time between urination
to improve bladder capacity and control. Recording urination times helps identify patterns
but is not the primary intervention. Fluid restriction and holding urine for extended
periods can be counterproductive. A sterile container is for specimen collection, not
retraining.
5. A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a
client who has recurrent UTIs. Which factors should the nurse include?
A) Frequent sexual intercourse
B) Lowering of testosterone levels
C) Wiping from front to back to clean the perineum
D) Location of the urethra closer to the anus
E) Frequent catheterization
Correct Answer: Location of the urethra closer to the anus
Rationale: In females, the urethra is shorter and closer to the anus, increasing the risk of
bacterial contamination and UTIs. Frequent sexual intercourse and frequent catheterization
also increase risk, but the anatomical factor is a primary risk. Wiping front to back reduces
risk. Lowering testosterone levels is not a primary UTI risk factor.
6. A nurse is teaching a client who reports stress urinary incontinence. Which instructions
should the nurse include?
A) Limit total daily fluid intake
B) Decrease or avoid caffeine
C) Take calcium supplements
D) Avoid drinking alcohol
E) Use the Crede maneuver
