Expert Verified | Latest Version 2024/2025
1. A nurse, who is assessing a client's neurologic system and stereognosis, should ask the client to close
their eyes and identify which of the following items?
A. A word the nurse whispers 30 cm from the ear.
B. A number the nurse draws on a communication board.
C. The vibration of a tuning fork the nurse places on the foot.
D. A familiar object the nurse places in the hand. - ✔✔D. A familiar object the nurse places in the hand
10. A nurse is preparing to measure a client's level of edema in both feet. The nurse should use what
technique to describe the patients edema?
A. Finger
B. Earlobe
C. Toe
D. Skin fold - ✔✔B. Earlobe
10. A nurse is using the communication principle of presence when establishing a collaborative
relationship with a client. Which of the following actions should the nurse take?
A. Focus on the client's present circumstances instead of his personal stories.
B. Verbalize understanding of how the client feels.
C. Offer the client personal thoughts and beliefs.
D. Use attentive listening with the client. - ✔✔D. Use attentive listening with the client
11. A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should
factor in which of the following principles influencing nonverbal communication?
A. Nonverbal communication conveys less truth than what the client states verbally.
B. The client's sociocultural background influences nonverbal communication.
C. Nonverbal communication is a poor reflection of what the client feels.
,D. The client enacts nonverbal communication consciously. - ✔✔B. The client's sociocultural background
influences nonverbal communication.
11. What signs of cyanosis does a nurse inspect for in a dark-skinned patient?
A. Pallor-blue color of the oral mucous membranes.
B. Pink color in the nail beds.
C. Pink color in the palms and soles of hands and feet.
D. Red color in the ear lobes. - ✔✔A. Pallor-blue color of the oral mucous membranes
12. A nurse is assessing a client: Which of the following factors should the nurse include when assessing
cultural context of the client?
A. The sense of self among individual family members
B. The future goals of the client in their work setting.
C. The patient's blood pressure.
D. The client's religious practices - ✔✔D. The client's religious practices
12. Which of the following tools are used in an assessment of the head and neck? Select all that apply:
A. Tape Measure
B.Penlight
C.Gloves
D.Stethoscope
E.Watch with a second hand for carotid pulse - ✔✔B. Penlight
C. Gloves
E.Watch with a second hand for carotid pulse
13. A nurse is providing dietary teaching for a client who is Asian-American and is gazing at the floor
during the instructions. Which of the following actions should the nurse take to demonstrate culturally
sensitive nursing care?
A. Stop the instructions to see what is on the floor.
B. Emphasize the significance of the information.
, C. Move closer to the client for eye contact.
D. Continue with the discussion - ✔✔D. Continue with the discussion
13. What are the following are steps the nurse must take to assess PERRLA? Select all that apply
A. Have the client sit facing the nurse at eye level.
B. Observe the pupils for size and response to light in both eyes.
C. Instruct the client to look directly at the light source.
D. Darken the room.
E. Instruct the client to focus on a distance above or behind the nurse. - ✔✔A. Have the client sit facing
the nurse at eye level.
B. Observe the pupils for size and response to light in both eyes.
C. Instruct the client to look directly at the light source.
D. Darken the room.
E. Instruct the client to focus on a distance above or behind the nurse.
14. A nurse is caring for a client of Chinese heritage. Which of the following actions should the nurse
take to demonstrate cultural competence?
A. Make sure the dietary department does not serve the client pork.
B. Ask the client's permission to add ice to drinking water.
C. Maintain direct eye contact with the client.
D. Place a hand on the client's head. - ✔✔B. Ask the client's permission to add ice to drinking water
14. What questions will the nurse ask when assessing Level of Consciousness/Orientation? Select all that
apply:
A. What is today's date?
B. What is your name and birthday?
C. Please rate your pain from your joints.
D. Who is the president?
E.Where are you at this current time? - ✔✔A. What is today's date?
B. What is your name and birthday?