Questions and answers
Objective. - ANS During the interview portio of the health assessment, a nurse notes
the person's posture, physical appearance, and ability to converse. How should the
nurse document these findings?
4th intercostal space, right midclavicular line. Correct - ANS The nurse is assessing a
A
client's middle lung lobe. What is the best location for the nurse to place a stethoscope
diaphragm to hear normal lung sounds in this lobe?
VI
Document a normal finding. - ANS While performing a head-to-toe assessment, the
nurse assesses the client's pupillary accommodation. During the second portion of the
TU
test, the nurse notes that the client's pupils constrict and there is convergence of the
axes of the eyes. What action should the nurse implement next?
Seek the assistance of a healthcare team member who speaks the client's preferred
IS
language. - ANS The nurse is conducting an interview with a client who speaks limited
English. What action should the nurse implement?
OM
Document at least 3 generations of the client's family medical history. Correct - ANS
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?
NA
Verbal descriptor scale. - ANS 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?
JP
Nocturia. - ANS Which term should the nurse use to document the condition of a client
who reports waking up frequently during the night to urinate?
Measure the apical pulse and compare it to the peripheral pulse. - ANS Which
procedure should the nurse use to assess for a pulse deficit?
Ask the client to urinate before beginning the examination. - ANS 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?