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A client comes to the clinic with a report of fever and a recent exposure to someone who
was diagnosed with meningitis. Which nursing assessment should be completed during
the initial examination of this client?
A. Level of consciousness
B. Gait characteristics
C. Presence of trauma
D. Bladder control ability. - CORRECT ANSWER: A. Level of consciousness
A client has just returned from the recovery room and asks to get out of bed to go to the
bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse
position the client to begin this procedure?
A. Lying
B. Sitting
C. Leaning
D. Standing - CORRECT ANSWER: A. Lying
A client is in the clinic and is reporting lower abdominal pain and constipation. Which
information is of greatest concern to the nurse when obtaining the health history from
this client?
A. Administration of rubeola vaccine at age 7.
B. Removal of gallbladder 5 years ago.
C. Family history of colon cancer on mother's side.
,D. Family history of hypertension on father's side. - CORRECT ANSWER: C. Family
history of colon cancer on mother's side.
A client is in the clinic for a routine health examination. The nurse notices the client
appears underweight. Which question is most important for the nurse to ask when
completing the health history of this client?
A. What types of food do you like or dislike?
B. Have you experienced sudden weight loss?
C. Do you use dietary supplements every day?
D. Can you recall the last 24 hours of food intake? - CORRECT ANSWER: B. Have you
experienced sudden weight loss?
A client is reporting chest pain. What statement made by the client helps the nurse to
understand the client has a naturalistic belief in the cause of illness?
A. "My life is really out of balance."
B. "I knew I should have changed my diet."
C. "I should have gone to church last week."
D. "I forgot to take my medicines last night." - CORRECT ANSWER: A. "My life is really
out of balance."
A client reports feeling increasingly fatigued for several months, and the nurse observes
that the client's lips are pale. Which additional data should the nurse collect based on
this presentation?
A. Current alcohol and tobacco use
B. A 24-hour dietary recall
C. Use of vitamin and iron supplements
D. Daily pattern of oral hygiene practices - CORRECT ANSWER: C. Use of vitamin and
iron supplements
, A client reports pain when taking a deep breath. Which lung auscultation sound should
the nurse anticipate hearing?
A. Pleural friction rub
B. Rhonchus
C. Coarse crackles
D. Wheezing - CORRECT ANSWER: A. Pleural friction rub
A client states that she had a mastectomy of her left breast last year and now
experiences lymphedema. What should the nurse expect to find when examining the
client?
A. Swelling of the left arm and non-pitting edema.
B. Bilateral swelling of the arms with weakened pulses.
C. Complaints of pain when taking the blood pressure on the affected side.
D. Metastasis of cancer due to cancer being in the lymph nodes. - CORRECT
ANSWER: A. Swelling of the left arm and non-pitting edema.
A client with dark skin is reporting a painful and itching area on the lower left leg. What
should the nurse look for when assessing this client's skin for inflammation?
A. Change in consistency
B. Change in turgor
C. Redness
D. Pallor - CORRECT ANSWER: A. Change in consistency
A client with progressive hearing loss appears distressed when the registered nurse
asks open-ended questions about the client's health history. Which forms of
communication should the RN use?