When teaching a client how to perform a monthly breast self-assessment,
the nurse
should tell the client that it is most important to assess which part of the
breast more
closely for changes? ( correct answers ) Upper outer
quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The
client measurement
chest has a of 42 inches, waist measurement of 45
inches, and hipof 50 inches. What important message should the nurse
measurement
explain
client toto the
promote health promotion?( correct answers ) A waist
circumference
greater than 35isinches in women puts you at higher risk for type 2
diabetes and heart
disease.
"
The nurse performs a physical assessment on an older female client.
Whichthe
from change
prior exam may be an indication of osteoporosis?
( correct answers
reduction of 1.5 ) Height
inches.
While conducting an interview to obtain a health history, the nurse notices
that thefrequently
pauses client and looks at the nurse expectantly. Which response is
best for
nurse to the
provide? ( correct answers ) Sit quietly to allow the client to
comfortabl
respond
y.
A client is in the clinical for a yearly physical examination. Which action
shouldtake
nurse the when preparing to examine the client's abdomen?
( correct
the clientanswers
to urinate
) before beginning the Ask
examination.
Which respiratory condition should the nurse document after measuring a
respiratory
rate of 8 breaths/minute? ( correct
answers ) Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit?
)( correct
Measure answers
the apical pulse and compare it to the
peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point
of maximal
impulse and the radial pulse palpated at
the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What
sound should the nurse expect to hear when percussing over the client's
percussion
(lower lobes?
correct answers ) Dull,
thud-like.
GRADED
A+
, A client is being assessed upon admission to the medical-surgical unit.
preparing
The nurse tois complete a head-to-toe assessment and will begin at the head
of the client.
Which technique should the nurse use to begin the assessment? ( correct
answersthe
Inspect ) hair and skin.
The nurse is assessing a healthy young adult during an annual physical
Which assessment technique should the nurse implement when
examination.
palpating the
abdominal aorta? ( correct answers ) Deep palpation above and to the
left of the
umbilicus.
The nurse is conducting a family history as part of the assessment
action
interview. should the nurse take to ensure that sufficient information about the
Which
client's blood
relatives is obtained? ( correct answers ) Document at
least 3 generations
client's family medical of the
history.
The nurse is testing the client's shoulders for range of motion. What
document
should the to record normal internal rotation?
nurse ( correct answers )
Range ofwhen
degrees 90 the hands are placed at the small of
the back.
A client presents with a rash along the occipital area of the hairline and
reports intense
itching. How should the nurse begin the objective part of the examination?
answers ) Inspect the scalp looking
( correct
for nits.
The nurse is assessing a client's range of motion as the client bends the
to
righttheknee
chest upwhile keeping the left leg straight, but is unable to keep the left
thigh on
table. Thetheassessment is repeated for the left knee, and the client is unable
to keep
right theon the table. How should the nurse document this finding?
thigh
answers ) A flexion deformity referred to as a positive
(Thomas
correct test.
During a skin asssessment, the nurse notes, round and discrete lesions
thatin
red arecolor
darkand will not blanch. The lesions range from 1 to 3 mm in size.
Whatquestion
first is the the nurse should ask the client? ( correct answers ) Have
you notice
any irregular bleeding
A client with progressive hearing loss appears distressed when the
(RN) asks open-ended
registered nurse questions about the client's health history.
Which forms of should the RN use?
communication ( correct answers )
Facesee
can thethe
client so the client
RN's
Check if the client's hearing aides are working
mouth.
properly.
Reduce environmental noise surrounding the
client.
A client states that she had a mastectomy of her left breast last
experiences
year and nowlymphedema. What should the nurse expect to find when
examining
client? the answers )
( correct Swelling of the left arm and non-
pitting edema.
GRADED
A+
the nurse
should tell the client that it is most important to assess which part of the
breast more
closely for changes? ( correct answers ) Upper outer
quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The
client measurement
chest has a of 42 inches, waist measurement of 45
inches, and hipof 50 inches. What important message should the nurse
measurement
explain
client toto the
promote health promotion?( correct answers ) A waist
circumference
greater than 35isinches in women puts you at higher risk for type 2
diabetes and heart
disease.
"
The nurse performs a physical assessment on an older female client.
Whichthe
from change
prior exam may be an indication of osteoporosis?
( correct answers
reduction of 1.5 ) Height
inches.
While conducting an interview to obtain a health history, the nurse notices
that thefrequently
pauses client and looks at the nurse expectantly. Which response is
best for
nurse to the
provide? ( correct answers ) Sit quietly to allow the client to
comfortabl
respond
y.
A client is in the clinical for a yearly physical examination. Which action
shouldtake
nurse the when preparing to examine the client's abdomen?
( correct
the clientanswers
to urinate
) before beginning the Ask
examination.
Which respiratory condition should the nurse document after measuring a
respiratory
rate of 8 breaths/minute? ( correct
answers ) Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit?
)( correct
Measure answers
the apical pulse and compare it to the
peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point
of maximal
impulse and the radial pulse palpated at
the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What
sound should the nurse expect to hear when percussing over the client's
percussion
(lower lobes?
correct answers ) Dull,
thud-like.
GRADED
A+
, A client is being assessed upon admission to the medical-surgical unit.
preparing
The nurse tois complete a head-to-toe assessment and will begin at the head
of the client.
Which technique should the nurse use to begin the assessment? ( correct
answersthe
Inspect ) hair and skin.
The nurse is assessing a healthy young adult during an annual physical
Which assessment technique should the nurse implement when
examination.
palpating the
abdominal aorta? ( correct answers ) Deep palpation above and to the
left of the
umbilicus.
The nurse is conducting a family history as part of the assessment
action
interview. should the nurse take to ensure that sufficient information about the
Which
client's blood
relatives is obtained? ( correct answers ) Document at
least 3 generations
client's family medical of the
history.
The nurse is testing the client's shoulders for range of motion. What
document
should the to record normal internal rotation?
nurse ( correct answers )
Range ofwhen
degrees 90 the hands are placed at the small of
the back.
A client presents with a rash along the occipital area of the hairline and
reports intense
itching. How should the nurse begin the objective part of the examination?
answers ) Inspect the scalp looking
( correct
for nits.
The nurse is assessing a client's range of motion as the client bends the
to
righttheknee
chest upwhile keeping the left leg straight, but is unable to keep the left
thigh on
table. Thetheassessment is repeated for the left knee, and the client is unable
to keep
right theon the table. How should the nurse document this finding?
thigh
answers ) A flexion deformity referred to as a positive
(Thomas
correct test.
During a skin asssessment, the nurse notes, round and discrete lesions
thatin
red arecolor
darkand will not blanch. The lesions range from 1 to 3 mm in size.
Whatquestion
first is the the nurse should ask the client? ( correct answers ) Have
you notice
any irregular bleeding
A client with progressive hearing loss appears distressed when the
(RN) asks open-ended
registered nurse questions about the client's health history.
Which forms of should the RN use?
communication ( correct answers )
Facesee
can thethe
client so the client
RN's
Check if the client's hearing aides are working
mouth.
properly.
Reduce environmental noise surrounding the
client.
A client states that she had a mastectomy of her left breast last
experiences
year and nowlymphedema. What should the nurse expect to find when
examining
client? the answers )
( correct Swelling of the left arm and non-
pitting edema.
GRADED
A+
