The nurse is performing a thoracic assessment on a client with chronic
asthma and hyperinflation of the lungs. Which finding should be expected
for this client?
( correct answers ) Barrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse
has heard bowel sounds in the right upper quadrant. What action should
the nurse take next?
( correct answers )
Note the character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a
tongue blade on the back of the tongue which causes the client to gag. After
removing the tongue blade, what action should the nurse take? ( correct
answers ) Document an intact gag reflex.
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 has a chest measurement of 42 inches, waist measurement of 45
inches, and hip measurement of 50 inches. What important message should
the nurse explain to the client to promote health promotion? ( correct
answers ) A waist circumference is greater than 35 inches 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. Which
change from the prior exam may be an indication of osteoporosis?
( correct answers ) Height reduction of 1.5
inches.
While conducting an interview to obtain a health history, the nurse notices
that the client pauses frequently and looks at the nurse expectantly. Which
response is best for the nurse to provide? ( correct answers ) Sit quietly to
allow the client to respond comfortably.
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?
GRADED
A+
( correct answers )
Ask the client to
urinate before beginning the 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 answers
) Measure 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
percussion sound should the nurse expect to hear when percussing over
the client's lower lobes? ( correct answers ) Dull, thud-like.
A client is being assessed upon admission to the medical-surgical unit. The
nurse is preparing to 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
answers ) Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical
examination. Which assessment technique should the nurse implement
when 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 interview.
Which action should the nurse take to ensure that sufficient information
about the client's blood relatives is obtained? ( correct answers )
Document at least 3 generations of the client's family medical history.
The nurse is testing the client's shoulders for range of motion. What
should the nurse document to record normal internal rotation? ( correct
answers ) Range of 90 degrees when 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? ( correct
answers ) Inspect the scalp looking for nits.
The nurse is assessing a client's range of motion as the client bends the
right knee up to the chest while keeping the left leg straight, but is unable
to keep the left thigh on the table. The assessment is repeated for the left
knee, and the client is unable to keep the right thigh on the table. How
should the nurse document this finding? ( correct
answers ) A flexion deformity referred to as a positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions
GRADED
that are dark red in color and will not blanch. The lesions range from 1 to 3
A+
mm in size. What is the first question the nurse should ask the client?
( correct answers ) Have you notice any irregular bleeding
asthma and hyperinflation of the lungs. Which finding should be expected
for this client?
( correct answers ) Barrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse
has heard bowel sounds in the right upper quadrant. What action should
the nurse take next?
( correct answers )
Note the character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a
tongue blade on the back of the tongue which causes the client to gag. After
removing the tongue blade, what action should the nurse take? ( correct
answers ) Document an intact gag reflex.
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 has a chest measurement of 42 inches, waist measurement of 45
inches, and hip measurement of 50 inches. What important message should
the nurse explain to the client to promote health promotion? ( correct
answers ) A waist circumference is greater than 35 inches 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. Which
change from the prior exam may be an indication of osteoporosis?
( correct answers ) Height reduction of 1.5
inches.
While conducting an interview to obtain a health history, the nurse notices
that the client pauses frequently and looks at the nurse expectantly. Which
response is best for the nurse to provide? ( correct answers ) Sit quietly to
allow the client to respond comfortably.
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?
GRADED
A+
( correct answers )
Ask the client to
urinate before beginning the 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 answers
) Measure 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
percussion sound should the nurse expect to hear when percussing over
the client's lower lobes? ( correct answers ) Dull, thud-like.
A client is being assessed upon admission to the medical-surgical unit. The
nurse is preparing to 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
answers ) Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical
examination. Which assessment technique should the nurse implement
when 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 interview.
Which action should the nurse take to ensure that sufficient information
about the client's blood relatives is obtained? ( correct answers )
Document at least 3 generations of the client's family medical history.
The nurse is testing the client's shoulders for range of motion. What
should the nurse document to record normal internal rotation? ( correct
answers ) Range of 90 degrees when 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? ( correct
answers ) Inspect the scalp looking for nits.
The nurse is assessing a client's range of motion as the client bends the
right knee up to the chest while keeping the left leg straight, but is unable
to keep the left thigh on the table. The assessment is repeated for the left
knee, and the client is unable to keep the right thigh on the table. How
should the nurse document this finding? ( correct
answers ) A flexion deformity referred to as a positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions
GRADED
that are dark red in color and will not blanch. The lesions range from 1 to 3
A+
mm in size. What is the first question the nurse should ask the client?
( correct answers ) Have you notice any irregular bleeding
