UPDATE!!!2025/2026|GUARANTEED
A 52-year-old male client is seen in the health care provider's (HCP's) office for a physical
examination after experiencing unusual fatigue over the last several weeks. The client's
height is 5 feet, 8 inches (173 cm) and his weight is 220 pounds (99.8 kg). Vital signs are as
follows: temperature, 98.6°F (37°C) orally; pulse, 86 beats/minute; and respirations, 18
breaths/minute. The blood pressure reading is 184/100 mm Hg. A random blood glucose
level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first? -
ANSWER "When was the last time you had your blood pressure checked?"
The nurse in the health care clinic is performing a neurological assessment and is testing the
motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse
implement to test the motor function of this nerve? - ANSWER Separate the client's
jaw by pushing down on the chin.
The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will
best observe these lesions in which body area? - ANSWER Oral mucosa
Rationale:In a dark-skinned client, petechiae are best observed in the conjunctivae and oral
mucosa. Jaundice would be best noted in the sclerae of the eye. Cyanosis would be best
noted in the palms of the hands and soles of the feet.
The nurse is preparing to perform a Weber test on a client. The nurse should obtain which
item needed to perform this test? - ANSWER A tuning fork
The nurse is reviewing a client's record and notes that the result of a vision test using a
Snellen chart is 20/30. How should the nurse explain these results to the client? -
1
, ANSWER "You can read at a distance of 20 feet (6 meters) what a person with normal
vision can read at 30 feet (9 meters)."
The nurse is performing an abdominal assessment on a client. The nurse determines that
which finding should be reported to the health care provider (HCP)? -
ANSWER Pulsation between the umbilicus and the pubis
The nurse is performing a physical examination on a hospitalized client. On abdominal
assessment, the nurse listens to the bowel sounds and hears these sounds. The nurse
documents that which sound is heard? - ANSWER Normal bowel sounds
Rationale:Normal bowel sounds are high-pitched, gurgling, cascading sounds occurring
irregularly between 5 and 30 times a minute. A bruit is a pulsatile blowing sound and occurs
with stenosis or occlusion of an artery. Hyperactive bowel sounds are loud, high-pitched,
rushing, tinkling sounds that signal increased motility. Hypoactive bowel sounds are either
diminished or absent, signal decreased motility, and occur after surgery or with
inflammation of the peritoneum.
The nurse is preparing to perform an abdominal examination on a client. The nurse should
place the client in which position for this examination? - ANSWER Supine with the
head raised slightly and the knees slightly flexed
The nurse is providing care to a client admitted for coronary artery disease (CAD) and a
history of tobacco use. What is the most important element of the nurse's focused
assessment of the client's smoking history? - ANSWER Number of pack-years
A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular
contractions and is placed on metoprolol tartrate. The client returns to the health care
provider's (HCP's) office 1 month later for a checkup. The nurse should implement which
type of database when performing an assessment? - ANSWER Follow-up database
2
A 52-year-old male client is seen in the health care provider's (HCP's) office for a physical
examination after experiencing unusual fatigue over the last several weeks. The client's
height is 5 feet, 8 inches (173 cm) and his weight is 220 pounds (99.8 kg). Vital signs are as
follows: temperature, 98.6°F (37°C) orally; pulse, 86 beats/minute; and respirations, 18
breaths/minute. The blood pressure reading is 184/100 mm Hg. A random blood glucose
level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first? -
ANSWER "When was the last time you had your blood pressure checked?"
The nurse in the health care clinic is performing a neurological assessment and is testing the
motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse
implement to test the motor function of this nerve? - ANSWER Separate the client's
jaw by pushing down on the chin.
The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will
best observe these lesions in which body area? - ANSWER Oral mucosa
Rationale:In a dark-skinned client, petechiae are best observed in the conjunctivae and oral
mucosa. Jaundice would be best noted in the sclerae of the eye. Cyanosis would be best
noted in the palms of the hands and soles of the feet.
The nurse is preparing to perform a Weber test on a client. The nurse should obtain which
item needed to perform this test? - ANSWER A tuning fork
The nurse is reviewing a client's record and notes that the result of a vision test using a
Snellen chart is 20/30. How should the nurse explain these results to the client? -
1
, ANSWER "You can read at a distance of 20 feet (6 meters) what a person with normal
vision can read at 30 feet (9 meters)."
The nurse is performing an abdominal assessment on a client. The nurse determines that
which finding should be reported to the health care provider (HCP)? -
ANSWER Pulsation between the umbilicus and the pubis
The nurse is performing a physical examination on a hospitalized client. On abdominal
assessment, the nurse listens to the bowel sounds and hears these sounds. The nurse
documents that which sound is heard? - ANSWER Normal bowel sounds
Rationale:Normal bowel sounds are high-pitched, gurgling, cascading sounds occurring
irregularly between 5 and 30 times a minute. A bruit is a pulsatile blowing sound and occurs
with stenosis or occlusion of an artery. Hyperactive bowel sounds are loud, high-pitched,
rushing, tinkling sounds that signal increased motility. Hypoactive bowel sounds are either
diminished or absent, signal decreased motility, and occur after surgery or with
inflammation of the peritoneum.
The nurse is preparing to perform an abdominal examination on a client. The nurse should
place the client in which position for this examination? - ANSWER Supine with the
head raised slightly and the knees slightly flexed
The nurse is providing care to a client admitted for coronary artery disease (CAD) and a
history of tobacco use. What is the most important element of the nurse's focused
assessment of the client's smoking history? - ANSWER Number of pack-years
A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular
contractions and is placed on metoprolol tartrate. The client returns to the health care
provider's (HCP's) office 1 month later for a checkup. The nurse should implement which
type of database when performing an assessment? - ANSWER Follow-up database
2
