Saunders Comprehensive Review
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? - ANS-"When was the last time you
had your blood pressure checked?"
\A chest x-ray report states that the client has a left apical pneumothorax. The nurse
caring for the client monitors the status of breath sounds in that area by placing the
stethoscope at which location? - ANS-Just under the left clavicle
Rationale:The apex of the lung is the rounded, uppermost part of the lung. The nurse
would place the stethoscope just under the left clavicle. The other options are
incorrect locations.
\A client diagnosed with conductive hearing loss asks the nurse to explain the cause
of the hearing problem. The nurse plans to explain to the client that this condition is
caused by which problem? - ANS-A physical obstruction to the transmission of
sound waves
\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? -
ANS-Follow-up database
\A client is diagnosed with external otitis. Which finding would the nurse expect to
note on assessment of the client? - ANS-Redness and swelling in the ear canal
\A client with a diagnosis of asthma is admitted to the hospital with respiratory
distress. Which type of adventitious lung sounds should the nurse expect to hear
when performing a respiratory assessment on this client? - ANS-Wheezes
\A clinic nurse is performing a cardiovascular assessment on a client and auscultates
the chest over the apex of the heart. The nurse should document this finding as
which sound?
(play sound ~*lub*) - ANS-First heart sound, S1
\A clinic nurse is preparing to evaluate the peripheral vision of a client by the
confrontational method. Which method describes the accurate procedure to perform
this test? - ANS-The examiner and client cover the eyes directly opposite to one
another and stare at each other's uncovered eye, and a small object is brought into
the visual field.
, Rationale:The confrontational method assumes that the examiner has normal
peripheral vision. The client sits facing the examiner, approximately 2 feet (60 cm)
away. The eyes of the client and the examiner should be at the same level. Both the
examiner and the client cover the eyes directly opposite each other and stare at
each other's uncovered eye. A small object is brought from the peripheral visual field
and tests the superior, temporal, inferior, and nasal field. The client states when he
or she sees the object.
\A clinic nurse is preparing to evaluate the peripheral vision of a client by the
confrontational method. Which statement demonstrates that the client correctly
understands the instructions for the test? - ANS-"I will tell you when the small object
is in my visual field."
Rationale:The confrontational method assumes that the examiner has normal
peripheral vision. The client sits facing the examiner approximately 2 feet (60 cm)
away. The eyes of the client and the examiner should be at the same level. Both the
examiner and the client cover the eyes directly opposite to one another and stare at
each other's uncovered eye. A small object is brought in from the peripheral visual
field, and the superior, temporal, inferior, and nasal fields are evaluated. The client
states when he or she sees the object.
\A confrontation test is prescribed for a client seen in the eye and ear clinic. How
should the nurse perform this test? Arrange the actions in the order that they should
be performed. All options must be used. - ANS-(arranged in order)
- Stands 2 to 3 feet (60 to 90 cm) in front of and faces the client
- Asks the client to cover 1 eye
- Examiner covers eye opposite to the eye covered by the client
- The examiner brings in an object gradually from periphery
- Asks the client to report when object is first noted
\A group of postmenopausal women are learning to do breast self-examination
(BSE) in a teaching session at the clinic. The clinic nurse should teach the group
which point about this procedure? - ANS-Do the exam on the same day every
month.
\A home care nurse is assessing a client's activities of daily living (ADLs) after a
stroke. What should the nurse include in the client's focused assessment? -
ANS-Self-care needs such as toileting, feeding, and ambulating
\A nursing student is asked about the procedure used to elicit Homans' sign. Which
response by the student indicates an understanding of this assessment technique? -
ANS-"I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex
the foot forward."
\A nursing student is performing a respiratory assessment on a female adult client
and is assessing for tactile fremitus. Which action by the nursing student indicates a
need for further teaching? - ANS-Palpating over the breast tissue to assess and
compare vibrations from 1 side to the other
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? - ANS-"When was the last time you
had your blood pressure checked?"
\A chest x-ray report states that the client has a left apical pneumothorax. The nurse
caring for the client monitors the status of breath sounds in that area by placing the
stethoscope at which location? - ANS-Just under the left clavicle
Rationale:The apex of the lung is the rounded, uppermost part of the lung. The nurse
would place the stethoscope just under the left clavicle. The other options are
incorrect locations.
\A client diagnosed with conductive hearing loss asks the nurse to explain the cause
of the hearing problem. The nurse plans to explain to the client that this condition is
caused by which problem? - ANS-A physical obstruction to the transmission of
sound waves
\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? -
ANS-Follow-up database
\A client is diagnosed with external otitis. Which finding would the nurse expect to
note on assessment of the client? - ANS-Redness and swelling in the ear canal
\A client with a diagnosis of asthma is admitted to the hospital with respiratory
distress. Which type of adventitious lung sounds should the nurse expect to hear
when performing a respiratory assessment on this client? - ANS-Wheezes
\A clinic nurse is performing a cardiovascular assessment on a client and auscultates
the chest over the apex of the heart. The nurse should document this finding as
which sound?
(play sound ~*lub*) - ANS-First heart sound, S1
\A clinic nurse is preparing to evaluate the peripheral vision of a client by the
confrontational method. Which method describes the accurate procedure to perform
this test? - ANS-The examiner and client cover the eyes directly opposite to one
another and stare at each other's uncovered eye, and a small object is brought into
the visual field.
, Rationale:The confrontational method assumes that the examiner has normal
peripheral vision. The client sits facing the examiner, approximately 2 feet (60 cm)
away. The eyes of the client and the examiner should be at the same level. Both the
examiner and the client cover the eyes directly opposite each other and stare at
each other's uncovered eye. A small object is brought from the peripheral visual field
and tests the superior, temporal, inferior, and nasal field. The client states when he
or she sees the object.
\A clinic nurse is preparing to evaluate the peripheral vision of a client by the
confrontational method. Which statement demonstrates that the client correctly
understands the instructions for the test? - ANS-"I will tell you when the small object
is in my visual field."
Rationale:The confrontational method assumes that the examiner has normal
peripheral vision. The client sits facing the examiner approximately 2 feet (60 cm)
away. The eyes of the client and the examiner should be at the same level. Both the
examiner and the client cover the eyes directly opposite to one another and stare at
each other's uncovered eye. A small object is brought in from the peripheral visual
field, and the superior, temporal, inferior, and nasal fields are evaluated. The client
states when he or she sees the object.
\A confrontation test is prescribed for a client seen in the eye and ear clinic. How
should the nurse perform this test? Arrange the actions in the order that they should
be performed. All options must be used. - ANS-(arranged in order)
- Stands 2 to 3 feet (60 to 90 cm) in front of and faces the client
- Asks the client to cover 1 eye
- Examiner covers eye opposite to the eye covered by the client
- The examiner brings in an object gradually from periphery
- Asks the client to report when object is first noted
\A group of postmenopausal women are learning to do breast self-examination
(BSE) in a teaching session at the clinic. The clinic nurse should teach the group
which point about this procedure? - ANS-Do the exam on the same day every
month.
\A home care nurse is assessing a client's activities of daily living (ADLs) after a
stroke. What should the nurse include in the client's focused assessment? -
ANS-Self-care needs such as toileting, feeding, and ambulating
\A nursing student is asked about the procedure used to elicit Homans' sign. Which
response by the student indicates an understanding of this assessment technique? -
ANS-"I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex
the foot forward."
\A nursing student is performing a respiratory assessment on a female adult client
and is assessing for tactile fremitus. Which action by the nursing student indicates a
need for further teaching? - ANS-Palpating over the breast tissue to assess and
compare vibrations from 1 side to the other
