Health Assessment Final Exam

D) Making clinical judgments

A nurse on a post-surgical unit is admitting a client following the client's cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client?

a. Collecting accurate data

b. Assisting the primary care provider

c. Validating previous data

d. Making clinical judgments

B) ED nurse

A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment?

A) Gastroenterologist

B) ED nurse

C) Admissions clerk

D) Diagnostic technician

A) Assessment

After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases?

A) Assessment

B) Planning

C) Implementation

D) Evaluation

A) Reassess previously detected problems

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason?

A) Reassess previously detected problems

B) Provide information for the client's record

C) Address areas previously omitted

D) Determine the need for crisis intervention

A) Inspection

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?

A) Inspection

B) Therapeutic communication

C) Interviewing

D) Active listening

C) "Are you allergic to any medications?"

A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement?

A) "Tell me about your relationship with your children?"

B) "Tell me what you eat in a normal day?"

C) "Are you allergic to any medications?"

D) "What is your typical day like?"

B) Provide a laundry list of descriptive words.

A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client's complaint?

A) Ignore the complaint for now and return to it later in the assessment.

B) Provide a laundry list of descriptive words.

C) Restate the question using simpler terms.

D) Wait in silence until the client can determine the correct words.

B) Ask the client to bring all the medications and supplements to an interview.

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?

A) Ask the client to identify which medications taken every day.

B) Ask the client to bring all the medications and supplements to an interview.

C) Ask the caregiver whether the client is taking prescribed medications.

D) Ask the client about the use of any over-the-counter medications.

B) Explain the purpose of the interview.

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?

A) Collaborate with the client to identify problems.

B) Explain the purpose of the interview.

C) Determine the client's vital signs.

D) Obtain family health history data.

C) Severity

The nurse is using the mnemonic "COLDSPA" to assess a client's complaint of lower abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint?

A) Character

B) Onset

C) Severity

D) Pattern

C) Wearing gloves to palpate the tongue and buccal membranes

11. A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which of the following actions?

A) Performing hand hygiene between examinations of each body part

B) Discarding in the trash can the safety pin that was used to assess sensory perception

C) Wearing gloves to palpate the tongue and buccal membranes

D) Wearing a gown, gloves, and mask during the physical exam

A) Newspaper

The nurse is preparing to assess an older adult client's near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use?

A) Newspaper

B) Snellen chart

C) Ophthalmoscope

D) Penlight

A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

13. A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "Absolutely not! There's no way I'll let you do that to me!" Which response by the nurse would be most appropriate?

A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

B) Tell the client that this is the only way she can be checked for cancer.

C) Ask the client if she would prefer another practitioner to perform the exam.

D) Proceed with the pelvic exam and document the client's protests in the health record.

D) Vital signs

The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations?

A) Head and neck examination

B) Palpation of lymph nodes

C) Breast examination

D) Vital signs

C) Pulses

16. The nurse is using her fingerpads to palpate a client's body part during the physical examination. Which of the following would the nurse best be able to detect?

A) Temperature

B) Vibrations

C) Pulses

D) Fremitus

C) Dorsal hand surface

15. When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate assessment data?

A) Finger pad surface

B) Palmar hand surface

C) Dorsal hand surface

D) Ulnar hand surface

A) Inspection

A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first?

A) Inspection

B) Palpation

C) Percussion

D) Auscultation

A) Subjective data and objective data

18. A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following?

A) Subjective data and objective data

B) Interpretation and inference

C) Observation and inspection

D) Data and results

B) "I think this client would benefit from an antiemetic."

19. A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which of the following statements?

A) "What would you like to do to address this client's nausea?"

B) "I think this client would benefit from an antiemetic."

C) "This client has no recent history of any nausea or vomiting."

D) "This client rates his nausea as seven out of ten."

A) Read the order back to the surgeon for confirmation.

A surgical client's pain has become increasingly severe overnight, and she has received her maximum current doses of analgesics. The nurse has consequently phoned the surgeon to obtain a new order for analgesia. After the surgeon tells the nurse the new order, how should the nurse best validate this information?

A) Read the order back to the surgeon for confirmation.

B) Compare the order with the standard timing and dosage of the analgesic.

C) Compare the order to the client's existing medication administration record (MAR).

D) Have another nurse read the order that the nurse has transcribed.

D) Perform further assessments addressing various aspects of the client's pain.

21. A client has illuminated his call light and tells the nurse that he is having "ten out of ten" pain. The nurse's initial inspection reveals that the client is watching videos on his tablet computer and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain?

A) Ask the client to repeat his rating of his pain.

B) Observe the client for several seconds to see if his demeanor or his behavior changes.

C) Consult the client's medication administration record (MAR) to check for recent analgesic use.

D) Perform further assessments addressing various aspects of the client's pain.

B) The man has a diffuse rash on his torso.

The nurse is reviewing and analyzing data from the initial assessment of a newly admitted client who is a 79-year-old man. What assessment finding most clearly indicates a need for further data?

A) The man has male pattern baldness.

B) The man has a diffuse rash on his torso.

C) The man's heart rate is 63 beats per minute.

D) The man had an inguinal hernia repair in 2008.

A) Validate the collected data.

The emergency department has collected extensive data from a client who has presented with a new onset of severe abdominal pain. What nursing action should the nurse perform before proceeding with data analysis?

A) Validate the collected data.

B) Formulate a nursing diagnosis.

C) Make inferences about the data.

D) Identify the client's strengths.

D) The client is separated from her usual social supports.

24. A nurse is planning a client's care following the completion of an initial assessment. When formulating a risk nursing diagnosis, which piece of data would be most useful?

A) The client has an elevated white blood cell count.

B) The client is 66 years of age.

C) The client has pain in her joints, especially in the morning.

D) The client is separated from her usual social supports.

C) Maintaining an open mind

A nurse has identified a goal of developing his critical thinking skills. In order to facilitate this goal, what action should the nurse prioritize?

A) Applying quick decision-making

B) Seeking new experiences

C) Maintaining an open mind

D) Maintaining a stable and static knowledge base

B) Neurologic

A nursing student has been assigned to the care of a client whose history suggests the need for a mental status assessment. This client most likely has a history of health problems affecting what body system?

A) Respiratory

B) Neurologic

C) Cardiovascular

D) Renal

B) "Can I ask you some questions about your memory?"

A client's recent episode of becoming lost near his home has prompted the nurse to use the Saint Louis University Mental Status (SLUMS) Assessment Tool. The nurse should begin this assessment by asking what question?

A) "How would you respond if someone said that you might have dementia?"

B) "Can I ask you some questions about your memory?"

C) "Do you generally consider yourself to be an intelligent person?"

D) "I want to ask you some questions to see if you have Alzheimer's."

D) Alert and oriented

The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following?

A) Deep coma

B) Coma

C) Obtunded

D) Alert and oriented

A) Hazardous and harmful alcohol use

A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted client, the nurse should recognize the possibility of which of the following?

A) Hazardous and harmful alcohol use

B) Imminent liver disease

C) Acute pancreatitis

D) Alcoholism

B) Internally rotated lower extremities

A nurse is assessing a client who is exhibiting decorticate posturing. Which of the following would the nurse observe?

A) Extended upper extremities

B) Internally rotated lower extremities

C) Pronated forearms

D) Flexed hands at the side of the body

A) Temperature

The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first?

A) Temperature

B) Pulse

C) Respiration

D) Blood pressure

C) The client's blood pressure will be slightly lower than standing readings.

A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the client's blood pressure reading in light of what principle?

A) The client's blood pressure will be slightly highly than the client's norm.

B) Position rarely affects the client's blood pressure.

C) The client's blood pressure will be slightly lower than standing readings.

D) There will be questionable accuracy of the blood pressure reading.

B) The cuff is placed about 1 inch above the antecubital area.

The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate?

A) The cuff is wrapped loosely around the arm.

B) The cuff is placed about 1 inch above the antecubital area.

C) The bladder inside the cuff encircles 50% of the arm circumference.

D) The nurse can fit three to four fingers under the inflated cuff.

C) Inflate the cuff 30 mm Hg above where the radial pulse disappears.

Which of the following would be most important for the nurse to do when assessing a client's blood pressure?

A) Palpate the pulsations of the ulnar artery.

B) Hold the client's arm slightly flexed with palm down.

C) Inflate the cuff 30 mm Hg above where the radial pulse disappears.

D) Deflate the cuff about 5 mm Hg per second.

B) Use of two middle fingers lightly applied to wrist area along the thumb side

A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates correct technique for this assessment?

A) Application of firm pressure on the wrist area along the side of the fifth digit

B) Use of two middle fingers lightly applied to wrist area along the thumb side

C) Use of the thumb and index finger applied to obliterate the wrist area along the thumb side

D) Application of the bell of the stethoscope to the antecubital area of the upper extremity

A) 44 mm Hg

The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure?

A) 44 mm Hg

B) 92 mm Hg

C) 114 mm Hg

D) 184 mm Hg

C) The client's report of her pain

A nurse is admitting a client to the postsurgical unit following breast reconstruction surgery. Which of the following would the nurse use as the primary assessment for the client's pain?

A) The client's spiritual view of the pain

B) Current pain therapies used preoperatively

C) The client's report of her pain

D) Psychosocial questions related to her perceptions of pain

D) The client's explanation of how her pain feels

38. The nurse is using the Verbal Descriptor Scale to assess a client's pain. The nurse will prioritize which of the following data?

A) The client's facial expressions

B) The client's report on a 0 to 10 numeric scale

C) The client's rating on a 0 to 10 visual analog scale

D) The client's explanation of how her pain feels

C) Heart rate of 110 beats per minute

The nurse collects vital signs on a hospital client who has recently been experiencing pain. Which of the following would suggest most strongly to the nurse that the client is experiencing pain?

A) Respiratory rate of 18 breaths per minute

B) Temperature of 99.1°F

C) Heart rate of 110 beats per minute

D) Blood pressure of 120/70 mm Hg

A) "What were you doing when the pain first stated?"

The nurse is assessing a client's pain. Which question would be most appropriate to ask the client when the goal is to identify precipitating factors that might have exacerbated the pain?

A) "What were you doing when the pain first stated?"

B) "Do concurrent symptoms accompany the pain?"

C) "When did the pain start?"

D) "Is the pain continuous or intermittent?"

B) Assess the client's pain according to COLDSPA.

A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the client from the stretcher to a bed and asked the client if he is experiencing pain. The client acknowledges that he is in pain. What should be the nurse's next action?

A) Ask the client to briefly explain his cultural background.

B) Assess the client's pain according to COLDSPA.

C) Assess the client's self-management skills.

D) Assess the client's pain by obtaining a set of vital signs.

B) Compressing the arteries bilaterally

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

A) Asking the client to flex his or her neck

B) Compressing the arteries bilaterally

C) Performing the examination while the client is seated

D) Asking the client to swallow water

A) Pain radiating from eye to temporal region

During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches?

A) Pain radiating from eye to temporal region

B) Throbbing and severe pain

C) Report of ringing in the ears prior to headache

D) Complaint of sensitivity to light

C) Consensual response

A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following?

A) Direct reflex

B) Optic chiasm

C) Consensual response

D) Accommodation

A) Far, then near

The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test?

A) Far, then near

B) Lateral, then near

C) Near, then far

D) Lateral, then far

C) Normal findings for client's age

During a health history, a 62-year-old male client reveals that he occasionally sees spots before his eyes. The nurse interprets this finding as the result of which of the following?

A) Increased ocular pressure

B) Vitamin A deficiency

C) Normal findings for client's age

D) Vascular spasm

C) The eye cannot look down when turned inward.

A review of a client's history reveals cranial nerve IV paralysis. Which of the following findings would the nurse expect to assess?

A) The eye cannot look to the outside side.

B) Ptosis will be evident.

C) The eye cannot look down when turned inward.

D) The eye will look straight ahead.

B) Narcotic use

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following?

A) Recent eye trauma

B) Narcotic use

C) Macular degeneration

D) Recent peripheral nervous system injury

D) Nystagmus

A nurse is performing an eye and vision assessment on a client who has an inner ear disorder. This disorder may contribute to what finding during the client's eye positions test?

A) Strabismus

B) Phoria

C) Tropia

D) Nystagmus

B) "Have you ever been tested for diabetes?"

A nurse is completing a comprehensive health history of a 69-year-old woman who is a new client of the clinic. Which of the nurse's interview questions most directly addresses the client's risk for developing cataracts?

A) "Do you exercise regularly?"

B) "Have you ever been tested for diabetes?"

C) "Do you ever take over-the-counter pain medications?"

D) "At what age did you first start wearing glasses?"

D) Glaucoma

A client has sought care because she states that she has begun to see halos around headlights and streetlights when she is out at night. The nurse should recognize the need to refer the client for further assessment related to what health problem?

A) Episcleritis

B) Strabismus

C) Macular degeneration

D) Glaucoma

A) A 55-year-old female client

====A nurse who works at an outpatient ophthalmic clinic has a large number of clients. Which client would be at the highest risk for developing cataracts?

A) A 55-year-old female client

B) A 40-year-old with arteriosclerosis

C) A client who has severe environmental allergies

D) A male client who is obese

C) Tender tragus

====When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment?

A) Darwin tubercle

B) Red, flaky cerumen

C) Tender tragus

D) Pearly gray tympanic membrane

B) "It helps to keep the ear drum soft and functioning well."

A client asks why cerumen is important, stating, "It just clogs up the ears anyway." How should the nurse best describe the purpose of cerumen?

A) "It helps protect the delicate ear drum from loud noise that may be damaging."

B) "It helps to keep the ear drum soft and functioning well."

C) "It helps to amplify the sound waves through the inner ear."

D) "It helps create the translucent, pearly color of the ear drum."

C) Inspect the client's external ear canal.

A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first?

A) Assess the client's tympanic membrane.

B) Palpate the client's tragus.

C) Inspect the client's external ear canal.

D) Perform hearing assessments.

D) Presbycusis

====A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis?

A) Vertigo

B) Otalgia

C) Tinnitus

D) Presbycusis

B) Otitis externa

A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect which of the following health problems?

A) Otitis media

B) Otitis externa

C) Ruptured tympanic membrane

D) Mastoiditis

A) Refer the client immediately for further evaluation.

The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next?

A) Refer the client immediately for further evaluation.

B) Assess for foreign body impaction.

C) Examine for postauricular cysts.

D)Position the patient to facilitate drainage.

C) Normal tympanic membrane

While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following?

A) Scarring from previous infections

B) Otitis media

C) Normal tympanic membrane

D) Otitis externa

B) The size and shape of children's eustachian tubes makes them vulnerable.

A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which of the following would the nurse describe?

A) Young children have a tendency to stick objects into their ear canal.

B) The size and shape of children's eustachian tubes makes them vulnerable.

C) Children's immune systems lack the maturity to fight infections.

D) Children generally have poorer hygiene than adults.

B) "What medications are you currently taking?"

A client has sought care at the clinic, telling the nurse, "This ringing in my ears has gone on for weeks, and it's driving me crazy." The patient denies exposure to excessive noise levels. The nurse recognizes the likely presence of tinnitus and should follow up with which of the following questions?

A) "Did your parents even complain of something similar?"

B) "What medications are you currently taking?"

C) "How would you describe your overall level of health?"

D) "How do you usually clean your ears?"

B) Leukoplakia

The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow-up?

A) Thrush

B) Leukoplakia

C) Gingivitis

D) Canker sore

C) Thoroughly chew small amounts of food with each mouthful.

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. Which of the following would be most appropriate for the nurse to include?

A) Sit with the head of the bed at 45 degrees during meals.

B) Be aware of the possibility of temporomandibular joint pain.

C) Thoroughly chew small amounts of food with each mouthful.

D) Drink fluids before and after, but not during, meals.

D) Assess the client's cranial nerve function.

While examining a client's mouth, the nurse notes the presence of fasciculations (fine tremors) of the client's tongue. How should the nurse best respond to this assessment finding?

A) Have the client provide a 24-hour diet recall.

B) Review the client's medication regimen.

C) Prepare the client for a thyroid screening.

D) Assess the client's cranial nerve function.

C) 3+

The nurse is inspecting a client's tonsils and notes that they make contact with the client's uvula. The nurse would document this finding as which of the following?

A) 1+

B) 2+

C) 3+

D) 4+

C) Checking for a deviated nasal septum

During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. Which of the following would be most important for the nurse to assess?

A) Asking if the client experiences dry mouth often

B) Inspecting for inflammation of the tonsils

C) Checking for a deviated nasal septum

D)Performing a focused respiratory assessment

D) Pinkish, spongy soft palate

The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which of the following findings would a nurse interpret as being normal?

A) Absence of red glow on transillumination of sinuses

B) Nasal mucosa pale pink and swollen

C) Tonsils 2+

D) Pinkish, spongy soft palate

C) Area under the tongue

When assessing a client for possible oral cancer, the nurse should most closely inspect which area?

A) Buccal mucosa

B) Hard palate

C) Area under the tongue

D) Along the gum line

C) "Do you use tobacco, whether smoking or chewing?"

A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer?

A) "Would you say that you're prone to getting mouth ulcers?"

B) "Do you brush and floss daily?"

C) "Do you use tobacco, whether smoking or chewing?"

D) "How often do you usually go to the dentist in a year?"

A) "How often do you use over-the-counter nasal sprays?"

The nurse is assessing a client who enjoys good health overall but who has brought a complaint of chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize?

A) "How often do you use over-the-counter nasal sprays?"

B) "How often do you take Tylenol?"

C) "How many drinks of alcohol do you have in a typical day?"

D) "Would you say that you eat a balanced diet?"

D) Pain on percussion

The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis?

A) Resonance on percussion

B) Dull sounds

C) Tympanic sounds

D) Pain on percussion

A) Softly repeat the words "one-two-three."

When assessing whispered pectoriloquy, the nurse should instruct a client to do which of the following?

A) Softly repeat the words "one-two-three."

B) Say the number "ninety-nine."

C) Cough each time the stethoscope is moved.

D) Say the letter "e" until instructed to stop.

D) Heart failure

During the health interview, a client tells the nurse that he "can't breathe all that well" at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for which of the following health problems?

A) Pneumonia

B) Tuberculosis

C) Bronchitis

D) Heart failure

C) Pink and frothy

A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about which of the following assessment findings related to the client's sputum?

A) White or cream-colored

B) Yellowish and foul-smelling

C) Pink and frothy

D) Rust-tinged

A) Hyperresonance

A client has a history of emphysema. During the respiratory assessment, the nurse percusses the client's chest, expecting to find which of the following?

A) Hyperresonance

B) Dullness

C) Resonance

D) Tympany

D) Have the client cough, then listen again.

While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. Which of the following actions should the nurse do first?

A) Refer the client for further medical evaluation.

B) Auscultate for egophony.

C) Perform bronchophony.

D) Have the client cough, then listen again.

C) Sonorous wheezes

An adult client has been diagnosed with bronchitis. Which of the following would the nurse most likely hear on auscultation?

A) Sibilant wheezes

B) Fine crackles

C) Sonorous wheezes

D) Coarse crackles

D) Bronchial breath sounds

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document which of the following?

A) Vesicular breath sounds

B) Bronchovesicular breath sounds

C) Adventitious breath sounds

D) Bronchial breath sounds

C) Flatness

When percussing the scapula of a client, which of the following would the nurse expect to hear?

A) Resonance

B) Dullness

C) Flatness

D) Hyperresonance

D) Right middle lobe

The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse must assess which lobe anteriorly?

A) Left upper lobe

B) Left lower lobe

C) Right upper lobe

D) Right middle lobe

B) History of tobacco use

During a health screening event, the nurse is assessing a client's risk factors for lung cancer. When addressing the most significant risk factor for lung cancer, the nurse should question the client about which of the following?

A) Childhood exposure to air pollution

B) History of tobacco use

C) History of working in a factory or smelter

D) History of recurrent lung infections

A) Myocardium

A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying this layer as which of the following?

A) Myocardium

B) Epicardium

C) Endocardium

D) Pericardium

C) Sinoatrial node

A nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. The nurse should be aware that the electrical signal originates in which of the following locations?

A) Bundle of His

B) Purkinje fibers

C) Sinoatrial node

D) AV node

D) Closure of the atrioventricular valves

The nurse is analyzing the data from the assessment of a client's heart and neck vessels. The client's first heart sound corresponds with what event in the cardiac cycle?

A) Isometric contraction

B) Closure of the semilunar valves

C) Beginning of diastole

D) Closure of the atrioventricular valves

A) Increased jugular venous pressure

The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate?

A) Increased jugular venous pressure

B) Bradycardia

C) Decreased blood pressure

D) Dysrhythmias

B) The client may be experiencing symptoms of heart failure.

The nurse is assessing a client with a cardiac condition who complains of not sleeping well and of having to get up frequently at night to urinate. The nurse should recognize what implication of this statement?

A) The client may have developed a cardiac conduction problem.

B) The client may be experiencing symptoms of heart failure.

C) The client's cardiac problem is being adequately compensated for.

D) The client may be at increased risk for myocardial infarction.

D) Inspect the suprasternal notch or around the clavicles.

The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse?

A) Perform the exam with the client in a supine position.

B) Have the client look straight ahead with chin slightly lifted.

C) Have the client sit up at a 90-degree angle.

D) Inspect the suprasternal notch or around the clavicles.

D) T wave

A nurse is reviewing a client's electrocardiogram (ECG). The nurse should identify which component as indicating ventricular repolarization?

A) P wave

B) QRS complex

C) ST segment

D) T wave

A) Palpate each artery individually to compare.

The nurse is preparing to assess a client's carotid arteries. Which of the following actions would be most appropriate?

A) Palpate each artery individually to compare.

B) Palpate the arteries before auscultating them.

C) Use the diaphragm of the stethoscope.

D) Ask the client to breathe in and out deeply.

B) 2+

The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following?

A) 1+

B) 2+

C) 3+

D) 4+

B) Palpate the carotid pulse while auscultating the heart.

A nurse is having difficulty identifying a client's heart sounds, specifically S1 and S2. Which of the following would be most appropriate for the nurse to do?

A) Use the bell of the stethoscope to help distinguish the sounds.

B) Palpate the carotid pulse while auscultating the heart.

C) Determine the pulse deficit.

D) Palpate the apical impulse.

B) Heart failure

A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessments should focus on the signs and symptoms of what health problem?

A) Myocardial infarction

B) Heart failure

C) Atherosclerosis

D) Heart block

A) "Do you have any other symptoms together with your chest pain, such as nausea, sweating?"

The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain. What interview question addresses the "A" in this assessment model?

A) "Do you have any other symptoms together with your chest pain, such as nausea, sweating?"

B) "In your experience, what kinds of activities tend to cause your chest pain?"

C) "Would you describe your chest pain as being acute, or is it chronic?"

D) "What changes do you have to make in order to accommodate your chest pain?"

D) Auscultate with the client in a variety of different positions.

The nurse is auscultating a client's heart sounds and hears what she believes to be a murmur. How should the nurse proceed with gathering further assessment data related to the suspected murmur?

A) Auscultate with the bell and then without the stethoscope.

B) Ask the client to "bear down" (perform the Valsalva maneuver) while auscultating.

C) Ask the client to inhale and exhale deeply while auscultating.

D) Auscultate with the client in a variety of different positions.

C) Elevate the head of the client's bed to 30 degrees.

The nurse has assessed a client's neck vessels and is now preparing to auscultate the client's heart sounds. What action should the nurse perform during this phase of assessment?

A) Rapidly auscultate all areas of the precordium and then repeat the assessments in greater detail.

B) Stand on the client's left side, nearest the heart.

C) Elevate the head of the client's bed to 30 degrees.

D) Begin by auscultating the entire precordium with the bell of the stethoscope.

D) "Your risk for heart disease will drop greatly if you're able to stop smoking."

The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease?

A) "If you can eliminate red meat from your diet, your risk of heart disease will drop significantly."

B) "Try to ensure that you're screened for heart disease at least once every six months."

C) "Anything that you can do to reduce stress in your life will benefit your heart health."

D) "Your risk for heart disease will drop greatly if you're able to stop smoking."

A) Arteries have thicker walls than veins.

During a health visit, a client says, "I know that arteries and veins are both blood vessels, but what's the difference?" Which of the following would the nurse include in the response?

A) Arteries have thicker walls than veins.

B) Arteries carry 70% of the body's blood volume.

C) Arteries have a lower pressure than veins.

D) Arteries carry waste from the tissues.

A) Arterial insufficiency

An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. Which of the following would the nurse suspect?

An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. Which of the following would the nurse suspect?

A) Arterial insufficiency

B) Musculoskeletal weakness

C) Venous insufficiency

D) Diabetic neuropathy

A) Venous insufficiency

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral?

A) Venous insufficiency

B) Stasis ulceration

C) Arterial occlusion

D) Dependent edema

B) The nurse should implement interventions to address severe arterial insufficiency.

The nurse reads in a client's electronic health record that her most recent ankle-brachial index (ABI) was 0.42. How should this assessment finding inform the nurse's care?

A) The nurse should inspect the client's feet and ankles for venous ulcers once per shift.

B) The nurse should implement interventions to address severe arterial insufficiency.

C) The nurse should assess the client's extremities for pitting edema at least once per shift.

D) The nurse should position the client to promote venous return.