Chapter 33: Health Assessment and Physical Examination Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

MULTIPLE CHOICE

1. The position that maximizes the nurses ability to assess the clients body for symmetry is:

1.

Sitting

2.

Supine

3.

Prone

4.

Dorsal recumbent

ANS: 1

Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts. The supine position maximizes the nurses ability to assess pulse sites. The prone position is used only to assess extension of the hip joint.

The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles.

PTS: 1 DIF: A REF: 559 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

2. When assessing the pallor of a client with dark skin, the nurse will specifically look at the:

1.

Buccal mucosa of the mouth

2.

Dorsal surface of the hands

3.

Ear lobe

4.

Sclera

ANS: 1

Pallor is more easily seen in the face, buccal mucosa of the mouth, conjunctiva, and nail beds. The palmar surface of the hands may be used to detect color hues in dark-skinned clients. The ear lobe is not a good site to assess for color changes, such as pallor, in a dark-skinned client. The best site to inspect for jaundice, not pallor, is the sclera.

PTS: 1 DIF: A REF: 567 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

3. A female client is seen in the outpatient clinic for numerous cuts, bruises, and apparent burns. In a discussion with the client, the nurse finds that the injuries are inconsistent with the stated cause. The client also states that she is having trouble sleeping, and she appears anxious. Based on these findings, the nurse suspects that the client may be experiencing:

1.

Substance abuse

2.

Domestic violence

3.

Vascular disease

4.

Mental illness

ANS: 2

Injuries and trauma that are inconsistent with the reported cause; multiple injuries including bruises, cuts, and burns; and behavioral findings of difficulty sleeping and appearing anxious are all indicators of possible domestic violence. The findings are not consistent with substance abuse. Indicators of substance abuse may include frequent missed appointments or emergency department visits, having a history of changing doctors, history of activities that place the client at risk for HIV infections, complaints of insomnia or chest pain, and a family history of addiction. People who abuse substances may have cuts, burns (especially of the fingers), needle marks, homemade tattoos, or increased vascularity of the face. These findings are not indicative of vascular disease. Symptoms of vascular disease may include edema, color changes of the lower extremities, and weakened pedal pulses. These findings are not indicative of mental illness. The client is coherent.

PTS: 1 DIF: C REF: 563 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

4. A client in the clinic has been having severe headaches and some visual disturbances. The nurse performs an eye examination. Which of the following is true concerning the procedure for this assessment?

1.

The red reflex should be assessed with the ophthalmoscope.

2.

To evaluate the lower eyelids, the nurse uses a syringe with sterile water.

3.

Accommodation is tested by asking the client to comply with the nurses requests.

4.

The lacrimal apparatus is assessed with a dull object to stimulate normal reflex conditions.

ANS: 1

To visualize internal eye structures, the nurse uses an ophthalmoscope to focus on the red reflex. To evaluate the lower eyelids, the nurse asks the client to open the eyes for inspection. A syringe and sterile water are not necessary for this assessment. Accommodation is tested by asking the client to gaze at a distant object and then at a test object held by the nurse approximately 10 cm from the clients nose. The pupils normally converge and accommodate by constricting when looking at close objects. The lacrimal apparatus is best assessed by inspecting for edema and redness; and palpating it gently to detect tenderness, which cannot be felt normally.

PTS: 1 DIF: A OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

5. In preparing to conduct a physical examination on a client, the nurse plans to:

1.

Perform painful procedures at the end of the exam

2.

Take long, detailed notes of all the findings during the exam

3.

Keep the TV or radio on to distract the client throughout the exam

4.

Assess the dominant side of the clients body only in the examination

ANS: 1

In organizing a physical examination, the nurse should perform painful procedures near the end of the examination. The nurse should record quick notes during the examination to avoid keeping the client waiting. Observations can be completed at the end of the examination. The TV or radio should be turned off so as to not distract the client throughout the examination, and to provide an environment conducive to auscultation.

Both sides of the body should be assessed for comparison to determine symmetry. A degree of asymmetry is normal in the dominant versus nondominant arm.

PTS: 1 DIF: A REF: 562 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

6. The client has an enlarged thyroid gland and is currently admitted to a medical nursing unit. Which of the following is accurate regarding the procedure for a thyroid assessment for this client?

1.

Deep palpation should be used anterior and posterior.

2.

Swallowing sips of water causes the isthmus of the thyroid gland to rise.

3.

The posterior approach is used when the fingers are placed over the trachea.

4.

The diaphragm of the stethoscope is best used for the auscultation of bruits.

ANS: 2

During assessment of the thyroid gland, the client holds a cup of water and takes a sip to swallow once instructed by the nurse. As the client swallows, the isthmus of the thyroid gland rises. The nurse should feel if it is enlarged. Normally the thyroid gland is small, smooth, and free of nodules. Light, gentle palpation is needed to feel any abnormalities.

For the posterior approach, both of the nurses hands are placed around the neck, with two fingers of each hand on the sides of the trachea just beneath the cricoid cartilage.

The bell of the stethoscope is best for auscultation of bruits.

PTS: 1 DIF: A REF: 591 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

7. When auscultating the clients lungs, a nurse notes normal vesicular sounds as:

1.

Medium-pitched blowing sounds with inspirations that equal expirations

2.

Loud, high-pitched, hollow sounds with expiration longer than inspiration

3.

Soft, breezy, low-pitched sounds with longer inspiration

4.

Sounds created by air moving through small airways

ANS: 3

Normal vesicular sounds are soft, breezy, and low-pitched. The inspiratory phase is 3 times longer than the expiratory phase. Medium-pitched blowing sounds with inspiration equaling expiration are bronchovesicular breath sounds. Loud, high-pitched, hollow sounds with longer expiration are bronchial breath sounds. Vesicular sounds are created by air moving through smaller airways. Abnormal breath sounds result from air passing through narrowed airways.

PTS: 1 DIF: A REF: 596 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

8. The nurse could best auscultate the point of maximum impulse (PMI) in an 8-year-old child at the:

1.

Fourth intercostal space, left of the midclavicular line

2.

Fifth intercostal space, left of the midclavicular line

3.

Second intercostal space, right of the midclavicular line

4.

Third intercostal space, right of the midclavicular line

ANS: 2

By the age of 7, a childs PMI is in the same location as in adults; that is, the fifth intercostal space, left of the midclavicular line. The PMI of an 8-year-old child is more likely to be located at the fifth intercostal space, left of the midclavicular line.

The PMI is not located to the right of the midclavicular line. The PMI of an infant is at the third or fourth intercostal space, left of the midclavicular line.

PTS: 1 DIF: A REF: 598 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

9. The nurse suspects that the client may have vascular disease. During the examination, the nurse is alert to the clients complaints of:

1.

Headache, dizziness, and tingling of body parts

2.

Diplopia, floaters, and headaches

3.

Leg cramps, numbness of extremities, and edema

4.

Pain and cramping in the lower extremities relieved by walking

ANS: 3

Leg cramps, numbness or tingling in extremities, sensation of cold hands or feet, pain in legs, or swelling or cyanosis of feet, ankles, or hands are indicative of vascular disease.

Headache, dizziness, and tingling of body parts are more likely associated with a neurological problem, not vascular disease. Diplopia, floaters, and headaches are indicative of an eye problem, not vascular disease. Pain and cramping in the lower extremities are usually worsened with activity in vascular disease.

PTS: 1 DIF: A REF: 602 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

10. A 21-year-old woman asks when she should perform a breast self-examination during the month. The nurse should inform the client:

1.

Any time you think of it.

2.

At the same time each month.

3.

On the first day of your menstrual period.

4.

Two to three days after your menstrual period.

ANS: 4

The best time for a BSE is 2 to 3 days after the menstrual period ends, when the breast is no longer swollen or tender from hormone elevations. The woman should check her breasts the same time each month 2-3 days after the menstrual period ends. At the same time each month is partially true. The client also should be informed to perform the BSE 2 to 3 days after the menstrual period ends. On the first day of the menstrual period is not the best time for a woman to perform a BSE. The breasts will be enlarged and tender from hormone elevations.

PTS: 1 DIF: A REF: 610 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

11. During an assessment of the clients integument, the nurse notes a flat, nonpalpable change in skin color that is smaller than 1 cm. This finding is documented by the nurse as a:

1.

Macule

2.

Papule

3.

Vesicle

4.

Nodule

ANS: 1

This finding is consistent with the definition of a macule. A papule is a palpable, circumscribed, solid elevation in skin, smaller than 0.5 cm. A vesicle is a circumscribed elevation of skin filled with serous fluid, smaller than 0.5 cm. A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5-2.0 cm.

PTS: 1 DIF: A REF: 570 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

12. The nurse asks a client to explain the meaning of the phrase, Every cloud has a silver lining. This part of the examination is designed to measure:

1.

Knowledge

2.

Judgment

3.

Association

4.

Abstract thinking

ANS: 4

Interpreting abstract ideas or concepts, such as in explaining the meaning of this phrase, reflects the capacity for abstract thinking. The client with altered mentation will likely interpret the phrase literally or merely rephrase the words. An example of assessing knowledge would be asking the client their reason for seeking health care. This example is not designed to measure knowledge. The nurse is not attempting to measure judgment. An example of assessing judgment would be to ask the client what they would do if they suddenly became ill when alone at home. The nurse is not attempting to measure association. An example of assessing association would be to ask the client to complete a phrase, such as a dog is to a beagle as a cat is to a _____.

PTS: 1 DIF: A REF: 633 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

13. Measurement of the clients ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?

1.

Optic

2.

Facial

3.

Trigeminal

4.

Oculomotor

ANS: 3

The trigeminal nerve is tested by lightly touching the cornea with a wisp of cotton, by assessing the corneal reflex, and by measuring sensation of light pain and touch across the skin of the face. The optic nerve is tested by using the Snellen chart or asking the client to read printed material. The facial nerve is tested by having the client smile, frown, puff out cheeks, and raise and lower eyebrows while looking for asymmetry. Also, having the client identify salty or sweet taste on the front of the tongue tests the facial nerve. The oculomotor nerve is tested by assessing directions of gaze and testing papillary reaction to light and accommodation.

PTS: 1 DIF: A REF: 634 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

14. Assessment of the clients skin reveals a fluid-filled circumscribed elevation of 0.4 cm. The nurse identifies this as a:

1.

Nodule

2.

Macule

3.

Vesicle

4.

Wheal

ANS: 3

This finding is consistent with the definition of a vesicle. A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5-2.0 cm. A macule is a flat, nonpalpable change in skin color, smaller than 1 cm. A wheal is an irregularly-shaped, elevated area or superficial localized edema that varies in size.

PTS: 1 DIF: A REF: 570 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

15. The expected appearance of the oral mucosa in a light-skinned adult is:

1.

Pinkish-red, smooth, and moist

2.

Light pink, rough, and dry

3.

Cyanotic, with rough nodules

4.

Deep red, with rough edges

ANS: 1

Normal mucosa in a light-skinned adult is glistening, pinkish-red, soft, moist, and smooth. Oral mucosa may appear more dry in an older adult because of reduced salivation but is not rough. Cyanotic mucosa with rough nodules would be an abnormal finding. Oral mucosa should not appear deep red with rough edges in a light-skinned adult.

PTS: 1 DIF: A REF: 587 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

16. The nurse notes an exaggeration of the posterior curvature of the thoracic spine, during the assessment of a 90-year-old client, as:

1.

Lordosis

2.

Osteoporosis

3.

Scoliosis

4.

Kyphosis

ANS: 4

Kyphosis is an exaggeration of the posterior curvature of the thoracic spine (hunchback).

Lordosis is an increased lumbar curvature (swayback). Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone. Scoliosis is a lateral curvature of the spine.

PTS: 1 DIF: A REF: 627 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

17. The best position for the nurse to position the client in order to auscultate the apical site, if a low-pitched murmur is suspected during prior assessment, is:

1.

Sitting up

2.

Standing

3.

Lying on the left side

4.

Dorsal recumbent

ANS: 3

Extra heart sounds or heart murmurs are heard more easily with the client lying on the left side (lateral recumbent) with the stethoscope at the apical site. Sitting upright is used for assessing lung expansion and symmetry of the upper extremities. Standing is not the best position for auscultating a heart murmur. The dorsal recumbent position is best used for abdominal assessment.

PTS: 1 DIF: A REF: 559 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

18. As part of the examination, the nurse will be assessing the clients balance. The test that should be administered is the:

1.

Weber test

2.

Allen test

3.

Romberg test

4.

Rinne test

ANS: 3

The Romberg test assesses the clients balance. The Weber test assesses for unilateral deafness. The Allen test assesses for patency of the arteries of the hand (usually before arterial puncture). The Rinne test compares bone conduction hearing with air conduction.

PTS: 1 DIF: A REF: 636-637 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

19. Part of the neurological exam is evaluating the response of the cranial nerves. To test cranial nerve VIII, the nurse should:

1.

Ask the client to read printed material

2.

Assess the directions of gaze

3.

Assess the clients ability to hear the spoken word

4.

Ask the client to say ah

ANS: 3

To test cranial nerve VIII (auditory), the nurse should assess the clients ability to hear the spoken word. To test cranial nerve II (optic), the nurse should assess the clients ability to read printed material. To test cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), the nurse should assess the clients directions of gaze. To assess cranial nerve X (vagus), the nurse should ask the client to say ah.

PTS: 1 DIF: A REF: 634 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

20. A student nurse is working with a client who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. The student expects to hear:

1.

Coarse crackles and bubbling

2.

High-pitched musical sounds

3.

Dry, grating noises

4.

Loud, low-pitched rumbling

ANS: 2

Wheezes are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration. Coarse crackles and bubbling are not descriptive of wheezes. Dry, grating noises are heard with a pleural friction rub. Loud, low-pitched rumbling is characteristic of rhonchi.

PTS: 1 DIF: A REF: 596 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

21. The nurse instructs the male client that the protocol for testicular self-examination is to:

1.

Perform the examination annually after age 35

2.

Use both hands to roll the testicles and feel the consistency

3.

Perform the examination before bathing or showering

4.

Contact the physician if a cordlike structure is felt on the top and back of the testicle

ANS: 2

The nurse instructs the male client that the protocol for testicular self-examination is to use both hands to gently roll the testicle, feeling for lumps, thickening, or a change in consistency (hardening). All men 15 years and older should perform the testicular self-exam monthly. The examination should be performed after a warm bath or shower when the scrotal sac is relaxed. A cordlike structure on the top and back of the testicle is a normal finding. It is the epididymis.

PTS: 1 DIF: A REF: 623 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

22. The nurse uses olfaction in the clients assessment. If a sweet, fruity smell is noticed in the oral cavity, the nurse suspects:

1.

Diabetic acidosis

2.

Gum disease

3.

Stomatitis

4.

Malabsorption syndrome

ANS: 1

A sweet, fruity smell noticed in the oral cavity is indicative of diabetic acidosis. Halitosis of the oral cavity is indicative of gum disease. Stomatitis is characterized by oral pain, bad breath, inflammation, and oral ulcers in the mouth. Foul-smelling stools in the infant is indicative of malabsorption syndrome.

PTS: 1 DIF: A REF: 557 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

23. A client with cardiopulmonary disease receives a physical examination performed by a nurse. Knowing the client history, the nurse is attentive when checking the nails for the presence of:

1.

Clubbing

2.

Paronychia

3.

Beaus lines

4.

Splinter hemorrhages

ANS: 1

Clubbing of the nails is caused by a chronic lack of oxygen, such as occurs in heart or pulmonary disease. Paronychia is caused by local infection or trauma. Beaus lines are caused by systemic illness such as severe infection or by injury to the nail. Splinter hemorrhages are caused by minor trauma, subacute bacterial endocarditis, or trichinosis (infection by the roundworm).

PTS: 1 DIF: A REF: 575 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

24. During the physical examination, the client tells the nurse that he has been told he has myopia. The nurse expects to find that the client:

1.

Is nearsighted

2.

Has decreased peripheral vision

3.

Has diminished night vision

4.

Experiences more glare, flashes, and floaters

ANS: 1

Myopia is nearsightedness. Peripheral vision is not reduced with myopia. The client with myopia is able to see close objects, but not distant objects. Peripheral vision may be decreased in open-angle glaucoma. Diminished night vision may occur with cataracts, not myopia. Problems with glare, flashes, and floaters may indicate eye disease and the client should be referred to a physician.

PTS: 1 DIF: A REF: 577 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

25. The school-aged child is taken to the school nurse after experiencing a nosebleed during a softball game. The appropriate intervention is for the nurse to:

1.

Have the child lean backward

2.

Apply pressure to the anterior nose

3.

Apply a warm cloth to the area

4.

Have the child close his mouth and blow his nose

ANS: 2

The nurse should have the child who is experiencing a nosebleed sit up and lean forward to avoid aspiration of blood, apply pressure to the anterior nose with the thumb and forefinger as the child breathes through the mouth, and apply ice or a cold cloth to the bridge of the nose if pressure fails to stop bleeding. The child should not lean backward as this may cause the child to aspirate blood. A cold cloth will slow bleeding and help blood to coagulate, not a warm cloth. The child should breathe through the mouth. Blowing his nose may only continue bleeding as it may disturb any clot formation

PTS: 1 DIF: A REF: 586 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

26. An older adult client is visiting the physicians office for a check-up. The client asks the nurse how often the influenza and pneumonia vaccines should be obtained. The nurse responds to the client that these vaccinations should be done:

1.

Every 6 months

2.

Annually

3.

Every 5 years

4.

Every 7 years

ANS: 2

Older adults should be counseled to receive annual influenza and pneumonia vaccinations. It is not necessary to receive these vaccinations every 6 months. The influenza and pneumonia vaccines should be obtained annually in the older adult because of their greater susceptibility to respiratory tract infection. It is recommended that older adults receive the influenza and pneumonia vaccines annually because they have a greater susceptibility to respiratory tract infection.

PTS: 1 DIF: A REF: Chapter 34, 649

OBJ: Knowledge TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

27. A pregnant client is seen by the nurse in the antenatal clinic. On inspection, the nurse expects that this clients breasts will have:

1.

Softer tissue

2.

Flatter nipples

3.

Darkened areola

4.

Diminished superficial veins

ANS: 3

Normal changes of the breasts during pregnancy include the areola becoming darker and the diameter increasing. Breast tissue becomes softer during menopause, not pregnancy.

Nipples become flatter in older adulthood. Superficial veins become more prominent during pregnancy.

PTS: 1 DIF: A REF: 612 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

28. At a medical clinic, a client with vascular insufficiency is seen frequently. The nurse will give the client additional instruction about her condition if the client:

1.

Walks regularly

2.

Wears knee-length stockings

3.

Elevates the feet when sitting

4.

Alternates periods of sitting and standing

ANS: 2

The client with risk or evidence of vascular insufficiency should not wear tight clothing over the lower body or legs, such as knee-length stockings. Walking regularly is recommended for the client with vascular insufficiency. The client with vascular insufficiency should elevate his or her feet when sitting. The client with vascular insufficiency should avoid sitting or standing for long periods.

PTS: 1 DIF: A REF: 605 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

29. During the physical examination, the nurse should assess the clients glands by using the:

1.

Dorsum of the hand

2.

Pads of the fingers

3.

Palmar surface of the hand

4.

Fingertip grasp of the tissue

ANS: 2

To assess the clients glands, the nurse should use the pads of the fingers and palpate gently. The dorsum of the hand may be used to detect skin temperature, not to assess the clients glands. The palmar surface of the hand is not used to assess the clients glands.

The nurse should not use a fingertip grasp of the tissue when assessing a clients glands.

PTS: 1 DIF: A REF: 589 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

30. The nurse is evaluating the client for conduction deafness in the right ear. In using Webers test, the nurse appropriately places the tuning fork and confirms this type of deafness when:

1.

Sound is not heard in either ear

2.

Sound is heard best by the client in the left ear

3.

Sound is heard best by the client in the right ear

4.

Sound is reduced and heard longer through air conduction

ANS: 3

In conduction deafness, sound is heard best in the impaired ear. Sound that is not heard in either ear is not indicative of conduction deafness. Sound would not be heard best by the client in the left ear if there was conduction deafness in the right ear. This option is describing the Rinnes test, not the Webers test. In conduction deafness, bone-conducted sound can be heard longer. In sensorineural loss, sound is reduced and heard longer through air.

PTS: 1 DIF: A REF: 584 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

31. The presence of arterial insufficiency is suspected during an inspection of the lower extremities when the nurse observes:

1.

Increased hair growth

2.

Cooler skin temperatures

3.

Marked edema

4.

Brown pigmentation

ANS: 2

In the presence of arterial insufficiency, the client has signs resulting from an absence of blood flow, such as pain, pallor, and decreased or absent pulses in the lower extremities. The lower extremities become dusky red when the extremity is lowered. They feel cool to touch because blood flow is blocked to the extremity. Decreased hair growth or the absence of hair growth over the legs may indicate arterial insufficiency. Marked edema is seen in venous insufficiency, not arterial insufficiency. Brown pigmentation around the ankles is seen in venous insufficiency. Skin changes in arterial insufficiency include thin, shiny skin, decreased hair growth, and thickened nails.

PTS: 1 DIF: A REF: 608 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

32. The sounds heard over the trachea during the auscultation of the thorax, are expected to be:

1.

Soft, low-pitched, and breezy

2.

Loud, high-pitched, and hollow

3.

Moist, crackling, and bubbling

4.

High-pitched and musical

ANS: 2

Sounds heard during auscultation over the trachea should be loud, high-pitched and hollow. Soft, low-pitched, and breezy sounds are heard over the lungs periphery.

Moist, crackling, and bubbling sounds are adventitious sounds known as crackles and are caused by sudden reinflation of groups of alveoli and disruptive passage of air. They are most commonly heard in dependent lobes: right and left lung bases. High-pitched and musical sounds are wheezes. Wheezes can be heard over all lung fields.

PTS: 1 DIF: A REF: 596 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

33. The nurse tests the function of the clients cranial nerves during the neurological component of the physical examination. In testing cranial nerve III, the nurse verifies the clients ability to:

1.

Smile and frown

2.

Read printed material

3.

Identify sweet and sour tastes

4.

React to light with changes in pupil size

ANS: 4

In testing cranial nerve III (oculomotor), the nurse determines the clients ability to react to light with changes in pupil size. Testing accommodation will also assess cranial nerve III. In testing cranial nerve VII (facial), the nurse determines the clients ability to smile and frown. In testing cranial nerve II (optic), the nurse determines the clients ability to read printed material. In testing cranial nerve IX (glossopharyngeal), the nurse determines the clients ability to identify sweet and sour tastes.

PTS: 1 DIF: A REF: 634 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

34. Which of the following statements made by a nurse reflects the best understanding of the health value of conducting a blood pressure (BP) screening at a senior citizens centers health fair?

1.

This is a high risk group, so assessing BP allows us to identify clients at risk and send them for treatment.

2.

Older adults enjoy health fairs, so its a good place to screen substantial numbers of clients for hypertension.

3.

Hypertension doesnt present symptoms early on, so screening elder adults is a wonderful preventive measure.

4.

Blood pressure problems are common among this group, so its a good way to monitor the effectiveness of their medications.

ANS: 1

Health screenings focus on a specific physical problem. For example, blood pressure screenings detect the risk for high blood pressure. If this screening determines that a client has a risk for disease, the nurse refers the client for a more complete physical examination. While the other options are not incorrect, they do not show the most thorough understanding of the value of health screenings.

PTS: 1 DIF: C REF: 553 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management

35. Which of the following statements made by the RN preparing to conduct a clients initial health history shows the best understanding of the therapeutic objective of the interview?

1.

Its all about finding out what the problems are and discovering the best way to fix them.

2.

Clients are more comfortable when you take the time to get to know them and their problems.

3.

I use it as an opportunity to show the client that his care is very important to the hospitals staff.

4.

It is the most appropriate way to initiate the therapeutic nature of the nurse-client relationship.

ANS: 1

The main objective of interacting with clients is to find out what their concerns are and to help them find solutions. While the other options are not incorrect, they do not express the primary objective of information gathering directed towards client care.

PTS: 1 DIF: C REF: 553 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management

36. A client reports pain in his left ankle since twisting it yesterday. Which of the following assessment findings best supports the clients claims of ankle pain?

1.

The client grimaces when walking to the examination room.

2.

The clients left ankle is swollen with noted bruising.

3.

The client reports a pain rating of 7 on a scale of 1 to 10.

4.

The clients heart rate increases after walking to the examination room.

ANS: 2

A subsequent physical assessment can reveal information that refutes, confirms, or supplements the history. Think critically about the information the client provides, apply knowledge from previous clinical care, and methodically conduct the examination to create a clear picture of the clients status. The objective signs of swelling and bruising best support the possible spraining of the ankle and the resulting claim of pain. The increase in heart rate is subjective but can be a result of various factors, pain being only one. The remaining options reflect objective data.

PTS: 1 DIF: C REF: 553 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management

37. While bathing an elderly client who has limited abilities for self-care, the nurse notices several patches of dry skin on the clients heels, elbows, and coccyx. The nurse cleans and dries all the areas well and applies a moisturizing lotion. The most appropriate immediate follow-up by the nurse to ensure appropriate nursing care for this clients skin is to:

1.

Revise the clients care plan to show the need for the application of moisturizing lotion

2.

Assume personal responsibility to apply the moisturizing lotion daily to the clients skin

3.

Encourage the client to tell whomever bathes her to apply the moisturizing lotion to her areas of dry skin

4.

Inform the staff that the clients skin is showing signs of breakdown and moisturizing lotion needs to be applied daily

ANS: 1

The nurse revises the written care plan so that other nurses and nursing assistive personnel know the type of skin care to provide. The other options are less likely to convey the information effectively.

PTS: 1 DIF: C REF: 553 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

38. Which of the following statements best reflects an understanding of the most effective means of showing nursing accountability for client care?

1.

I always try to tailor client education to my clients care needs.

2.

A clients care plan is never stagnate; it always needs updating.

3.

Selecting the most appropriate interventions is the key to quality care.

4.

By re-assessing the client regularly, I can tell if the interventions are working.

ANS: 4

Nurses demonstrate accountability for their nursing care through evaluating the results of nursing interventions. Nurses make accurate, detailed, objective measurements through physical assessment. These measurements determine whether the expected outcomes of care are met. The remaining options are correct but not as directly related to nursing accountability for effective client care.

PTS: 1 DIF: C REF: 554 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

39. The nurse encourages the client to relax and take a deep, slow breath in order to prepare for a palpating assessment of the abdomen. The primary reason for this is to:

1.

Encourage the client to be emotionally comfortable and relaxed

2.

Distract the client from the actual possible discomfort the pressure may cause

3.

Facilitate the effectiveness of the palpating technique to detect abdominal masses

4.

Allow the client an opportunity to cope with any bad feelings regarding the examination

ANS: 3

Before palpation, help the client relax and be comfortable because muscle tension during palpation impairs effective assessment. To promote relaxation, have the client take slow, deep breaths and place the arms along the side of the body. While the other options may be reasonable, they are not the primary reason for encouraging the client to relax.

PTS: 1 DIF: C REF: 554 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

40. The nurse is about to palpate the clients abdomen to determine the margins of the liver. The primary reason for using the bimanual palpation method is to:

1.

Minimize client discomfort

2.

Minimize lower hand desensitivity

3.

Assist in manipulation of the organ

4.

Facilitate quick assessment of the abdomen

ANS: 2

When using bimanual palpation, relax one hand (sensing hand) and place it lightly over the clients skin. Use the other hand (active hand) to apply pressure to the sensing hand. The lower hand does not exert pressure directly and thus remains sensitive to detect organ characteristics. This technique does assist in the effective, efficient assessment of the abdomen, but its primary purpose is directed towards hand sensitivity.

PTS: 1 DIF: C REF: 555 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

41. Which of the following statements made by a nursing student regarding assessment technique requires immediate follow-up by the clinical instructor?

1.

I always rub my hands together before touching the client.

2.

I found that both of the clients carotid arteries beat simultaneously.

3.

It will take a lot of practice for me to be master the art of percussion.

4.

I always warm the stethoscopes diaphragm before listening for bowel sounds.

ANS: 2

Do not palpate a vital artery with pressure that obstructs blood flow nor assess both such arteries at the same time since this could result in a dangerous lack of blood flow to the brain. The remaining options are not inaccurate and so do not require immediate follow-up.

PTS: 1 DIF: C REF: 602 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

42. The primary reason for encouraging a client to urinate before beginning a physical examination is:

1.

It avoids stimulation of the bladder during palpation or percussion of the abdomen

2.

It minimizes the possibility of urinary incontinence caused by embarrassment or awkward positioning

3.

A full bladder can hinder the examination of the clients abdominal, genitalia, and rectal areas

4.

Voiding before the examination will encourage the client to relax, thus facilitating the assessment

ANS: 3

An empty bladder and bowel facilitate examination of the abdomen, genitalia, and rectum. The remaining options may be plausible reasons, but they are not the primary one.

PTS: 1 DIF: C REF: 558 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

43. The nurse recognizes that which of the following clients should be thoroughly assessed for their ability to be safely placed in the supine position?

1.

An 18-year-old who suffered a fractured elbow playing football

2.

A 20-year-old hospitalized with abdominal pain to rule out an appendicitis

3.

A 74-year-old client who requires 3 L of continuous oxygen via nasal cannula

4.

A 37-year-old reporting complaints of vaginal bleeding between menstrual periods

ANS: 3

Clients who are experiencing any degree of respiratory distress will not find this position comfortable and should not be placed in this position because it will make breathing even more difficult. If the client becomes short of breath easily, raise the head of the bed. The other clients may not prefer this position, but there is no medical reason for avoiding it.

PTS: 1 DIF: C REF: 558-589 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

44. A male nursing student is assigned to change the abdominal dressing of a 74-year-old female. The clinical nursing instructor asks that a female nurse assist him with the procedure. The primary reason for this decision is:

1.

It diverts the clients attention during the assessment and procedure

2.

It provides a third party to ensure proper conduct of all involved

3.

It facilitates a comfortable, efficient environment for the client

4.

It assists with the wound assessment and changing of the abdominal dressing

ANS: 2

When the client and nurse are of opposite gender, it helps to have a third person of the clients gender in the room. The presence of a third person ensures the client that the examiner will behave ethically. This person is also a witness to the examiners conduct as well as the clients. While a second health care provider may be useful during the assessment and procedure, that is not the primary reason for their presence.

PTS: 1 DIF: C REF: 560 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

45. The shift report states that a client has crackles in both lungs. Which statement by the nurse, preparing to assess the client, best reflects a thorough understanding of the recorded assessment finding?

1.

I wonder if they are fine, medium, or coarse.

2.

Ill listen again and reassess after I ask him to cough.

3.

That musical sound is hard to miss as they breathe out.

4.

I wish it was recorded where in the lungs they were heard.

ANS: 2

Crackles are most common in dependent lobes: right and left lung bases. Fine crackles are high-pitched, fine, short, interrupted crackling sounds heard during the end of inspiration and usually not cleared with coughing; medium crackles are lower, more moist sounds heard during the middle of inspiration and not cleared with coughing; and coarse crackles are loud, bubbly sounds heard during inspiration and not cleared with coughing. Reassessing and asking the client to cough provide the clearest understanding of this type of breath sound. Musical sounds are representative of wheezes, not crackles.

PTS: 1 DIF: C REF: 596 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

46. The most appropriate method to use to assess a carotid artery for the presence of a bruit is to:

1.

Palpate each artery lightly; first the right side and then the left

2.

Have the client turn the head towards the side being auscultated

3.

Place the bell of the stethoscope over the artery near the outer edge of the clavicle

4.

Have the client hold the breath while auscultating with the stethoscope bell

ANS: 3

Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid muscle. Have the client turn the head slightly away from the side being examined. Ask the client to hold the breath for a moment so that breath sounds do not obscure a bruit. Normally you do not hear any sounds during carotid auscultation. Palpate the artery lightly for a thrill (palpable bruit) if you hear a bruit.

PTS: 1 DIF: C REF: 603 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

47. The shift report states that a client has crackles in both lungs. Which statement by the nurse preparing to assess the client best reflects a thorough understanding of the recorded assessment finding?

1.

I wonder if they are fine, medium or coarse.

2.

Ill listen again and reassess after I ask him to cough.

3.

That musical sound is hard to miss as they breathe out.

4.

I wish it was recorded where in the lungs they were heard.

ANS: 2

Crackles are most common in dependent lobes: right and left lung bases, Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during end of inspiration, usually not cleared with coughing. Medium crackles are lower, more moist sounds heard during middle of inspiration; not cleared with coughing and coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing. Reassessing and asking the client to cough provides the clearest understanding of this type of breath sounds. Musical sounds are representative of wheezes not crackles.

PTS: 1 DIF: C REF: 553 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test Plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

48. The most appropriate method to use to assess for a carotid artery for the presence of a bruit is to:

1.

Palpate each artery lightly; first the right side and then the left

2.

Have the client turn the head toward the side being auscultated

3.

Place the bell of the stethoscope over artery near outer edge of the clavicle

4.

Have the client hold the breath while auscultating with the stethoscope bell

ANS: 3

Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid muscle. Have the client turn the head slightly away from the side being examined. Ask the client to hold the breath for a moment so that breath sounds do not obscure a bruit. Normally you do not hear any sounds during carotid auscultation. Palpate the artery lightly for a thrill (palpable bruit) if you hear a bruit.

PTS: 1 DIF: C REF: 553 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test Plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

MULTIPLE RESPONSE

1. The primary outcome for information collected during a nursing physical examination should be to: (Select all that apply.)

1.

Establish the clients baseline of function

2.

Evaluate both nursing and client outcomes

3.

Identify any changes in the clients health status

4.

Provide rationale for client admission or discharge

5.

Identify appropriate nursing diagnoses to determine nursing care

6.

Determine accuracy of information obtained from the client interview

ANS: 1, 2, 3, 5, 6

Providing rationale for client admission or discharge is not an outcome of a nursing physical assessment.

PTS: 1 DIF: C REF: 553 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management

2. During the health history, the client reports back and knee pain. Which of the following interview questions should the nurse ask in order to further define the clients complaints? (Select all that apply.)

1.

When did the pain start?

2.

What, if anything, lessens the pain?

3.

Have you sought help for this pain before?

4.

Can you describe the pain you feel to me?

5.

Is there anything that makes the pain worse?

6.

Has the pain affected your ability to earn a living?

ANS: 1, 2, 4, 5

The health history involves a lengthy client interview to gather subjective data about the clients condition. Gather information about the clients health from the health history. The answers are questions designed to obtain subjective information related to the clients complaints. The remaining options are not of significant value related to the cause and treatment of the clients pain.

PTS: 1 DIF: C OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management

3. The nurse recognizes the importance of an accurate, thorough physical assessment and health history. Which of the following facets of care are directly dependent on the database of information collected? (Select all that apply.)

1.

Identification of client likes and dislikes

2.

Support of the nurse-client relationship

3.

Selection of client-centered interventions

4.

Revision of client care plan as appropriate

5.

Evaluation of nursing and client outcomes

6.

Identification of appropriate nursing diagnosis

ANS: 3, 4, 5, 6

The accuracy of the database allows for the development of an individualized nursing diagnosis. Physical assessment findings determine the etiology of the diagnosis so that the selection of interventions is appropriate for the care plan. Physical assessment is ongoing, and thus the care plan changes with the clients condition. Monitor the clients progress and responses to therapies to review existing diagnoses and identify new problems.

PTS: 1 DIF: C REF: 554 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management

4. Which of the following health history and physical assessment findings place an elderly client admitted for abdominal pain at risk for infection? (Select all that apply.)

1.

Redness at the IV site

2.

Productive yellow cough

3.

Foley catheter placement

4.

History of bipolar disorder

5.

Oral temperature of 98.8 F

6.

Recent radiation for prostate cancer

ANS: 1, 2, 3, 6

Learn to group significant findings into clusters of data that reveal actual or risk for nursing diagnoses. A history of bipolar disorder and an oral temperature of 98.8 F do not indicate the client is at risk for an infection.

PTS: 1 DIF: C REF: 563 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management

5. Which of the following nursing actions best shows an understanding of the guiding principles regarding the inspection method of physical assessment? (Select all that apply.)

1.

Positioning the client so as to expose body parts adequately but with attention to modesty

2.

Providing a general survey of the clients body, area by area and extremity by extremity

3.

Comparing each area inspected with the same area on the opposite side of the clients body

4.

Evaluating each body area for size, shape, color, symmetry, position, and abnormalities

5.

Providing sufficient lighting to ensure adequate visualization of the clients body during the assessment

6.

Conducting the assessment in a time conscious manner to minimize the clients physical and emotional discomfort

ANS: 1, 3, 4, 5

The inspection portion of the assessment is detail-oriented and must be done thoroughly, which may be time-consuming.

PTS: 1 DIF: C REF: 596 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

6. A 76-year-old adult female is brought to a neighborhood client after being found wandering around the local park. The client appears disheveled and reports being hungry. Which of the following assessment and interview findings would cause the nurse to suspect elder abuse? (Select all that apply.)

1.

Keeps asking when she can go

2.

Repeatedly states, Dont hurt me.

3.

Chafing around wrists and ankles

4.

Bruises in various stages of healing

5.

Falls asleep in the examination room

6.

Cant name the President of the United States

ANS: 2, 3, 4

These findings and behaviors are consistent with those exhibited by older adults who have experienced physical and/or emotional abuse. The remaining options are not as directly connected with abuse and may be a result of other physical or cognitive disorders.

PTS: 1 DIF: C REF: 603 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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