True/False: Subjective and objective data are both important parts of an assessment. Subjective data are things the client or his or her family tells the nurse. Show
True A client has presented for care with complaints of persistent lower back pain. When assessing the client's pain, which statement, made by the nurse, would be most appropriate? A. "Did either of your parents have back
pain?" C. "What makes your pain better or worse?" Rationale: The nurse would assess the client's pain pattern by asking what makes a sign or symptom better or worse. A client's level of pain is subjective and the nurse would not question this level. Pain is not hereditary. The nurse would not state what makes their pain better, but rather focus on assessing the client's pain. A client with a 5-day history of constipation describes a sensation of "burning" in the perianal area. This information is considered which part of the assessment data? A. Physical examination C. Subjective data Rationale: The client is describing a problem from their own perspective; therefore, this data is considered subjective. The objective data set comprises the client signs, or what the nurse observes in the assessment. The health history and physical exam are also part of the objective data set. Considering the acronym OLDCART, the nurse is asking a newly admitted client questions during the assessment process. The client is a 35-year-old man who presents with pain in the upper arm since lifting weights 3 days ago. What question would be appropriate to ask that would give information for the "D" in the acronym? A. "Can you point to where the pain is located?" D. "Does the pain come and go or is it constant?" Rationale: The "D" in OLDCART represents the duration of the symptom. Asking if the pain comes and goes provides an answer to that question. The nurse recognizes the following to be a necessary component of performing an accurate assessment. (Select all that apply.) A. Collection and organization of data A. Collection and organization of data Rationale: Before beginning to analyze data, the nurse must make sure the assessment is accurately performed, which includes collection and organization, validation and documentation of the data. The nurse does not want to include any inaccurate or incomplete data — doing so will lead to a faulty assessment. A client reports chest pain that occurs with exercise but subsides with rest. The nurse recognizes this as what type of data? A.
Reflective C. Subjective Rationale: Subjective data includes the following: sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values and personal information collected from the client. This information can be elicited and verified only by the client. Introspection and reflection are not types of data collection but ways in which a nurse can assist a client to work toward changing behaviors. Objective data are obtained by the nurse through observation using the four physical assessment techniques. A nurse is interviewing a client who has recently been diagnosed with terminal disease. In covering the lifestyle and health practices profile, the nurse asks the client, "Are you close to any extended family members in the area?" The client objects to the question and asks why the nurse needs to know that. Which is the best rationale for the nurse posing this question? A. "I just wanted to see what kind of social support you might have to help care for you during your illness." A. "I just wanted to see what kind of social support you might have to help care for you during your illness." Rationale: Ask clients to describe the composition of the family into which they were born and about past and current relationships with these family members. In this way, you can assess problems and potential support from them client's family or origin. Just being friendly and determining what acquaintances the nurse might have in common with the client are not proper rationales for asking this personal information. Mentioning plans for the client's funeral is blunt and would likely upset the client. During the introduction phase of the interview, the client begins to talk nonstop about health problems, family issues and fears related to illness. What can the nurse do to control the interview process? A. Tap the pen on the paper while the client talks B. Courteously interrupt the client to clarify some information Rationale: The nurse should only interrupt the client when necessary in a courteous manner. The purpose of the interruption should be to clarify some information that the client provided while talking. Glancing at the clock on the wall and tapping the pen on the paper are signs of impatience and should not be done when working with a talkative client. Contacting security is not necessary when interviewing a talkative client. The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment? A. In a circle D. Head to toe Rationale: Reviewing the body systems from head to toe is one way to ensure that all areas are included. Following a circle, right to left or alphabetical are not identified as patterns to complete the review of systems. When caring for a client, what aspect is important in conducting a conversation? A. Keep the conversation at the knowledge level of the client A. Keep the conversation at the knowledge level of the client Rationale: It is important to conduct a conversation at the knowledge level of the client. Medical terminology is used only if the client is already familiar with the terms. Discussing the least important topics first is not correct. Important or time sensitive topics should be prioritized and discussed first. The client's permission should always be asked before carrying out a conversation with family present. A client comes to the Emergency Department with bruises on her upper and lower body and appears to be withdrawn. The injuries do not appear consistent with the explanations for them. The client's boyfriend refuses to leave the examination room and is overly protective of her. The nurse suspects: A. Anorexia nervosa C. Human violence Rationale: The indications should raise the nurse's suspicions of abuse of the client by the boyfriend. Commonly, abusers are overly protective in the presence of others and will not leave the examination room. Hypertension, inability to perform ADLs and the eating disorder anorexia nervosa are not indicated in this scenario of bruising and withdrawal. The nurse is asking the client about the health of her parents, siblings and grandparents. This is part of the health history and is done for what reason? A. To get to know the client better C. To identify diseases for which the client may be at risk Rationale: Family history is taken to identify those diseases for which the client may be at risk. Getting to know the client and establishing rapport are important but that is not why the family history is taken. Taking family history does not help to assess the client's quality of life. A nurse is interviewing a client complaining of abdominal pain for the last 2 weeks. Why is a history of the present illness vital to treating this client? A. It is only important to know when it started
and the level of pain on a scale of 0-10 C. A complete description of the present illness is essential to an accurate diagnosis Rationale: The nurse collects information about the present illness by beginning with open-ended questions and have the client explain symptoms. A complete description of the present illness is essential to an accurate diagnosis. Nurses do not diagnose the problem for which the client is seeking medical help; even if knowing where the pain is, it is necessary for a nurse to take a complete health history. It is important to know not only where the pain started but also the quality and intensity of the pain as well as what aggravates or alleviates the pain. The student nurse is studying therapeutic communication and realizes that it is an important aspect of collecting a health history. When gathering information about the client's current illness, the student nurse understands that she should use which technique? A. Asking yes and no questions
B. Asking open-ended questions Rationale: The nurse should use the therapeutic technique of asking open-ended questions to allow the client to verbalize. Yes and no questions may not elicit a proper response or allow the client to give comprehensive information. Showing disapproval and avoiding eye contact are examples of nontherapeutic techniques. The nurse observes a client crying while staring out the window. What should the nurse do first? A. Leave the client alone D. Assess the reason for the client's emotions Rationale: The nurse needs to further assess the client to determine the reason for the sadness and crying. The client may be experiencing a physical problem that is causing moral or spiritual distress. Leaving the client alone is not appropriate since this does not provide support to the client when it is obviously needed. Suggesting that the client "cheer up" is inappropriate since the reason for the client's display of emotion is unknown. Completing a pain assessment assumes that crying is because the client is experiencing pain. A nurse is preparing to conduct an initial interview on a client from a different culture. Which of the following is important for the nurse to consider before beginning the interview? A. Specific talents of the client D. Verbal and nonverbal communication Rationale: When getting ready to conduct an initial interview with a client from a different culture, many different things must be considered. All communication is culturally based, and verbal communication can have many variables based on both language differences and usual tone of voice. Nonverbal communication is most frequently misinterpreted. Workforce issues are important but do not have to be considered in the initial interview. The client's economic status and specific talents also are good factors to consider but are not necessary information to obtain in the initial interview. A nurse is preparing to perform a physical examination on a young man who appears anxious about the procedure. Which of the following should the nurse do to ease this client's anxiety? A. Have him urinate before the examination D. Before performing each procedure, explain what it involves and its purpose Rationale: Explaining what you are doing and why helps to ease your client's anxiety. If a urine sample is not necessary, ask the client to urinate before the examination to promote an easier and more comfortable examination of the abdominal and genital areas, although it will not likely ease the client's anxiety. Begin the examination with the less intrusive procedures such as measuring the client's vital signs, height and weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with you and help to ease client anxiety about the examination. Having the client undress and put on an examination gown, although required, is not likely to ease his anxiety. The nurse places the back of the hand on the forehead of a client. What is the nurse assessing when using this part of the hand? A. Temperature A. Temperature Rationale: The dorsal or back surface of the hand is used to assess temperature. The pads of the fingers are used to assess pulses and texture. The ulnar or palmar surface of the hand is used to assess vibration. Which action by a nurse is appropriate before beginning a physical examination of a client? A. Approach the client from the left side of the examination table C. Wash hands before examination in the examination room Rationale: The nurse should wash hands before examination room in front of the client to ensure the client that his or her safety is first priority. To avoid injury, the nurse should not recap used needles, and all disposable needles and blades should be placed in puncture-resistant containers. The nurse should always approach the client from the right-hand side of the examination table, not the left-hand side, because most examination techniques are performed with the examiner's right hand. The nurse should change gloves if they become soiled at any time during the examination and apply new pair of clean or sterile gloves. A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from post-anesthetic recovery. The nurse should plan to perform which technique first? A. Auscultation C. Inspection Rationale: Inspection is always done first before palpation, percussion and auscultation because the latter techniques can potentially alter the appearance of what is being inspected. After completing the physical examination of a client who is 12 weeks pregnant, a new nurse leaves the room only to realize she forgot to complete an examination of the skin. What should the nurse do? A. Go back in to complete a physical examination of the skin A. Go back in to complete a physical examination of the skin Rationale: It is common to forget part of the physical examination, especially at first. It is not unusual to go back to the client and ask to check one or two items that have been overlooked. Omitting this part of the physical examination could lead to missing important clinical data for planning client care. Reviewing the documented client history will not provide objective information about the current status of the client's skin. Asking a colleague who saw the client earlier is not an accurate way to collect information for a physical examination of the skin. The new nurse should not rely on the memory of her colleague alone for this information. What tool does the nurse use to auscultate the client's abdomen? A. None D. Stethoscope Rationale: The nurse uses a stethoscope to perform auscultation, in which movements of air or fluid are heard in the body over the lungs and abdomen. A fetoscope is used to hear the fetal heartbeat. An otoscope is used to view portions of the ear. A nurse needs to position a client in the supine position for the physical examination. The nurse should ask the client to: A. Lie down, with knees bent, legs separated, and feet flat on the table C. Lie on the back with the legs together on the examining table Rationale: The nurse should assist the client to a supine position by instructing him or her to lie down with legs together on the examining table. To get the client into the dorsal recumbent position, the nurse instructs the client to lie down, with knees bent, legs separated and feet flat on the table. In the prone position, the lies down on his abdomen with head to the side. In the knee-chest position, the client kneels on the table with the weight of the body supported by the chest and the knees. The nurse is assessing a client's pain. Which of the following would lead the nurse to suspect that the client is experiencing pain? A. Regular, unlabored breathing D. Facial grimacing, leaning forward Rationale: Facial expressions such as grimacing, and body positions such as leaning forward, suggest pain. Regular unlabored breathing, sitting upright with hands on the lap and an alert talkative demeanor suggest that he client is comfortable and relaxed. A nurse takes a client's vital signs. Which of the following is considered a vital sign? A. Visual acuity C. Blood pressure Rationale: Vital signs are a person's temperature, pulse, respiration and blood pressure. Mental status, visual acuity and urinary output are not considered vital signs, even though they are frequently assessed. A nurse is assessing the blood pressure of a client who has come to the healthcare facility for the first time. Which of the following is the best site for obtaining the client's blood pressure reading? A. Arm A. Arm Rationale: The first time the blood pressure is measured, its is assessed in each arm. The two blood pressure measurements should not vary more than 5 to 10 mm Hg unless pathology (disease) is present. The blood pressure is not measured in shoulders, wrist or thighs of clients for the first time. Nurses use the thighs to assess the blood pressure when they cannot obtain readings in either of the client's arms. Which of the following would the nurse use as the primary assessment for a client's pain? A. The client's spiritual view of pain B. The client's report of pain Rationale: Pain is a subjective phenomenon, and thus the main assessment lies in the client's reporting of the pain. The client's spiritual views, current therapies used and psychosocial questions about the client's perception may provide additional information about the pain. However, the client's pain is whatever the person says it is. Acute pain can be differentiated from chronic pain because... A. Acute pain is not treated and left to subside on its own, whereas chronic pain is
referred for treatment B. Acute pain is associated with a recent onset of illness or injury with a duration of less than 6 months, whereas chronic pain persists longer than 6 months Rationale: Acute pain is usually associated with a recent injury or illness and lasts less than 6 months. A client reports pain and rates it as a 9 on a scale of 0 to 10. The nurse administers pain medication as ordered and returns 20 minutes later to assess the severity of the client's pain. To assess the severity, the nurse would: A. Ask about the
location of the pain B. Ask the client to rate the pain on a scale of 0 to 10 Rationale: When assessing a client's pain, the nurse should ask about location, duration, intensity, quality, alleviating/aggravating factors, management goal and functional goal. To assess severity or intensity, the nurse should ask the client to rate the pain on a scale of 0 to 10 or 1 to 10. A nurse assesses the radial pulse of a client. Which pulse rate would the nurse document as bradycardia? A. 94 beats/minute B. 56 beats/minute Rationale: Bradycardia is a rate less than 60 beats/minute. Rates of 64, 88 and 94 would be considered within the normal range of pulse rates. A nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, "Do you spend long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question? A. To determine the client's risk for dehydration C. To determine the client's risk for pressure ulcers Rationale: Older, disabled or immobile clients who spend long periods of time in one position are at risk for pressure ulcers. Spending long periods of time sitting or lying in one position is not associated with increased risk for skin cancer, dehydration or herpes zoster. The nurse performs the action of pinching the skin on the client's chest and pulling it straight up during the assessment of a client. What is the nurse assessing? A. Carotid pulse C. Skin turgor Rationale: Turgor refers to the skin's elasticity and how quickly the skin returns to its original shape after being pinched. Pinching the skin is not performed when assessing the carotid pulse, lymph nodes or intercostal spaces. A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response? A. Abnormalities may be a sign of poor hygiene C. Nail problems can be caused by an underlying systemic illness Rationale: Diseases or disorders of the nails can be a local problem or they may be a sign of an underlying systemic disease that needs to be assessed. A nurse should be sensitive when interviewing a client with nail problems because they can be damaging to a person's self-image. A nurse should ask questions in a nonjudgmental manner if the client has abnormalities of the nails that are due to poor hygiene. Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents? A. Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens A. Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens Rationale: Among kids and teens, concussions in sports and motor vehicle accidents account for the largest number of TBIs. It is not surprising that males are more likely to sustain a TBI than females due to more risk-taking behaviors and contact sports or hazardous occupations. Firearm incidents are not listed as a significant cause of TBIs. For older adults, falls and maltreatment account for most TBIs. When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination? A. To prevent further dehydration
D. To observe the movement of the thyroid gland Rationale: Although providing the client with water may help the client feel more at ease during the assessment and promote development of the nurse-client relationship, the significance of bringing a cup of water into the assessment is to help observe the movement of the gland. As the client swallows, the nurse can visualize upward movement, contours and symmetry of the thyroid. Dehydration can be a feature of hypothyroidism; however, the nurse is conducting the assessment, not providing supportive management or treatment. Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels? A. Veins C. Lymphatic Rationale: Lymphatic vessels filter potential pathogens from the body. They also drain the fluid that has moved outside of the circulation back into the vessels. Arteries carry oxygenated blood from the heart to the body. Veins carry unoxygenated blood from the body to the lungs. Aortic is an adjective for aorta, which is the large vessel carrying oxygenated blood away from the heart. A client is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The client also has a history of vomiting with the headache. What type of headache could these findings indicate? A. Benign C. Migraine Rationale: A throbbing, severe, unilateral headache that lasts 6 to 24 hours and is associated with photophobia, nausea and vomiting suggests migraine. The scenario does not indicate tension, cluster or benign headaches. The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling? A. Deep scar B. Lymph node Rationale: A useful way to discern lymph nodes from other masses in the neck is to check for their mobility in all directions. Many other masses are mobile in only two directions. Cancerous masses may also be fixed or immobile. The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to: A. Sit in an upright position A. Sit in an upright position Rationale: Have the client remain seated upright. Then palpate the lymph nodes with your finger pads in a slow walking, gentle, circular motion. When using the PERRLA acronym, the nurse is assessing which body part(s)? A. Ears D. Eyes Rationale: PERRLA stands for pupils equal, round and reactive to light and accommodation. A client is concerned because the sclera of the right eye has been pink in color for several days and tearing. What should the nurse suspect is occurring with this client? A. Exophthalmos D. Conjunctivitis Rationale: Pink-colored sclera with tearing is associated with conjunctivitis which can be caused by allergies, or bacterial or viral infections. Hyphema is blood in the anterior chamber of the eye which is usually caused by blunt trauma. Anisocoria is a term used to describe pupils of unequal size. Exophthalmos is protrusion of the eye ball usually caused by a problem with the thyroid gland. True/False: The nurse tests the six cardinal directions to test extraocular movement of the eye. True A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? A. Client did not wear his glasses for this test and therefore it is not
accurate B. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet Rationale: The Shelley chart tests distant visual acuity by seeing how far the client can read the letters standing 20 feet from the chart. The top number is how far the client is from the chart and the bottom number refers to the last line the client can read. A reading of 20/50 means the client sees at 20 feet what a person with normal vision can see at 50 feet. The minus number is the number of letters missed on the last line the client can distinguish. A 30-year-old client arrives at the community healthcare center complaining of dizziness and a feeling of the room spinning. Based on the client's symptoms, which condition best describes what the client is most likely experiencing? A. Presbycusis C. Vertigo Rationale: The feeling of dizziness and the room spinning that is experienced by the client is vertigo. The client is not experiencing an inner ear infection, or presbycusis, the degenerative loss in hearing, which often begins at about 60 years of age. The feeling of dizziness and the feeling of the room spinning are not the symptoms of presbycusis, an inner ear infection, or tinnitus. The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to: A. Use a speculum that measures 10 mm in diameter B. Firmly pull the auricle out, up and back Rationale: Use the thumb and fingers of your opposite hand to grasp the client's auricle firmly but gently. Pull out, up and back to straighten the external auditory canal. Do not alter this positioning at any time during the otoscope examination. A nurse is examining a client's nose. Which characteristics of the nasal mucosa should the nurse expect to find if the client is healthy? A. Red, swollen, with purulent discharge B. Dark pink, moist, and free of discharge Rationale: Dark pink, moist nasal mucosa which is free of exudate is a normal finding. The nurse should find red, swollen nasal mucosa with purulent discharge in the client diagnosed with upper respiratory tract infection. Pale pink, swollen nasal mucosa with watery exudate and bluish-gray, swollen nasal mucosa with watery exudate is found in cases of allergy. A client is brought to the ED in a confused state. Upon examination of the client's mouth, the nurse detects a fruity odor to the breath. The nurse recognizes this finding as a characteristic of what disease process? A.
Diabetic ketoacidosis A. Diabetic ketoacidosis Rationale: The nurse should suspect the client to having diabetic ketoacidosis on the basis of the fruity smell of his breath. Clients with end-stage liver disease have a sulfur odor in their breath. Clients with small-bowel obstructions have a fecal smell, and clients with respiratory infection have foul odors in their breath. A nurse is interviewing a client whose chief complaint is temporomandibular joint pain. Which of the following questions should the nurse ask regarding a causative factor? A. "Do you grind your teeth?" A. "Do you grind your teeth?" Rationale: Grinding the teeth (bruxism) may be a sign of stress or of slight malocclusion. The practice may also precipitate temporomandibular joint (TMJ) problems and pain. The other answers are not causative factors associated with TMJ pain. The nurse performs an assessment by gently pressing up under the brow bone with each thumb on both sides of the nose. What is the nurse assessing in this client? A. Nasal septum B. Frontal sinus Rationale: The frontal sinuses are located above the eyebrow bone. A speculum is required to assess the nasal cavity and septum. The maxillary sinuses are located just below the cheekbones. Which characteristic of the gums should a nurse expect to assess in a client who is healthy? A. Enlarged, reddened D. Pink, moist, firm Rationale: Pink, moist, firm gums are normal findings of the gums. The nurse may find enlarged, reddened gums as an adverse effect of the phenytoin treatment. Red, swollen, bleeding gums are seen in gingivitis, scurvy and leukemia. A grey-white line along the gum line is seen in cases of lead poisoning. The nurse applies the pulse oximeter to the client's finger. What measurement is appropriate for this device? A. Hemoglobin level 13.9 mg/dL C. Oxygen saturation 97% on room air Rationale: Pulse oximetry measures the arterial oxygenation saturation, or SpO2. A probe is placed on the client's finger or earlobe. The toe is used for infants and young children. This device does not measure hemoglobin level, white blood cell count or blood glucose level. The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states, "It shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker." The nurse should recognize the need to teach the client about what topic? A. Genetic causes of lung cancer C. Health risks of secondhand smoke Rationale: Second-hand smoke puts clients at risk for COPD (including emphysema and chronic bronchitis) or lung cancer later in life. The relationship between genetics and lung disease is not a high priority, and the husband himself must be motivated for smoking cessation. Age-related respiratory changes are not likely to be a priority in this woman's respiratory health. What characteristic nail color should the nurse recognize as an indication of hypoxia? A. Greenish B. Cyanotic Rationale: Pale or cyanotic nails indicate hypoxia. A normal healthy client would have pink tones in their nail beds. Yellowish nails are observed in clients with hepatitis. Greenish nails are indicative of localized fungal infection. Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting the body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder? A. Heart failure D. Chronic obstructive pulmonary disease Rationale: The client is assuming the tripod position which is often seen in COPD. A client with heart failure would most likely assume an orthopneic position to ease any breathing difficulties. The tripod position is usually not associated with diabetes or systemic lupus. True/False: When assessing a client with asthma, the nurse would expect to hear wheezing. True Rationale: Wheezing indicates narrowing of the airways due to spas or obstruction. Wheezing is associated with CHF, asthma (reactive airway disease) or excessive secretions. What is the most important lifestyle changes a client can make to improve cardiovascular health? A. Quitting smoking A. Quitting smoking Rationale: Nurses work with clients over time to modify lifestyle choices that reflect healthy behaviors. The most important are stopping smoking, reducing high blood pressure and reducing high cholesterol. 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. How would the students identify this layer? A. Epicardium
B. Myocardium Rationale: The myocardium is the thickest layer of the heart and is made up of contractile cardiac muscle cells. The epicardium is the serous membrane that covers the outer surface of the heart; the endocardium is a thin layer of endothelial tissue that forms the innermost layer of the heart. The pericardium is a tough non-dispensable loose-fitting fibroserous sac that attaches to the greatest vessels and thereby surrounds the heart. Which of the following would the nurse suspect when a client with a cardiac condition complains of not sleeping well and having to get up frequently at night to urinate? A. The client most likely sleeps without a pillow at night B. Increased urination at rest may indicate heart failure Rationale: With heart failure, increased renal perfusion during periods of rest or recumbency may cause nocturia. Nocturia does not indicate that the heart is working efficiently. Depending on the client's fatigue level from not sleeping well, as well as other complaints, the client's ability to perform activities of daily living may be affected. If the client is experiencing dyspnea at night, he or she will likely be sleeping on more than one pillow at night. The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location? A. Third intercostal space, left axillary line D. Fifth intercostal space, left midclavicular line Rationale: The apical impulse is palpated at the fourth or fifth intercostal space at the midclavicular line. Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what? A. Gastrointestinal D. Angina Rationale: Angina is temporary heart pain, resolving in less than 20 minutes. It can be aggravated by physical activity and stress, or there may be no triggers (unstable angina). This type of pain is not musculoskeletal, gastrointestinal or crushing. A client with peripheral vascular disease is discharged from the health care facility. Which risk-reduction teaching tip should the nurse discuss during discharge teaching? A. Limit physical activity C. Avoid smoking Rationale: The nurse should encourage the client to stop smoking, because it causes vasoconstriction (also contributes to further plaque formation), which increases the complications brought about by peripheral vascular disease. The nurse should ask the client to increase, not decrease, dietary fiber intake, and to eat a low-fat diet, not a low-protein diet. The nurse should ask the client to get regular exercise and maintain a moderate level of physical activity rather than avoid physical activity. Regular exercise improves peripheral vascular circulation and decreases stress, pulse rate and blood pressure, thereby decreasing the risk for developing peripheral vascular disease. Which of the following arteries can be palpated below the inguinal ligament between the anterior superior iliac spine and the symphysis pubis? A. Dorsalis pedis artery B. Femoral artery Rationale: The femoral artery may be felt in the given location, while the popliteal and dorsalis pedis arteries are both distal to this point. The ulnar artery is located in the arm. A nurse asks a supine client to raise his knee partially. The nurse then places the thumbs on the knee while positioning the fingers deep in the bend of the knee. The nurse is palpating the pulse of which artery? A. Femoral C. Popliteal Rationale: The femoral artery is the major supplier of blood to the legs. Its pulse can be palpated just under the inguinal ligament. This artery travels down the front of the thigh then crosses to the back of the thigh, where it is termed the popliteal artery. The popliteal pulse can be palpated behind the knee. The popliteal artery divides below the knee into anterior and posterior branches. The anterior branch descends down the top of the foot, where it becomes the dorsalis pedis artery. Its pulse can be palpated on the great toe side of the top of the foot. The posterior branch is called the posterior tibial artery. A student in the vascular surgery clinic is asked to perform a physical examination on a client with known peripheral vascular disease in the legs. Which of the following aspects are most important to note? A. Lower extremity strength B. Size, symmetry and skin color Rationale: Size, symmetry and skin color are important aspects to note in physical examination. Swelling in the legs, cyanosis and lack of appropriate hair growth are all signs of peripheral vascular disease. A 27-year-old woman comes to the emergency department reporting severe right lower quadrant pain. Her temperature is 101.5°F (38.6°C), BP 122/80 mm Hg, pulse 95 beats/min, and respirations 22 breaths/min. What might the nurse suspect the client has? A. Chronic gallbladder disease C. Acute appendicitis Rationale: In classic appendicitis, the client reports pain beginning at the umbilicus and moving to the RLQ. If you ask the client to cough, he or she reports pain in the RLQ. The client has local tenderness on palpation in the RLQ, at the McBurney point. A rectal examination, or in women, a pelvic examination, will reveal local tenderness, especially if the appendix is retrocecal. After teaching a group of students about the important organs to be assessed during an abdominal assessment, the instructor determines that the teaching was successful when the students identify which organ as the largest solid organ in the body? A. Kidney C. Liver Rationale: The liver is the largest solid organ in the body. While conducting the physical examination, which of the following assessments would require the nurse to auscultate the abdomen? A. To identify bowel sounds A. To identify bowel sounds Rationale: Auscultation is used to identify bowel sounds when conducting the physical examination of the gastrointestinal system. Deep palpation is used to identify the edges of the liver, kidney and other abdominal masses. Light palpation is applied to identify abdominal tenderness along with muscular resistance and some superficial organs and masses. Percussion is used to identify the amount and distribution of gas in the abdomen. As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? A. Right upper quadrant A. Right upper quadrant Rationale: The liver is the largest solid organ in the body. It is located below the diaphragm in the right upper quadrant of the abdomen. A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says: A. "I should discontinue the iron tablets and eat foods that are high in iron." C. "I can decrease the constipation if I eat foods high in fiber and drink water." Rationale: High iron intake may lead to chronic constipation. The client presents to the nurse stating that his jaws feel "stuck". What joint should the nurse assess? A. Subtalar D. Temporomandibular Rationale: The temporomandibular is where the mandible and temporal joint articulate. The sternoclavicular is at the junction of the manubrium and clavicle. The radioulnar is at the radius and ulna. The subtalar is in the foot. A client complains of temporomandibular joint (TMJ) pain. What would the nurse most likely assess? A. Recent weight gain D. Difficulty chewing Rationale: A client with temporomandibular joint problems may describe the jaw "getting locked" or difficulty chewing. Jaw tenderness, pain or clicking sound may be present with range of motion. Knife-like pain, history of fracture and recent weight gain are not associated with TMJ pain. Loss of bone density that occurs with greatest frequency in postmenopausal women is called? A. Kyphosis B. Osteoporosis Rationale: Loss of bone density is termed osteoporosis. Some osteoporosis occurs in all people, but it is most evident in women with small bone frames. Women experience rapid loss of bone density for the first 5 to 7 years after menopause. Lordosis, kyphosis and scoliosis are conditions that affect the spinal alignment. When preparing an education session for a group of women who have been identified as postmenopausal, the nurse should include which teaching point? A. Drink two or three glasses of red
wine per day D. Increase intake of vitamin D and calcium Rationale: Dietary intake of vitamin D and calcium promotes bone strength by increasing bone mineralization and density. Muscle strengthening exercise is encourages as it appears to maintain and possibly increase bone mass. Although moderate alcohol consumption can be beneficial in the postmenopausal years, taking more than one to two alcoholic drinks per day can promote bone loss. If a client is required to take a proton pump inhibitor, the client should not be told to take it for bone health. Instead, the client should be advised to take a calcium citrate supplement to support normal acid production leading to decreased bone loss in association with this medication. The nurse is using a goniometer while conducting the physical examination of a client's musculoskeletal status. What will the nurse use this device to measure? A. Length of extremities D. Degree of joint motion Rationale: The goniometer is used to measure the degrees of join motion. A tape measure is used to measure extremity length. No device is used to measure the ease of ambulatory. Skinfold caliper is used to measure the amount of subcutaneous tissue. A 50-year-old man has sought care because of the intense shoulder pain that resulted when he threw a baseball to home plate from the outfield the previous evening. The client states that he has never had problems with his shoulder previously. The nurse has asked the client to slowly abduct his affected arm to shoulder level and maintain the position. Which of the following shoulder problems does the nurse suspect? A. Bicipital tendinitis D. Rotator cuff tear Rationale: A rotator cuff tear is often the result of a strong, single throwing motion and is assessed for using the drop arm test. Calcific tendinitis, adhesive capsulitis and bicipital tendinitis are degenerative diseases that typically have a more gradual onset.
The nurse is assessing a client's gait. Which finding would alert the nurse to the need for a referral for further evaluation? A. Arms swinging in opposition D. Shuffling of feet Rationale: Shuffling of the feet suggest a problem that would most likely require a referral for further evaluation. Evenly distributed weight, ability to stand on heels and toes and arms swinging in opposition are considered normal findings. What is the rationale for asking the client whether he or she has noticed any new or changed moles?What is the rationale for asking the client whether he or she has noticed any new or changed moles? Changes in existing moles or the appearance of new moles can indicate melanoma.
What are you testing when you ask the patient to follow your finger or pencil as you move it in toward the bridge of the nose?Testing for the accommodation reflex follows nicely on from eye movements. Ask the patient to keep focusing on the tip of your index finger and slowly move it towards them, aiming for the tip of their nose.
Which nose assessment findings should be considered abnormal?Abnormal findings might be documented as: “Bright red nasal mucosa with purulent discharge.”. Inspect the external surface of the nose for colour. ... . Inspect the contour and external surface of the nose for symmetry, swelling, and malformations such as masses and lesions.. Which action by the student nurse performing a cardiovascular assessment requires correction?Which action by the student nurse performing a cardiovascular assessment requires correction? Assessing the heart sounds by first using the bell of the stethoscope.
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The nurse observes a client crying while staring out the window. what should the nurse do first?
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