Chapter 28 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 28

Question 1

Type: MCMA

The nurse is preparing to perform an interview to obtain information about the client. Which of the following are classified as secondary sources of information?

Standard Text: Select all that apply.

1. The clients wife

2. The clients medical record from his last hospital admission

3. The client

4. The clients daughter

5. The clients physical therapist

Correct Answer: 1,2,4,5

Rationale 1: The clients wife: The clients wife is an example of a secondary source of information.

Rationale 2: The clients medical record from his last hospital admission: The clients medical record is an example of a secondary source of information.

Rationale 3: The client: The client is the primary source of information.

Rationale 4: The clients daughter: The clients daughter is an example of a secondary source of information.

Rationale 5: The clients physical therapist: The clients physical therapist is another member of the clients health team and is a secondary source of information.

Global Rationale: The clients wife is an example of a secondary source of information. The clients medical record is an example of a secondary source of information. The clients daughter is an example of a secondary source of information. The clients physical therapist is another member of the clients health team and is a secondary source of information. The client is the primary source of information.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.1: Use professional communication skills to gather subjective data in a health history.

Question 2

Type: MCMA

The nurse is interviewing the client. Which of the following may lead to communication breakdown between the nurse and client?

Standard Text: Select all that apply.

1. The client is a Native American and the nurse is of Northern European descent.

2. During the interview, the nurse is trying to remember what the healthcare provider asked her to do earlier in the day.

3. The young nurse creates an informal atmosphere to discuss safe sexual practices with a teenaged client.

4. The young nurse uses a serious and respectful tone to discuss erectile dysfunction with an older client.

5. The nurse states, So, you experience pain with micturation.

Correct Answer: 1,2,5

Rationale 1: The client is a Native American and the nurse is of Northern European descent. Communication has an increased chance of breaking down when the nurse and the client are from different cultures. Some Native Americans believe that direct eye contact is an invasion of privacy and a firm handshake can be an aggressive action. A person of Northern European descent may feel that a person who avoids direct eye contact is untrustworthy and a weak handshake indicates the client has a weak demeanor.

Rationale 2: During the interview, the nurse is trying to remember what the healthcare provider asked her to do earlier in the day. Communication can break down when the nurse fails to decode the messages by not actively listening to the client.

Rationale 3: The young nurse creates an informal atmosphere to discuss safe sexual practices with a teenaged client. It is appropriate for the nurse to create an informal atmosphere when discussing a sensitive topic with a younger client.

Rationale 4: The young nurse uses a serious and respectful tone to discuss erectile dysfunction with an older client. It is appropriate for the young nurse to use a serious and respectful when discussing a sensitive topic with an older client.

Rationale 5: The nurse states, So, you experience pain with micturation. Communication can break down easily when nurses use words that clients do not understand. The nurse should avoid medical jargon.

Global Rationale: Communication has an increased chance of breaking down when the nurse and the client are from different cultures. Some Native Americans believe that direct eye contact is an invasion of privacy and a firm handshake can be an aggressive action. A person of Northern European descent may feel that a person who avoids direct eye contact is untrustworthy and a weak handshake indicates the client has a weak demeanor. Communication can break down when the nurse fails to decode the messages by not actively listening to the client. Communication can break down easily when nurses use words that clients do not understand. The nurse should avoid medical jargon. It is appropriate for the nurse to create an informal atmosphere when discussing a sensitive topic with a younger client. It is appropriate for the young nurse to use a serious and respectful when discussing a sensitive topic with an older client.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28.1: Use professional communication skills to gather subjective data in a health history.

Question 3

Type: FIB

The client weighs 224 pounds. How many kilograms does the client weigh? Round to the nearest tenth.
_____ kilograms

Standard Text:

Correct Answer: 101.8 kilograms

Rationale: There are 2.2 pounds in 1 kilogram. The client weighs 224 pounds. The nurse can divide the clients weight in pounds by 2.2 and determine that the client weighs 101.8181 kilograms. When rounded to the nearest tenth, the client weighs 101.8 kilograms.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 4

Type: FIB

The client weighs 145 kilograms. The client is 1.75 meters. What is this clients body mass index (BMI) using the following formula: BMI = weight (kg)/height2 (meters)? Round to the nearest whole number. ____

Standard Text:

Correct Answer: 47

Rationale: Body mass index (BMI) is widely used to assess appropriate weight for height using the following formula: BMI = weight (kg)/ height2 (meters). 145 divided by 1.752 = 47.3469. When rounded to the nearest whole number, the clients BMI is 47. 

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 5

Type: MCSA

The nurse is interviewing the client and learns that the client has an open leg wound that has been draining a moderate amount of yellowish drainage over the last 3 days. Prior to assessing the clients wound, which of the following pieces of personal protective equipment is most important for the nurse to wear based on the principles of standard precautions?

1. Fluid-resistant gown

2. Shoe covers

3. Mask

4. Gloves

Correct Answer: 4

Rationale 1: A fluid-resistant gown should be worn if the clients leg drainage cannot be contained adequately and the drainage has the potential to contaminate the nurses clothing.

Rationale 2: Shoe covers are important to wear if the clients drainage cannot be contained adequately and has the potential to contaminate the nurses shoes. Along with the shoe covers, the nurse should also wear a fluid-resistant gown and gloves if the drainage cannot be contained.

Rationale 3: A mask should be worn if the client has a productive cough.

Rationale 4: The nurse should always follow standard precautions while assessing the client. The most important personal protective equipment for the nurse to wear is a pair of gloves.

Global Rationale: The nurse should always follow standard precautions while assessing the client. The most important personal protective equipment for the nurse to wear is a pair of gloves. A fluid-resistant gown should be worn if the clients leg drainage cannot be contained adequately and the drainage has the potential to contaminate the nurses clothing. Shoe covers are important to wear if the clients drainage cannot be contained adequately and has the potential to contaminate the nurses shoes. Along with the shoe covers, the nurse should also wear a fluid-resistant gown and gloves if the drainage cannot be contained. A mask should be worn if the client has a productive cough.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 6

Type: MCMA

The nurse is performing a physical assessment of the client. Which of the following pieces of information are examples of objective data?

Standard Text: Select all that apply.

1. Apical pulse is 94 beats per minute.

2. Blood pressure in right arm is 118/74.

3. The client has a nonproductive cough.

4. The client reports that his pain is severe and throbbing.

5. Respiratory rate is 18 breaths per minute.

Correct Answer: 1,2,3,5

Rationale 1: Apical pulse 94 beats per minute. Objective data can be observed or measured by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the professional nurse. An apical pulse is objective data because it can be auscultated. A blood pressure can be auscultated by any professional nurse.

Rationale 2: Blood pressure in right arm 118/74. Objective data can be observed or measured by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the professional nurse. A blood pressure can be auscultated by any professional nurse.

Rationale 3: The client has a nonproductive cough. Objective data can be observed or measured by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the professional nurse. A clients cough can be heard by any professional nurse.

Rationale 4: The client reports that his pain is severe and throbbing. The clients description of his pain is subjective data because the nurse must rely on the client to provide this information.

Rationale 5: Respiratory rate 18 breaths per minute. Objective data can be observed or measured by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the professional nurse. The clients respiratory rate can be measured by any professional nurse.

Global Rationale: Objective data can be observed or measured by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the professional nurse. An apical pulse is objective data because it can be auscultated. A blood pressure can be auscultated by any professional nurse. A clients cough can be heard by any professional nurse. The clients respiratory rate can be measured by any professional nurse. The clients description of his pain is subjective data because the nurse must rely on the client to provide this information.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 7

Type: MCSA

The student nurse is preparing to assess the client while the more experienced nurse assists. Prior to the physical assessment, the client indicates that he has been experiencing severe left lower quadrant pain. Which of the following statements by the student nurse indicates that the student nurse requires further education prior to performing this part of the assessment?

1. Im going to start by percussing and palpating the clients left lower quadrant first.

2. I will start the abdominal assessment by inspecting the clients abdomen.

3. Im going to auscultate the abdomen prior to percussing the abdomen.

4. I need to ask the client about the characteristics of his pain.

Correct Answer: 1

Rationale 1: Beginning the assessment with the nontender areas permits the nurse to establish the borders of the affected area. Examination of the painful area can exacerbate symptoms, increase the pain, and force termination of the assessment process. The nurse should delay this part of the assessment until the last portion of the examination.

Rationale 2: The nurse should begin the assessment of the clients abdomen with inspection of the abdomen.

Rationale 3: The nurse should auscultate the clients abdomen, and then percuss the abdomen.

Rationale 4: The nurse should inquire about the characteristics of the clients pain.

Global Rationale: Beginning the assessment with the nontender areas permits the nurse to establish the borders of the affected area. Examination of the painful area can exacerbate symptoms, increase the pain, and force termination of the assessment process. The nurse should begin the assessment of the clients abdomen with inspection of the abdomen. The nurse should auscultate the clients abdomen, and then percuss the abdomen. The nurse should inquire about the characteristics of the clients pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 8

Type: MCMA

The nurse is performing a physical assessment on a client in an outpatient clinic. The nurse is inspecting and palpating the clients face, skin folds, axillae, palms, and soles of the feet. The nurse determines the client is diaphoretic. Which of the following statements by the client are expected?

Standard Text: Select all that apply.

1. Your elevator is out and I had to climb three flights of stairs.

2. Ive been running a fever for the last few days.

3. I think I have hypothyroidism.

4. Im in a lot of pain today.

5. I heard a rumor at work yesterday that layoffs were inevitable.

Correct Answer: 1,2,4,5

Rationale 1: Your elevator is out and I had to climb three flights of stairs. Diaphoresis can occur with exertion, such as climbing stairs.

Rationale 2: Ive been running a fever for the last few days. Clients who have a fever may become diaphoretic.

Rationale 3: I think I have hypothyroidism. It is not typically associated with hypothyroidism. More commonly, it is associated with hyperthyroidism.

Rationale 4: Im in a lot of pain today. Clients who are in pain may become diaphoretic.

Rationale 5: I heard a rumor at work yesterday that layoffs were inevitable. Clients who are experiencing emotional stress may become diaphoretic.

Global Rationale: Diaphoresis can occur with exertion, such as climbing stairs. Clients who have a fever may develop diaphoresis. Clients who are in pain may become diaphoretic. Clients who are experiencing emotional stress may become diaphoretic. It is not typically associated with hypothyroidism. More commonly, it is associated with hyperthyroidism.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 9

Type: HOTSPOT

The nurse prepares to palpate the clients preauricular lymph nodes. Identify the location of the preauricular lymph nodes on the following figure by drawing an arrow.

Screen Shot 2015-09-24 at 12.54.57 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The preauricular lymph nodes are located in the front of the clients ears.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 10

Type: MCSA

The student nurse is preparing to insert the otoscope into the adult clients ear. Which of the following statements indicates that the student nurse requires further education?

1. Im going to use the largest speculum that will fit easily into the ear canal.

2. Im going to prepare to insert the otoscope by pulling the pinna down and back.

3. The tympanic membrane should look gray and translucent.

4. I will ask the client to perform the valsalva maneuver so that I can see how well the tympanic membrane moves.

Correct Answer: 2

Rationale 1: For the best visualization, use the largest speculum that will fit into the auditory canal.

Rationale 2: In infants, the pinna is pulled down and back due to the shorter, straight external ear canal. In the adult client, pull the pinna up, back, and out to straighten the canal.

Rationale 3: The membrane should be flat, gray, and translucent with no scars.

Rationale 4: The valsalva maneuver lets the nurse assess the mobility of the tympanic membrane.

Global Rationale: In infants, the pinna is pulled down and back due to the shorter, straight external ear canal. In the adult client, pull the pinna up, back, and out to straighten the canal. For the best visualization, use the largest speculum that will fit into the auditory canal. The membrane should be flat, gray, and translucent with no scars. The valsalva maneuver lets the nurse assess the mobility of the tympanic membrane.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 11

Type: MCSA

The nurse holds the tuning fork by the handle and gently strikes the fork on the palm of his hand. Then, the nurse places the base of the fork on the clients mastoid process. The nurse requests that the client indicate when the sound can no longer be heard. Which of the following tests is the nurse performing?

1. Weber

2. Whisper

3. Rinne

4. Romberg

Correct Answer: 3

Rationale 1: The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. The nurse holds the tuning fork by the handle and strikes the fork on the palm of the hand. The nurse places the base of the vibrating fork against the clients skull. The midline of the anterior portion of the frontal bone is used.

Rationale 2: The whisper test is performed by standing to the side of the client at a distance of 12 feet and whispering information to the client. The client then repeats the information back to the nurse.

Rationale 3: The Rinne test is used to compare air and bone conduction of sound and is performed in this manner.

Rationale 4: The Romberg test is used to assess equilibrium. The client stands with feet together and arms at sides, first with eyes opened and then with eyes closed. The clients ability to maintain balance for 20 seconds with only mild swaying is documented as a negative Romberg test.

Global Rationale: The Rinne test is used to compare air and bone conduction of sound and is performed in this manner. The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. The nurse holds the tuning fork by the handle and strikes the fork on the palm of the hand. The nurse places the base of the vibrating fork against the clients skull. The midline of the anterior portion of the frontal bone is used. The whisper test is performed by standing to the side of the client at a distance of 12 feet and whispering information to the client. The client then repeats the information back to the nurse. The Romberg test is used to assess equilibrium. The client stands with feet together and arms at sides, first with eyes opened and then with eyes closed. The clients ability to maintain balance for 20 seconds with only mild swaying is documented as a negative Romberg test.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 12

Type: MCSA

During the physical assessment of the client, the nurse notes that the client is able to shrug her shoulders bilaterally. The function of which of the following cranial nerves is intact?

1. Cranial nerve I (olfactory)

2. Cranial nerve II (optic)

3. Cranial nerve VII (facial)

4. Cranial nerve XI (spinal accessory)

Correct Answer: 4

Rationale 1: Cranial nerve I (olfactory) is also referred to the olfactory nerve. The client with an intact cranial nerve I will be able to identify familiar odors.

Rationale 2: Cranial nerve II (optic) is responsible for the client being able to see.

Rationale 3: The client who has a functioning cranial nerve VII (facial) will be able to use her facial muscles symmetrically.

Rationale 4: An intact cranial nerve XI (spinal accessory) is responsible for allowing the client to shrug her shoulders.

Global Rationale: An intact cranial nerve XI is responsible for allowing the client to shrug her shoulders. Cranial nerve I is also referred to as the olfactory nerve. The client with an intact cranial nerve I will be able to identify familiar odors. Cranial nerve II is responsible for the client being able to see. The client who has a functioning cranial nerve VII will be able to use her facial muscles symmetrically.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 13

Type: MCSA

The function of the clients cranial nerve XII (hypoglossal) is intact. The nurse is able to assess this nerve by asking the client to perform which of the following activities?

1. Can you stick out your tongue?

2. Im going to ask you to taste something and tell me what you think it is.

3. Close your eyes and tell me when you feel me touch your face with this wisp of cotton.

4. Im going to lightly touch the back of your throat with this tongue depressor.

Correct Answer: 1

Rationale 1: An intact cranial nerve XII (hypoglossal) allows the client to stick out the tongue.

Rationale 2: An intact cranial nerve VII (facial) allows the client to taste.

Rationale 3: An intact cranial nerve V (trigeminal) allows the client to identify sensations on the face.

Rationale 4: Cranial nerve X (vagus) is responsible for producing the gag reflex when the back of the clients throat is lightly touched.

Global Rationale: An intact cranial nerve XII (hypoglossal) allows the client to stick out the tongue. An intact cranial nerve VII (facial) allows the client to taste. An intact cranial nerve V (trigeminal) allows the client to identify sensations on the face. Cranial nerve X (vagus) is responsible for producing the gag reflex when the back of the clients throat is lightly touched.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 14

Type: HOTSPOT

The nurse is performing a physical assessment of the client. Identify the location of the right costovertebral angle on the following figure by drawing an arrow to the site.

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The costovertebral angle is formed as the ribs articulate with the vertebra.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 15

Type: HOTSPOT

The nurse is auscultating the clients lungs and is able to auscultate bronchovesicular sounds over the clients right lung. Identify the area where the nurse is able to auscultate these sounds by drawing an arrow to this area.

Screen Shot 2015-09-24 at 12.56.00 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : Bronchovesicular sounds may be auscultated at the second and third intercostal spaces at the left and right sternal borders. The nurse will hear bronchovesicular sounds.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 16

Type: MCMA

The nurse is assessing the clients cardiovascular system. The nurse is preparing to assess the client for the presence of a lift or heave. Which of the following directions should the nurse provide for the client?

Standard Text: Select all that apply.

1. I am going to put you into a position where your feet are actually above your head.

2. I need you to turn to your left side.

3. Can you please turn onto your stomach?

4. I need you to sit up straight.

5. I am going to elevate your head to a 30-degree angle while you lie on your back.

Correct Answer: 4,5

Rationale 1: I am going to put you into a position where your feet are actually above your head. The client should not be placed into Trendelenburg position to assess for heaves or lifts.

Rationale 2: I need you to turn to your left side. The client does not need to turn to the left side to evaluate the presence of heaves or lifts.

Rationale 3: Can you please turn onto your stomach? The nurse should not evaluate the clients chest for the presence of heaves or lifts while the client is in a prone position.

Rationale 4: I need you to sit up straight. The nurse should inspect the clients chest for heaves or lifts while the client is sitting upright.

Rationale 5: I am going to elevate your head to a 30 degree angle while you lie on your back. The nurse should inspect the clients chest for heaves or lifts while the client is in a semi-fowler position with the head of bed at 30 degrees.

Global Rationale: The nurse should inspect the clients chest for heaves or lifts while the client is sitting upright. The nurse should inspect the clients chest for heaves or lifts while the client is in a semi-fowler position with the head of bed at 30 degrees. The client should not be placed into Trendelenburg position to assess for heaves or lifts. The client does not need to turn to the left side to evaluate the presence of heaves or lifts. The nurse should not evaluate the clients chest for the presence of heaves or lifts while the client is in a prone position.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 17

Type: HOTSPOT

The nurse is assessing the clients cardiovascular system during the physical assessment. Identify the point of maximal impulse/apical impulse on the following figure by drawing an arrow to this site.

Screen Shot 2015-09-24 at 12.56.39 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The point of maximum impulse (PMI) is located at the fifth intercostal space in the left midclavicular line.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 18

Type: MCSA

The student nurse is performing a physical assessment for the client. The student nurse has identified a venous hum while auscultating the clients abdomen. Which of the following statements by the student nurse is most consistent with this type of vascular sound?

1. The sound is a blowing, pulsing sound.

2. The sound is soft and constant. The pitch of the sound is low.

3. It is grating, rough sound.

4. It is tinkling and has a high pitch. The sound is sort of gurgling and irregular.

Correct Answer: 2

Rationale 1: Vascular sounds include bruits and venous hum. A bruit is pulsatile and blowing.

Rationale 2: Vascular sounds include bruits and venous hum. A venous hum is soft, continuous, and low-pitched.

Rationale 3: A friction rub refers to a rough, grating sound caused by the rubbing together of organs or an organ rubbing on the peritoneum.

Rationale 4: The normal bowel sounds heard upon auscultation of the abdomen are irregular, high-pitched, gurgling sounds.

Global Rationale: Vascular sounds include bruits and venous hum. A venous hum is soft, continuous, and low-pitched. A bruit is pulsatile and blowing. A friction rub refers to a rough, grating sound caused by the rubbing together of organs or an organ rubbing on the peritoneum. The normal bowel sounds heard upon auscultation of the abdomen are irregular, high-pitched, gurgling sounds.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 19

Type: MCSA

The student nurse percusses the clients abdomen. Which of the following statements by the student nurse indicate that tympany is present?

1. The sound is low-pitched, loud, and hollow-sounding.

2. It is a high-pitched, soft sound that doesnt last very long.

3. The sound is very loud and has a low tone. The sound has a long duration.

4. It sounds like a drum, loud and high-pitched.

Correct Answer: 4

Rationale 1: Resonance is a low-pitched, hollow sound that is loud. Resonance is often heard when percussing the lungs.

Rationale 2: Dullness is a high-pitched sound with a short duration. Dullness can be heard when percussing over solid body organs.

Rationale 3: Hyperresonance is an abnormally loud, low-toned sound that has a long duration. It is associated with trapped air.

Rationale 4: Tympany is a loud, high-pitched, drumlike tone that can be heard when percussing an organ that is filled with air. When percussing the abdomen, tympany is normally present because the intestines are hollow and filled with air.

Global Rationale: Tympany is a loud, high-pitched, drumlike tone that can be heard when percussing an organ that is filled with air. When percussing the abdomen, tympany is normally present because the intestines are hollow and filled with air. Resonance is a low-pitched, hollow sound that is loud. Resonance is often heard when percussing the lungs. Dullness is a high-pitched sound with a short duration. Dullness can be heard when percussing over solid body organs. Hyperresonance is an abnormally loud, low-toned sound that has a long duration. It is associated with trapped air.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 20

Type: MCSA

The nurse is assessing the clients neurologic system. The nurse tests the clients ability to perform stereognosis. Which of the following activities will accurately test this?

1. The nurse places a vibrating tuning fork over the clients ankle and asks the client to indicate when the vibration can no longer be felt.

2. The nurse asks the client to close her eyes and writes the number 7 in the clients palm with the base of the nurses pen. The nurse asks the client to identify what was written.

3. The nurse asks the client to close her eyes and places a pen in the clients hand. The nurse asks the client to name the object in her hand.

4. The nurse asks the client to close her eyes and indicate where the nurse is touching the client.

Correct Answer: 3

Rationale 1: Vibratory sense is the test to identify if the client can perceive vibration. The inability to perceive vibration may indicate neuropathy.

Rationale 2: Graphesthesia is the ability to perceive writing on the skin. The inability to perceive a number on the skin may indicate cortical disease.

Rationale 3: Stereognosis is the ability to identify an object without seeing it. The inability to identify a familiar object could indicate cortical disease.

Rationale 4: Topognosis is the ability of the client to identify an area of the body that has been touched. The inability of the client to identify a touched area demonstrates sensory or cortical disease.

Global Rationale: Stereognosis is the ability to identify an object without seeing it. The inability to identify a familiar object could indicate cortical disease. Vibratory sense is the test to identify if the client can perceive vibration. The inability to perceive vibration may indicate neuropathy. Graphesthesia is the ability to perceive writing on the skin. The inability to perceive a number on the skin may indicate cortical disease. Topognosis is the ability of the client to identify an area of the body that has been touched. The inability of the client to identify a touched area demonstrates sensory or cortical disease.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 21

Type: MCSA

The nurse has palpated an abnormal mass within the clients scrotum. Which of the following assessment activities is appropriate for the nurse to perform next?

1. The nurse should percuss the clients scrotum.

2. The nurse should attempt to transilluminate behind the area in which the abnormal mass was palpated.

3. The nurse should inspect the inguinal area.

4. The nurse should gently squeeze the mass between the fingers.

Correct Answer: 2

Rationale 1: The nurse should not attempt to percuss the clients scrotum due to an increased number of nerve endings located in this area. Percussing would cause the client unnecessary pain.

Rationale 2: If the nurse detects a mass within the clients scrotum, the nurse should attempt to transilluminate the area. Light will not penetrate a mass. Masses may indicate testicular tumor or a spermatocele.

Rationale 3: The nurse should inspect the inguinal area after attempting to transilluminate the clients scrotal mass.

Rationale 4: The nurse should never squeeze or pinch any mass that has been identified.

Global Rationale: If the nurse detects a mass within the clients scrotum, the nurse should attempt to transilluminate the area. Light will not penetrate a mass. Masses may indicate testicular tumor or a spermatocele. The nurse should not attempt to percuss the clients scrotum due to an increased number of nerve endings located in this area. Percussing would cause the client unnecessary pain. The nurse should inspect the inguinal area after attempting to transilluminate the clients scrotal mass. The nurse should never squeeze or pinch any mass that the nurse has identified.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 22

Type: MCSA

The nurse is performing a physical assessment of a male client. The nurse must assess the clients sacrococcygeal area. Which of the following positions will allow the nurse to assess this area adequately?

1. Orthopneic position

2. Semi-Fowlers position

3. Lithotomy

4. On his left side with his knees drawn up

Correct Answer: 4

Rationale 1: Orthopneic position is utilized by clients who are unable to breathe with the head of bed lower. Orthopneic position allows the client to sit up straight and use a tripod position to lean over a bedside table.

Rationale 2: The semi-Fowlers position is when the client is positioned on his back in a dorsal recumbent position.

Rationale 3: The nurse can use a lithotomy position to perform a pelvic examination on a female client.

Rationale 4: The nurse can visualize the sacrococcygeal area by asking the client to bend over a table at the waist or to lie on the left side with the knees flexed.

Global Rationale: The nurse can visualize the sacrococcygeal area by asking the client to bend over a table at the waist or to lie on the left side with the knees flexed. Orthopneic position is utilized by clients who are unable to breathe with the head of bed lower. Orthopneic position allows the client to sit up straight and use a tripod position to lean over a bedside table. The semi-Fowlers position is when the client is positioned on his back in a dorsal recumbent position. The nurse can use a lithotomy position to perform a pelvic examination.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 23

Type: MCSA

The nurse is performing an assessment of the female clients genitalia. The nurse has inserted a speculum and notices that the client has a frothy greenish-yellowish discharge present within the clients vagina. Based on the nurses findings, the nurse believes that the client has developed which of the following conditions?

1. Trichomoniasis

2. Gonorrhea

3. Chlamydia

4. Candidiasis

Correct Answer: 1

Rationale 1: Frothy, yellow-green discharge is seen in a client with trichomoniasis.

Rationale 2: Green discharge that has a foul smell is associated with gonorrhea.

Rationale 3: A yellow discharge can be visualized in a client with a chlamydial infection.

Rationale 4: Thick whitish discharge can be visualized in a client with candidiasis.

Global Rationale: Frothy, yellow-green discharge is seen in a client with trichomoniasis. Green discharge that has a foul smell is associated with gonorrhea. A yellow discharge can be visualized in a client with a chlamydial infection. Thick, whitish discharge can be visualized in a client with candidiasis.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general survey and physical assessment of a client.

Question 24

Type: SEQ

The nurse is documenting information about the client using Problem-Oriented Charting and the acronym SOAP. Rank the following pieces of information in the order that they should be documented.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. The clients skin is cool and dusky. Poor capillary refill noted. Oxygen saturation level is 90% on room air. The client was diagnosed with COPD in 1993.

Choice 2. The nurse will apply oxygen at 2 liters per minute, per healthcare providers orders when the clients oxygen saturation level is below 92%.

Choice 3. The client states, I am so tired all of the time. I feel like Im not getting enough air into my lungs.

Choice 4. The client is most likely experiencing an exacerbation of a chronic lung disease.

Correct Answer: 3,1,4,2

Rationale 1: S refers to subjective data that are provided by the client regarding the symptoms that the client is experiencing.

Rationale 2: O refers to objective data. The nurse documents information about the signs that the client is exhibiting.

Rationale 3: A refers to assessment. The nurse draws conclusions regarding the subjective and objective data that the nurse has collected about the client.

Rationale 4: P refers to planning. Planning indicates that interventions that the nurse can use to help resolve the clients problems or address the clients needs.

Global Rationale: S refers to subjective data that are provided by the client regarding the symptoms that the client is experiencing. O refers to objective data. The nurse documents information about the signs that the client is exhibiting. A refers to assessment. The nurse draws conclusions regarding the subjective and objective data that the nurse has collected about the client. P refers to planning. Planning indicates that interventions that the nurse can use to help resolve the clients problems or address the clients needs.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.3: Document findings from the comprehensive health assessment.

Leave a Reply