Chapter 30 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 30

Question 1

Type: MCSA

The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment?

1. Auscultate, percuss, palpate, inspect

2. Inspect, auscultate, palpate, percuss

3. Inspect, auscultate, percuss, palpate

4. Palpate, percuss, auscultate, inspect

Correct Answer: 3

Rationale 1: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.

Rationale 2: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.

Rationale 3: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.

Rationale 4: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: o. Assessing the abdomen.

MNL Learning Outcome: 3.2.4. Apply the proper techniques and considerations to perform auscultation.

Page Number: 514

Question 2

Type: MCSA

The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse should document this as being

1. cyanosis.

2. jaundice.

3. pallor.

4. erythema.

Correct Answer: 2

Rationale 1: Cyanosis is a bluish color to the skin, mucous membranes, or nails.

Rationale 2: Jaundice is a yellow tinge that is abnormal and is often noticed in the sclera of the eye.

Rationale 3: Pallor is a term used to describe paleness.

Rationale 4: Erythema is a term used to describe redness.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Demonstrate appropriate documentation and reporting of health assessment..

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 524

Question 3

Type: MCSA

While performing an assessment of the integument system, the nurse notes the clients eyeballs are protruding and the upper eyelids are elevated. What term should the nurse use to document this finding?

1. Erythema

2. Cyanosis

3. Exophthalmos

4. Normocephalic

Correct Answer: 3

Rationale 1: Erythema is a term used to describe redness.

Rationale 2: Cyanosis is a term used to describe a bluish cast to the skin, nails, or mucous membranes.

Rationale 3: Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression.

Rationale 4: Normocephalic is a term used to describe a normal sized head.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: e. Assessing the skull and face.

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 533

Question 4

Type: MCSA

The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel?

1. Vital signs

2. Filling of water pitchers

3. Skull and face assessment

4. Ambulation of surgical clients

Correct Answer: 3

Rationale 1: Vital signs can appropriately be delegated to unlicensed assistive personnel.

Rationale 2: Filling of water pitchers can be appropriately delegated to unlicensed assistive personnel.

Rationale 3: Assessment of the skull and face may not be delegated to unlicensed assistive personnel.

Rationale 4: Ambulation of surgical clients can be appropriately delegated to unlicensed assistive personnel.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Recognize when it is appropriate to delegate assessment skills to unlicensed assistive personnel.

MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety.

Page Number: 533

Question 5

Type: MCSA

The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should the nurse report to the physician immediately?

1. Chest symmetrical

2. Breath sounds equal bilaterally

3. Asymmetrical chest expansion

4. Bilateral symmetric vocal fremitus

Correct Answer: 3

Rationale 1: Symmetrical chest expansion is an expected finding.

Rationale 2: Bilaterally equal breath sounds is a normal assessment finding.

Rationale 3: Chest expansion should be symmetrical.

Rationale 4: Bilaterally equal vocal fremitus is a normal assessment finding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: k. Assessing the thorax and lungs.

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 557

Question 6

Type: MCSA

While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins?

1. 90-degree angle

2. 30- to 45-degree angle

3. 15-degree angle

4. 60-degree angle

Correct Answer: 2

Rationale 1: This is not the correct angle.

Rationale 2: The nurse should place the client in the semi-Fowlers position (30- to 45-degree angle) while inspecting the jugular veins for distention.

Rationale 3: This is not the correct angle.

Rationale 4: This is not the correct angle.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels.

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 566

Question 7

Type: MCSA

The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which finding should the nurse report to the physician immediately?

1. Pulses equal bilaterally

2. Full pulsations

3. Thready pulses

4. Pulses present bilaterally

Correct Answer: 3

Rationale 1: Bilateral equal pulses is a normal assessment finding.

Rationale 2: Full pulsations is a normal assessment finding.

Rationale 3: Thready, weak, or decreased pulses are abnormal and should be reported to the physician.

Rationale 4: Bilaterally present pulses is a normal assessment finding.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: m. Assessing the peripheral vascular system.

MNL Learning Outcome: 3.2.2. Apply the proper techniques and considerations to perform palpation.

Page Number: 567

Question 8

Type: MCSA

During the assessment of a clients breasts, the nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What should the nurse do next?

1. Notify the charge nurse.

2. Notify the physician.

3. Document the findings in the nurses notes as normal.

4. Document the findings in the nurses notes as abnormal.

Correct Answer: 3

Rationale 1: The findings are all normal, so the nurse does not need to notify the charge nurse.

Rationale 2: The findings are all normal, so the nurse does not need to notify the physician.

Rationale 3: The findings are all normal, so the nurse would document the assessment in the nurses notes as normal.

Rationale 4: The findings are all normal, so the nurse would not document the findings as abnormal.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify expected findings during health assessment; 8. Demonstrate appropriate documentation and reporting of health assessment.

MNL Learning Outcome: 3.2.2. Apply the proper techniques and considerations to perform palpation.

Page Number: 572

Question 9

Type: MCSA

The nurse is preparing a client for an abdominal examination. What should the nurse done before beginning the examination?

1. Ask the client to urinate.

2. Ask the client to drink 8 ounces of water.

3. Assess vital signs.

4. Assess heart rate.

Correct Answer: 1

Rationale 1: The nurse should ask the client to urinate because an empty bladder makes the assessment more comfortable.

Rationale 2: Drinking fluids will cause the clients bladder to fill and cause discomfort.

Rationale 3: The clients vital signs do not need to be assessed prior to an abdominal examination.

Rationale 4: The client does not need to have an apical heart rate assessed prior to having an abdominal assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: o. Assessing the abdomen.

MNL Learning Outcome: 3.2.2. Apply the proper techniques and considerations to perform palpation.

Page Number: 574

Question 10

Type: MCSA

The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to perform which action?

1. Grasp the nurses index and middle fingers while the nurse tries to pull the fingers out.

2. Hold an arm up and resist while the nurse tries to push it down.

3. Flex each arm and then try to extend it against the nurses attempt to keep the arm in flexion.

4. Shrug the shoulders against the resistance of the nurses hands.

Correct Answer: 1

Rationale 1: This is the technique to assess muscle grip strength.

Rationale 2: This is a technique to assess muscle strength but not grip strength.

Rationale 3: This is a technique to assess muscle strength but not grip strength.

Rationale 4: This is a technique to assess muscle strength but not grip strength.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: p. Assessing the musculoskeletal system.

MNL Learning Outcome: 3.2.2. Apply the proper techniques and considerations to perform palpation.

Page Number: 579

Question 11

Type: MCSA

The nurse is preparing to conduct a mental status assessment. What should the nurse include in this assessment?

1. Cognitive and affective functions

2. Cognitive and effective functions

3. Affective and memory functions

4. Affective and knowledge functions

Correct Answer: 1

Rationale 1: Cognitive (intellectual) and affective (emotional) functions are assessed.

Rationale 2: There are no effective functions.

Rationale 3: The mental status assessment does not include an assessment of memory.

Rationale 4: A mental status assessment does not include a knowledge assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: a. Assessing appearance and mental status.

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 581

Question 12

Type: MCSA

The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he is unable to respond by speech or writing. What type of aphasia should the nurse realize this patient is demonstrating?

1. Auditory aphasia

2. Acoustic aphasia

3. Sensory aphasia

4. Expressive aphasia

Correct Answer: 4

Rationale 1: Clients with auditory aphasia have lost the ability to understand the symbolic content associated with sounds.

Rationale 2: This is the same as auditory aphasia.

Rationale 3: Sensory or receptive aphasia is the loss of the ability to comprehend written or spoken words.

Rationale 4: Motor or expressive aphasia involves loss of the power to express oneself by writing, making signs, or speaking. Clients may find that even though they can recall words, they have lost the ability to combine speech sounds into words.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: q. Assessing the neurologic system.

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 581

Question 13

Type: MCSA

The nurse is preparing to assess a clients reflexes. What equipment should the nurse gather before entering the room?

1. Sterile gloves

2. Clean gloves

3. Percussion hammer

4. Penlight

Correct Answer: 3

Rationale 1: Sterile gloves are not needed to test reflexes.

Rationale 2: Clean gloves are not needed to test reflexes.

Rationale 3: A percussion hammer is used to test reflexes.

Rationale 4: A penlight is not used to test reflexes.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: q. Assessing the neurologic system.

MNL Learning Outcome: 3.2.3. Apply the proper techniques and considerations to perform percussion.

Page Number: 582

Question 14

Type: MCSA

The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. What should the nurse expect the health care provider to perform?

1. Pap test

2. Breast exam

3. Rectal exam

4. Abdominal exam

Correct Answer: 1

Rationale 1: For sexually active adolescent and adult women, a Papanicolaou test (Pap test) is used to detect cancer of the cervix.

Rationale 2: A breast examination is not done specifically for sexually active clients.

Rationale 3: A rectal exam is not done specifically for sexually active clients.

Rationale 4: An abdominal exam is not done specifically for sexually active clients.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: r. Assessing the female genitals and inguinal area.

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 589

Question 15

Type: MCSA

The nurse is preparing the morning assignments. Which assessment could the nurse delegate to unlicensed assistive personnel?

1. Neurological assessment

2. Musculoskeletal assessment

3. Vital signs assessment

4. Female genital assessment

Correct Answer: 3

Rationale 1: The UAP cannot perform a neurological assessment.

Rationale 2: The UAP cannot perform a musculoskeletal assessment.

Rationale 3: The nursing assistant can only assess vital signs.

Rationale 4: The UAP cannot perform a female genital assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Recognize when it is appropriate to delegate assessment skills to unlicensed assistive personnel.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 520

Question 16

Type: MCSA

The nurse is preparing to administer a cardiotonic drug to a client. Which assessment should the nurse perform before administering the medication?

1. Respiratory rate

2. Apical pulse

3. Popliteal pulse

4. Capillary blanch test

Correct Answer: 2

Rationale 1: The nurse does not need to assess the clients respiratory rate before providing the medication.

Rationale 2: The apical pulse should be assessed before administering any cardiotonic medication.

Rationale 3: The clients popliteal pulse does not need to be assessed prior to receiving this medication.

Rationale 4: The clients capillary blanching does not need to be assessed prior to receiving this medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels.

MNL Learning Outcome: 3.2.4. Apply the proper techniques and considerations to perform auscultation.

Page Number: 514

Question 17

Type: MCMA

The nurse is preparing to complete a physical examination on a client. What should the nurse realize as being the purpose for this examination?

Standard Text: Select all that apply.

1. Obtain baseline data.

2. Obtain data to help determine nursing diagnoses.

3. Identify areas for disease prevention.

4. Identify the clients employment status.

5. Obtain data about the clients leisure activities.

Correct Answer: 1, 2, 3

Rationale 1: One purpose of the physical examination is to obtain baseline data.

Rationale 2: One purpose of the physical examination is to obtain data to help determine nursing diagnoses.

Rationale 3: One purpose of the physical examination is to identify areas for disease prevention.

Rationale 4: The physical examination is not done to identify the clients employment status.

Rationale 5: The physical examination is not done to obtain data about a clients leisure activities.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Identify the purposes of the physical examination.

MNL Learning Outcome: 3.0.1. Assessing Health Status

Page Number: 514

Question 18

Type: MCMA

A client has been receiving a new medication to address specific symptoms. The nurse will perform a physical examination to determine

Standard Text: Select all that apply.

1. the progress of the clients health problem.

2. the physiological impact of the prescribed medication.

3. baseline data.

4. data to support nursing diagnoses.

5. areas for health promotion.

Correct Answer: 1, 2

Rationale 1: The nurse will perform a physical examination on a client to determine the progress of the clients health problem.

Rationale 2: The nurse will perform a physical examination on a client to determine the physiological impact of the prescribed medication.

Rationale 3: The nurse will not be performing a physical examination to collect baseline data.

Rationale 4: The nurse will not be performing a physical examination to support nursing diagnoses.

Rationale 5: The nurse will not be performing a physical examination to identify areas for health promotion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Identify the purposes of the physical examination.

MNL Learning Outcome: 3.0.1. Assessing Health Status

Page Number: 514

Question 19

Type: MCMA

The nurse is utilizing the technique of inspection during a physical examination with a client. When using this technique, the nurse will take which actions?

Standard Text: Select all that apply.

1. Visually observe a body area.

2. Obtain information through the sense of smell.

3. Obtain information through the sense of hearing.

4. Examine the body through the use of touch.

5. Strike the body to elicit a sound from a body part.

Correct Answer: 1, 2, 3

Rationale 1: When using inspection, the nurse will visually observe a body area.

Rationale 2: In addition to visual observation, olfactory cues are noted.

Rationale 3: In addition to visual observation, auditory cues are noted.

Rationale 4: Examining the body through use of touch describes palpation.

Rationale 5: Striking the body to elicit a sound from a body part describes percussion.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Explain the four techniques used in physical examination: inspection, palpation, percussion, and auscultation.

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 517

Question 20

Type: MCMA

The nurse is planning to perform indirect percussion on an area of a clients body during a physical examination. Which actions should the nurse take to use this assessment technique?

Standard Text: Select all that apply.

1. Place the middle finger of the nondominant hand on the clients skin.

2. Use the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand.

3. Perform a striking motion by moving the wrist.

4. Perform short, rapid, firm blows.

5. Use a stethoscope to transmit sounds to the ears.

Correct Answer: 1, 2, 3, 4

Rationale 1: Placing the middle finger of the nondominant hand on the clients skin is the first step when performing indirect percussion.

Rationale 2: Using the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand is the second step when performing indirect percussion.

Rationale 3: The nurse should perform a striking motion by moving the wrist.

Rationale 4: The nurse should perform short, rapid, firm blows.

Rationale 5: Using a stethoscope to transmit sounds to the ears is done during auscultation, not indirect percussion.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Explain the four techniques used in physical examination: inspection, palpation, percussion, and auscultation.

MNL Learning Outcome: 3.2.3. Apply the proper techniques and considerations to perform percussion.

Page Number: 518

Question 21

Type: MCMA

The nurse is assessing the nose and sinuses of a client. Which findings should the nurse identify as being within normal limits?

Standard Text: Select all that apply.

1. Nose straight

2. Nares symmetrical

3. No tenderness over the bridge

4. Air movement restricted in one nare

5. Clear drainage from one nare

Correct Answer: 1, 2, 3

Rationale 1: A straight nose is a normal finding.

Rationale 2: Symmetrical nares are a normal finding.

Rationale 3: No tenderness over the nose bridge is a normal finding.

Rationale 4: Air movement restricted in one nare is an abnormal finding.

Rationale 5: Clear drainage from one nare is an abnormal finding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: h. Assessing the nose and sinuses.

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 533

Question 22

Type: MCSA

The nurse is planning a physical examination of a client following a head-to-toe format. In which order should the nurse conduct this assessment?

1. Head, upper extremities, abdomen, lower extremities

2. Neck, head, vital signs, chest and back

3. Lower extremities, abdomen, upper extremities, chest and back

4. Head, neck, lower extremities, abdomen

Correct Answer: 1

Rationale 1: When conducting a physical examination from head to toe, the nurse would start with the head, move down to the upper extremities, then to the abdomen, and finally to the lower extremities.

Rationale 2: The neck should not be examined before the head. Vital signs are assessed before the head is examined.

Rationale 3: The lower extremities and abdomen would not be assessed before the upper extremities or the chest and back.

Rationale 4: The lower extremities would not be assessed before the abdomen.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Describe suggested sequencing to conduct a physical health examination in an orderly fashion.

MNL Learning Outcome: 3.0.1. Assessing Health Status

Page Number: 514

Question 23

Type: MCSA

The nurse is assessing the peripheral vascular status of an older client. Which finding should the nurse consider as being normal for this client?

1. Easy to palpate upper extremity arteries

2. Easy to palpate lower extremity arteries

3. Reduction in the number of varicosities

4. Increase in diastolic blood pressure

Correct Answer: 1

Rationale 1: In some older clients, arteries may be palpated more easily because of the loss of supportive surrounding tissues.

Rationale 2: The most distal pulses of the lower extremities are more difficult to palpate, not easier to palpate, because of decreased arterial perfusion.

Rationale 3: The number of varicosities increases in the older client.

Rationale 4: The systolic blood pressure might increase.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels.

MNL Learning Outcome: 3.2.2. Apply the proper techniques and considerations to perform palpation.

Page Number: 569

Question 24

Type: MCMA

The nurse is preparing to perform an eye assessment. What equipment should the nurse have available to complete this assessment?

Standard Text: Select all that apply.

1. Penlight

2. Snellens chart

3. Sterile gloves

4. Gauze square

5. Millimeter ruler

Correct Answer: 1, 2, 4, 5

Rationale 1: When performing an eye examination, the nurse will need a penlight.

Rationale 2: When performing an eye examination, the nurse will need a Snellens chart.

Rationale 3: Sterile gloves are not needed to perform an eye assessment.

Rationale 4: When performing an eye examination, the nurse will need a gauze square.

Rationale 5: When performing an eye examination, the nurse will need a millimeter ruler.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: f. Assessing the eye structures and visual acuity.

MNL Learning Outcome: 3.0.1. Assessing Health Status

Page Number: 535

Question 25

Type: MCMA

The nurse is preparing to conduct an assessment of the heart. Where should the nurse place the stethoscope to auscultate heart sounds?

Standard Text: Select all that apply.

1. Aortic region

2. Pulmonic region

3. Tricuspid valve region

4. Abdomen

5. Mitral valve region

Correct Answer: 1, 2, 3, 5

Rationale 1: The nurse will auscultate heart sounds over the aortic region.

Rationale 2: The nurse will auscultate heart sounds over the pulmonic region.

Rationale 3: The nurse will auscultate heart sounds over the tricuspid valve region.

Rationale 4: The abdomen is not assessed during the assessment of the heart.

Rationale 5: The nurse will auscultate sounds over the mitral valve region.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels.

MNL Learning Outcome: 3.2.4. Apply the proper techniques and considerations to perform auscultation.

Page Number: 562

Question 26

Type: MCMA

The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing in this patient?

Standard Text: Select all that apply.

1. Eye response

2. Motor response

3. Verbal response

4. Orientation

5. Musculoskeletal response

Correct Answer: 1, 2, 3

Rationale 1: The Glasgow Coma Scale tests in three major areas: eye response, motor response, and verbal response.

Rationale 2: The Glasgow Coma Scale tests in three major areas: eye response, motor response, and verbal response.

Rationale 3: The Glasgow Coma Scale tests in three major areas: eye response, motor response, and verbal response.

Rationale 4: The Glasgow Coma Scale is not used to assess orientation.

Rationale 5: The Glasgow Coma Scale is not used to assess musculoskeletal response.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: q. Assessing the neurologic system.

MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection.

Page Number: 582

Question 27

Type: MCMA

A client is experiencing abdominal pain. What assessments should the nurse perform to assess this complaint?

Standard Text: Select all that apply.

1. Inspect the abdomen.

2. Auscultate the abdomen.

3. Palpate the abdomen.

4. Assess vital signs.

5. Assess peripheral pulses.

Correct Answer: 1, 2, 3, 4

Rationale 1: The nurse should inspect the clients abdomen.

Rationale 2: The nurse should auscultate the abdomen.

Rationale 3: The nurse should auscultate the abdomen.

Rationale 4: The nurse should assess vital signs.

Rationale 5: Although peripheral pulses may be palpated, this is not specific to a client with abdominal pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: o. Assessing the abdomen.

MNL Learning Outcome: 3.0.1. Assessing Health Status

Page Number: 576

Question 28

Type: MCMA

The nurse is assessing the musculoskeletal status of a 4-year-old child. What findings should the nurse consider as being expected in this client?

Standard Text: Select all that apply.

1. Lordosis

2. Genu valgus

3. Genu varum

4. Pronation of the feet

5. Asymmetric leg abduction

Correct Answer: 1, 2

Rationale 1: Lordosis (swayback) is common in children before age 5.

Rationale 2: Genu valgus (knock-knee) is normal in preschool and early-school-age children.

Rationale 3: Genu varum (bowleg) is normal in children for about 1 year after beginning to walk.

Rationale 4: Pronation and toeing in of the feet are common in children between 12 and 30 months of age.

Rationale 5: Asymmetric abduction of the legs (Ortolani and Barlow tests) assesses for developmental dysplasia of the hip in infants.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6. Discuss variations in examination techniques appropriate for clients of different ages.

MNL Learning Outcome: 3.0.1. Assessing Health Status

Page Number: 580

Question 29

Type: MCMA

The nurse is concerned that an older client has nutritional deficiencies. What did the nurse find when assessing this clients nails to make this clinical decision?

Standard Text: Select all that apply.

1. White spots

2. Curved nails

3. Deep purple areas

4. Spoon-shaped nails

5. Bands across the nails

Correct Answer: 1, 4, 5

Rationale 1: White spots may indicate zinc deficiency.

Rationale 2: Curved nails may be a normal finding or indicate a breathing difficulty.

Rationale 3: Deep purple areas indicate an injury to the nail region.

Rationale 4: Spoon-shaped nails may indicate iron deficiency.

Rationale 5: Bands across the nails may indicate protein deficiency.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6. Discuss variations in examination techniques appropriate for clients of different ages.

MNL Learning Outcome: 3.0.1. Assessing Health Status

Page Number: 532

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